Step 2CS All You Need to Know: Difference between revisions
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# Write down on given paper Name/Last-name, Age, Altered vitals, chief complaint | # Write down on given paper Name/Last-name, Age, Altered vitals, chief complaint | ||
# If possible write quickly 3 differential diagnosis for the chief complaint | # If possible write quickly 3 differential diagnosis for the chief complaint | ||
# Knock the door and enter the room | # Knock the door and enter the room | ||
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# Hello Mrs/Mr Wiki-patient (Shake hands with the patient) | # Hello Mrs/Mr Wiki-patient (Shake hands with the patient) | ||
# I am Dr. Romero I will be your doctor today, I will ask you some questions and perform a brief physical exam on you. Is that OK with you? | # I am Dr. Romero I will be your doctor today, I will ask you some questions and perform a brief physical exam on you. Is that OK with you? | ||
# Is the room OK for you? (Dim light or adjust temperature if possible) | # Is the room OK for you? (Dim light or adjust temperature if possible) | ||
# Let me make you more comfortable | # Let me make you more comfortable | ||
# How would you like to be addressed? (Wiki-patient says he/she likes to be called Wiki) | # How would you like to be addressed? (Wiki-patient says he/she likes to be called Wiki) | ||
# How may I help you today? (Wiki-patient describes chief complaint) | # How may I help you today? (Wiki-patient describes chief complaint) |
Revision as of 12:26, 11 July 2013
Type chapter name here Microchapters |
Physical Examination |
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Patient Note |
Differential Diagnosis |
Step 2CS All You Need to Know On the Web |
Study Guide
For study purposes the patient will be called Wiki and the Dr. is Romero
Overview
Test Structure
Please help Wikidoc add content
Interviewing Process
Doorway Information
-Mr/Mrs
Age BP HR RR Temp
- Comes due to symptom (back pain/ sore throat)
- Write down on given paper Name/Last-name, Age, Altered vitals, chief complaint
- If possible write quickly 3 differential diagnosis for the chief complaint
- Knock the door and enter the room
Introduction to Wiki-Patient
- Hello Mrs/Mr Wiki-patient (Shake hands with the patient)
- I am Dr. Romero I will be your doctor today, I will ask you some questions and perform a brief physical exam on you. Is that OK with you?
- Is the room OK for you? (Dim light or adjust temperature if possible)
- Let me make you more comfortable
- How would you like to be addressed? (Wiki-patient says he/she likes to be called Wiki)
- How may I help you today? (Wiki-patient describes chief complaint)
- I am sorry to hear that. I will do my best to help you.
===Asking
Introduction
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
Avoid using medical terms when interviewing. Use Layman terms instead.
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