#step2cs

VS (Vital Signs): Copy & Paste!  or bp 90/60, p 80, T 36C, rr 17

GA (General Appearance):  NAD (No Acute Distress)

 HEENT & Neck

Head: NCAT, NT: NormoCephalic/ATraumatic, Non-Tender

Eyes: no scleral icterus/ anemic/ erythema/ exudate. PERRLA, EOMI,

           Fundi- red reflex intact, no papilledema / No visual defect.  

Ears: no discharge. NT. EAC NL, TM intact or TM: No bulging, perforation, redness b/l

         Rinne AC>BC, Weber not lateralized  

Nose: no nasal congestion, discharge, erythema, and perforation or salute

Throat: MMM (Mucous Membranes Moist). no exudate, tonsillar enlargement, erythema, exudates, vesicular lesions /

Neck: no LAD(Lymphadenopathy) / no Bruits, JVD/ thyroid No enlargement, nodules, tender and bruits

 Full CV: RRR (Regular Rate and Rhythm), S1S2NL, no MRGs (Murmurs, Rubs, or Gallops), PMI (Point of Maximal Intensity) not displaced.  Carotid: no bruits, no JVD, Pulses: Radial, DP, PT (Dorsalis pedis, post. Tibialis) 2+ b/l.  No Edema in LE , Fundoscopy: no vessel changes & Exudate & Hemorrhage, no papilledema.

Chest:  NT, equal chest excursion b/l, TVF NL (Tactile Vocal Fremitus Normal), Lungs clear to A&P(Auscultation, percussion) b/l, no WRR(Wheezing, Rales, Rhonchi).

 Abdomen: no scars or bruises. Soft, ND (NonDistended) / BS (Bowel Sound) + x 4Q, no bruits.  / tympanicx4Q. no masses & HSM(Hepatosplenomegaly)/ NT (NonTender)  

Negative- Murphy, Rovsing ’s, psoas, obturator sign. CVA tenderness.

 Full Neuro:  

A&O3 (Alert to Oriented x3)

Eyes: no visual defect, EOMI, Fundoscopy- no vessel changes, hemorrhage,

CN2-12 grossly intact. motor 5/5 in all 4 ext, DTR: 2+ in all 4 ext., Sensory Intact to light touch SILT/position/vibration intact b/l.

No dysdiadochokinesia (flip hands), no dysmetria or [coordination intact], Roberg negative, Gait - NL,

Brudzinski +/ Babinski - / Kernig -

 Extremities: IPR MSRP (Inspection, Palpitation, Range of movement, Motor, Sense, Reflex, Pulse)

No swelling, erythema, warmth, tenderness (Inspection, Palpitation)

ROM intact

Motor 5/5, Sensation intact to light touch, sharp and dull, DTR 2+ in all 4 extremities.

Peds was great guys. I didn’t see myself doing this rotation because i usually don’t know what to do with kids haha..but it was great. I saw a lot of different cases-saw a ruptured tympanic membrane, Parotitis, WAGR syndrome, autism, testicular torsion, UTIs, bronchiolitis etc. It was amazing. I definitely needed to learn to do the HPI for this rotation. 

HPI is different for neonates and for preschoolers and for adolescents, so you had to tailor your questions to the specific age group. 

Overall you asked if they were in Daycare (If they were less than 5-6 years old), dental visits, smokers or pets in the house along with the general questions (fever, vomiting, diarrhea etc)

Neonates you ask the mom which hospital they were born at, vaginal or C-section, bottle or breast, term or preterm, any complications etc. 

Up to 1 Year old you ask about bottle or breast feeding, if bottle, then what formula and how much they feed. If they breast feed how many minutes they latch onto each breast and how many hours apart do they feed. You ask about wet and dirty diapers. You ask about consistency of the stool. Don’t forget those developmental milestones as well (Refer to Maxwell’s Pocketbook). Then you ask the general qs about any fever, vomiting, cough, or diarrhea

Kids in school( Elementary, middle or HS) you ask how they are doing in school, if they have any friends, and about their grades, and which school they attend.Also ask if they are involved in any extra-curricular activities.

For HS girls you ask about periods, age of Menarche, LMP, how their periods are like etc along with sexual history. 

Any patients coming in with asthma, you ask if the asthma is related to weather changes, exercise induced or year around. 

That’s all i have. 

Sneaking in a selfie during break while on Gastroenterology rotation, back in February.

This rotation was a little different We had to play-role or act out cases, in addition to seeing real patients as usual. So half of the group were patients and the other half were doctors. The patients were given their diseases and the doctors had to figure out the disease from the patient history and physical exam. It was fun and a good into to Step 2 CS. 

* All Abbreviations in History Taking part are in ‘Basic Question List’ (the 1st post of this Blog.)

Chest Pain

Key Doorway Information:  Check Age (Young vs Above 40s) / Vital (Esp. Temp & BP)

DDX List – Coronary + GUT HAC

Coronary:  Stable Angina / Unstable Angina / Myocardial Infarction (maybe HTN or Above the 40s in the doorway information)

+ GUT HAC

GI – Heartburn, Gastritis & PUD +- Pancreatitis / Esophagitis

(previous) URI – Myocarditis, Pericarditis, Pneumonia, Pleural empyema

Trauma – Rib fracture, (+- tension) Pneumothorax, Hemothorax

Herpes Zoster

Aortic Dissection & Pulmonary embolism

Cocaine-induced MI

Costochondritis.

 *Thinks Coronary Artery Disease 1st in Above 40s & HTN

  Think U T C 1st in young patients / if your Pt has a fever – think U!

 H/T

(1) LIQORAAA – Location(check Abd pain), Intensity, Quality(Dull vs Sharp vs Pressure like), Onset (CDEFG- Constant or intermittent, Duration, Events, Frequency, Gradually vs Abruptly started), Radiation

Alleviating – Resting(coronary) / Leaning forward (Pericarditis, Myocarditis, +- pancreatitis)

Aggravating – Exercise, Activity(coronary) / MLB (eat Meals – GI, Lie down-pericarditis, Breath in – Pleuritic pain)

*Pleuritic pain>> Infection: Pericarditis/ Pleural effusion/ Pneumonia

                           Vessels : Ao-dissection / Pul-embolism / MI

                          T: Pneumothorax/Hemothorax/Rib Fx

Another pain (= previous similar pain)

 (2) Neck: STR+Cough > prev. URI or Infection

(3) Chest: CDHW + LLENT(related to CVD)

(4) Abd: R/O GI diseases

(5) Other Targeting Questions

Herpes Zoster – Pain >> Vesicles/ Rash

Pulmonary embolism – Calf pain / Immobilization

Cocaine-induced MI – Illicit drug

 P/E: Full CV & Lungs + Chest Tenderness

Consider: 

Abd exam if Abd H/T positive

Cocaine+: Eyes & Nose (nasal perforation)

*All Abbreviations in H/T are in Basic Question List in the 1st post of this Blog.

 DDX List: MEB  MTCT  SSTTP

O Febrile+: Meningitis, Encephalitis, Brain Abscess, +- SAH, Sinusitis

O Afebrile + Primary Head (Previous similar episodes in their 20s~40s, Recurrent)

Migraines: pulsing HA, nausea, photophobia, phonophobia

Tension HA: bandlike pressure b/l + not accompanied by other symptoms

Cluster headaches: short episodes (15–180 minutes) / severe pain / tearing, red eye, nasal congestion/ occur at the same time /

Trigeminal neuralgia: shooting face pain

O Afebrile + Secondary (usually accompanied with other Neurologic Symptoms)

Stroke / TIA: Ipsilateral numbness, weakness, aphasia, vision, H/O HTN, DM, HLD

SAH: Acute, severe headache, stiff neck, Trauma(also consider Epidural, Subdural, Concussion), F/H of aneurysm,  

Brain tumor: dull headache, AGG with exertion & position change, N/V(not specific)

Temporal Arteritis: Elderly (60s~), mild fever, weight loss, jaw claudication, tender vessels by the temples, PMH of polymyalgia rheumatica

Pseudotumor Cerebri: OCP, Obese, Female, Vision problems

 History Taking

(1) LIQORAAA – Location, Intensity, Quality(Dull vs Sharp vs Pressure like), Onset (CDEFG- Constant or intermittent, Duration, Events, Frequency, Gradually vs Abruptly started), Radiation

Alleviating – Quiet, Dark (Check photophobia, phonophobia)

Aggravating –Light, noisy (photophobia, phonophobia) Stress (tension, migraines)

Another pain (=> can be primary)

(2) Other Neurologic: VHD DS SWNT (Cranial Nerves) / LLHH SFNG

Vision (CN3,4,6), Hearing & Dizziness(CN8), Dysphagia(CN9,10), Speaking(CN9,10,brain), Swallowing(CN9,10), Weakness- Numbness(Tingling sensation)

Lightheadedness, LOC, Headaches, Head Trauma

Seizure, history of Falling down, Nausea, Gait problems

(3) Neck: Stiffness (Meningitis, SAH, Pseudotumor Cerebri)

(4) If your patient has a fever > check recent infection (URI)  

(5) Other Targeting Questions

Migraines: Aura

Cluster headaches: tearing, red eye, nasal congestion

Stroke / TIA: H/O HTN, DM, HLD

SAH: Trauma

Temporal Arteritis: Jaw claudication, PMH of polymyalgia rheumatica

Pseudotumor Cerebri: OCP, Obese

*All Abbreviations in History Taking part are in ‘Basic Question List’ (the 1st post of this Blog.)

DDX List: PCOS MM LIT

Presbycusis: Bilateral / Gradual onset / Tinnitus /Sensorineural/ Age/ HTN &DM & Smoke

Cochlear nerve injury: Bilateral / Gradual onset / Tinnitus/ Sensorineural/ + Noisy Area (Construction site)

Otosclerosis: Bilateral / Gradual onset / Conductive / Age

Stroke: Other Neurologic Symptoms!  + h/o HTN, DM, HLD.

Medication: ASA / Antibiotics (Ototoxicity)

Meniere’s: + Vertigo

Labyrinthitis: + Vertigo + Prev. URI

Infection: Exudate, Ear Pain, Fever

Trauma

  History Taking 

(1) Chief Complain: DOC-DEF AAA + KEW DJ US

Describe chief complain, Onset, Constant, Duration, Events, Frequency, Aggravating, Alleviating, Another episode (previous similar episodes)

 Kind of sound / Ear pain / how do Word sound – Distorted, Jumbled / Understand speech / locate the Source of the sound

 (2) Other Neurologic: VHD DS SWNT (Cranial Nerves) / LLHH SFNG

Vision (CN3,4,6), Hearing & Dizziness(CN8), Dysphagia(CN9,10), Speaking(CN9,10,brain), Swallowing(CN9,10), Weakness- Numbness(Tingling sensation)

Lightheadedness( Can be Cardiovascular problems/ Hypotension), LOC, Headaches, Head Trauma

Seizure, history of Falling down, Nausea, Gait problems

 (3) Other Targeting Questions

Cochlear nerve injury: Noisy Area (Construction site)

Medication: ASA / Antibiotics (Ototoxicity)

Meniere’s: + Vertigo

Labyrinthitis: + Vertigo + Prev. URI

Trauma

During Introduction: I'm Dr. Yu, it's a pleasure to meet you.   I'm a physician at this clinic. I will be helping you today! First of all, Are you comfortable now? How'd you like to be addressed?

Your comfort is my top priority. Would you want me to stand up or take a seat? What brought you here today?

If your Pt seems uncomfortable, > you seem to be uncomfortable. Is there anything that I can help you with? OK, Plz let me know if there is something that I can do to make you feel better!

If the Chief Complain is "PAIN" > I heard from my nurse that you have pain in your chest. Am I correct?,  Does it hurt now? > I'm sorry to hear that. I'll do my best to relieve your pain quickly.

During History Taking : (1) when Pt says their Chief Complain > I’m sorry to hear that. I will do my best to help you. Let's find out /figure out what's going on! ~~" (2) Lots of questions, isn't it?  It's almost ended. Plz, bear with me.

During Physical Exam: My hands could be cold, bear with me plz. I'll prepare the leg extension for your comfort! I'll prepare the footstool for your comfort!

Ending: (1) If a serious situation,  your symptoms are quite serious. So from now on, our medical staff and I will closely monitor you and If you notice any changes in your condition or your symptoms get any worse, please let us know. Then we'll try to address it as soon as possible.

(2) Not an emergency situation, If you have any problems or your symptoms get any worse, feel free to contact me. After this meeting, my nurse will give you my contact information.

it was nice meeting you. we will meet again very soon. Until then, take care.