Step 2CS All You Need to Know

Counseling

• Immediately when the patient gives you the information
• When washing your hands
• During closure

History

• HPI
• ROS
• ALL
• MED
• PMH
• PSH
• OBGYN
• FH
• SH

Patient Note

HISTORY (SUMMARY) "Does NOT mean you ask it with these terms"

HPI

LIQORAAA (for pain) OCDPF ROS (IF PERTINENT)

PAMHITSFOSS ROS: negative except as above PMHx: previous symptoms like this or major medical condition Hipertension, Diabetes, MI. HOSP. NKDA, Medics: prescribed and OTC PSHx: TRAUMA, SURGERY FHX: none (only pertinent) OB-GYN Hx FMP, LMP, Period every 30 days, lasts 5 days, tampons/pads, GPA (gestation, pregnancy, aborption) SHx: Occupation. . Occupation. Support (SAFE). SEXUAL: active with. multiple Men/wome/both. Condoms every time. No STDs. HIV test. smoking (PPD: 1pack per day for 30 years, EtOH (CAGE 0/4), Illicit drugs, Travel history.

PAM HUGS FOSS WA FOR KIDS ON CALL IDIOT: onset number cry asociated sxs listless liquid (urine) inmunization diet, dehydration, daycare infection/ill contacts ORS:Oral rehydration solution Travel

Physical Examination

Report unable to due to pain NAD (hydrated, afebrile, tired, flat affect, tired, speech, movement) VS: WNL except: BP RR HR Temp.

HEENT (head, eyes, ears, nose, throat) Head: AT, NC (atraumatic, normocephalic) Eyes: EOMI, PERRLA, normal eye funds. No conjuctival pallor Nose: no nasal congestion. Throat: No tonsillar erythema, exudates or enlargement. Mouth: moist mucous membranes, good dentition

Neck: Supple, no JVD, no carotid bruits, no cervical LAD, normal thyroid. (CAT ORGAN: Carotid, Abdomen, Thyroid)

Chest/Lung: no tenderness, clear to percussion bilaterally, tactile fremitus normal, clear breath sounds bilaterally. (No wheezes, crackles, rhonchi, rubs)

Heart: PMI not displaced, RRR,normal S1/S2 WNL, no M, G, R.

Abdomen: ND, BS +, Soft, NT. (NO Murphy, McBurney, Rovsing, CVA tenderness, psoas/obturator sign "just one"). No Hepatosplenomegaly/ organomegaly.

Extremities: No edema +2 +3, clubbing, cyanosis, hairless, asterixis, skin changes. Peripheral pulses (don't write it radial, brachial, dorsal is pedis, posterior tibilalis) 2+ and symmetric. No bruises. ROM (limited passive/active "abduction/adduction/flexion/extension/external rotation" MRS (motor, reflexes, sensation)

Neuro Mental Status: A & O x3, spells backward, recalls 3 objects. CN 2-12 WNL/grossly intact. Rinne WNL, AC> BC?. Weber not lateralized. Motor: strength 5/5 in all limbs except DTRs: 2/4 except (normal) absent ankle jerks. Babinksy - Left or right. Sensation: intact to pinprick and soft touch (sharp and dull). Vibration and position normal. Gait: normal, Cerebellar: finger to nose normal (dysmetria, diadococinesia) Romberg -.

Skin: preserved turgor.

Mental Status exam Pt speaks slowly No hostile behavior toward interviewer Blunt affect with poor aye contact Inattentive to interviewer 3/3 registration, 3/3 recall at 3 times Distant memories are impaired Oriented to person, date and place Completed 3 step command Right handed 1/5 on serial 7s Poor judgement

Reporting Physical Exam Briefly

HEENT:

• NC/AT: normocephalic / atraumatic
• Ø LAD: no lymphadenopathy

Cardiac exam (CV):

• Ø M/G/R: no murmurs, gallops, rubs
• 2+ PT/DP B: 2+ posterior-tibial and dorsalis pedis pulses bilaterally
• Ø JVD: no jugular venous distension
• Ø LE edema: no lower extremity edema

Lung exam:

• CTA B: clear to auscultation bilaterally

Abdomen exam:

• NT/ND: non-tender, non-distended
• Ø HSM: no hepatosplenomegaly
• + BS: bowel sounds present

Back exam:

• Ø CVAT: no costovertebral angle tenderness

Neuro:

• EOMI / PERRL: extraocular mvmnts intact / pupils equal, round, reactive to light.

Differential Diagnosis

Give 3 to 5 differential diagnosis with pertinent positives or negatives from HISTORY AND PHYSICAL EXAM

Diagnostic Workup

1. Specific physical examination (rectal, pelvic, breast, genital) if applicable
2. CBC and electrolytes
3. Cultures
4. Imaging