Step 2CS All You Need to Know: Difference between revisions
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===Physical Examination=== | ===Physical Examination=== | ||
* Unable to examine due to pain | |||
NAD (hydrated, afebrile, tired, flat affect, tired, speech, movement) | * NAD (hydrated, afebrile, tired, flat affect, tired, speech, movement) | ||
VS: WNL except: BP RR HR Temp. | * VS: WNL except: BP RR HR Temp. | ||
HEENT (head, eyes, ears, nose, throat) | * HEENT (head, eyes, ears, nose, throat) | ||
Head: AT, NC (atraumatic, normocephalic) | Head: AT, NC (atraumatic, normocephalic) | ||
Eyes: EOMI, PERRLA, normal eye funds. No conjuctival pallor | Eyes: EOMI, PERRLA, normal eye funds. No conjuctival pallor | ||
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Mouth: moist mucous membranes, good dentition | Mouth: moist mucous membranes, good dentition | ||
Neck: Supple, no JVD, no carotid bruits, no cervical LAD, normal thyroid. (CAT ORGAN: Carotid, Abdomen, Thyroid) | * 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) | * 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. | * 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. | * 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) | * 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 | * Neuro | ||
Mental Status: A & O x3, spells backward, recalls 3 objects. | Mental Status: A & O x3, spells backward, recalls 3 objects. | ||
CN 2-12 WNL/grossly intact. Rinne WNL, AC> BC?. Weber not lateralized. | CN 2-12 WNL/grossly intact. Rinne WNL, AC> BC?. Weber not lateralized. | ||
Motor: strength 5/5 in all limbs except | Motor: strength 5/5 in all limbs except | ||
DTRs: 2/4 except (normal) absent ankle jerks. Babinksy - Left or right. | 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 | Sensation: intact to pinprick and soft touch (sharp and dull). Vibration and position normal | ||
Gait: normal | Gait: normal | ||
Cerebellar: finger to nose normal (dysmetria, diadococinesia) Romberg -. | Cerebellar: finger to nose normal (dysmetria, diadococinesia) Romberg -. | ||
Skin: preserved turgor. | * Skin: preserved turgor. | ||
Mental Status exam | * Mental Status exam | ||
Pt speaks slowly | Pt speaks slowly | ||
No hostile behavior toward interviewer | No hostile behavior toward interviewer |
Revision as of 21:29, 16 June 2013
Study Guide
Overview
Test Structure
Interviewing Tecniques
Counseling
- Immediately when the patient gives you the information
- When washing your hands
- During closure
Challenging Questions
Physical Exam
Performance
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
- Unable to examine 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
- Specific physical examination (rectal, pelvic, breast, genital) if applicable
- CBC and electrolytes
- Cultures
- Imaging