Step 2 CS Success

Step 2 CS Success

INTERVIEW

1)knock on door
2)Introduction:
a.Use patient name, greet, give my name and say my occupation.
b.Shake hands if sitting or tap shoulder if lying.
c.Explain all steps I will do.
d.Drape the patient
e.Ask: Why you came in today?

3)HPI: LIQOR AAA
a.Location
b.Intensity.
c.Quality
d.Onset
i.Prior events.
ii.Frequency.
iii.Duration.
iv.Change in time.
e.Alleviating
f.Aggravating
g.Associated
i.Headache
ii.Hearing Loss
iii.Eye Problems/Vision loss
iv.Seizures
v.Nose bleed
vi.Dizziness
vii.Sputum
viii.Cough
ix.SOB
x.Wheezing
xi.Fever
xii.Sweats
xiii.Nausea/Vomit
xiv.Stomachache/Dysphagia
xv.Bowel Movements
xvi.Eating habits
xvii.Weight change
xviii.Urinary Freq/Burning/Incont…
xix.Rash.

4)PMH: PAM HUGS DWS FOSS or PAM HUGS FOSS WEED
a.Previous event
b.Allergies
c.Medication
d.Hospitalizations
e.Urinary
f.GI
g.Surgery
h.Diet
i.Weight
j.Sleep
k.Family
i.Similar
ii.Other
iii.Disease
l.OB/GYN
i.Period
ii.Pregnancy
iii.Abortions
iv.Contraceptives/Condoms
v.Menarche
vi.Cramps
m.Sexual
i.Active
ii.Condoms
iii.Partners
iv.Disease (STD)
v.HIV
vi.Function (erectile)
n.Social
i.Occupation
ii.Stress
iii.Expositions (hazardous)
iv.Tobacco
v.Alcohol
vi. Drugs
vii.Home

PEDIATRIC HISTORY

1)HPI: LIQOR AAA
2)BIRTH
a.Term
b.Check up
c.Sonogram
d.Problems
e.Substance use
f.Deliver
g.Medical
h.Stay
3)FEEDING
a.Type
b.Solid
c.Taste
d.Appetite
e.Vitamins
f.Allergies
4)ROUTIN CARE
a.Doctor / Development
b.Clinic
c.Immunization (Ask for Chart)
d.Check up
e.Hospitalization
f.Illness (Past)
g.Medication
h.Smokers at home
5)GROWTH DEVELOPMENT HISTORY
a.Weight
b.Height
c.Vision
d.Hearing
e.Milestones

OBSTETRIC HISTORY
1)Period
2)Complication
3)Contraction
4)Vaginal discharge or bleed
5)Moving Baby

GYNECOLOGY HISTORY
1)Period (LMP)
2)Pregnancy
3)Abortions
4)Contractions
5)Menarche
6)Children (How is he/her or them)
7)Active (Sexually)
8)Condom use
9)Partners
10)Diseases

PSYCHIATRIC HISTORY
1)Past
2)Substance use
3)Family
4)Social
5)Mental Status
a.Appearance
b.Alert
c.Orientation
d.Concentration
e.Speech
f.Memory
i.Immediate (repeat chair, bed and pen)
ii.Short (same as above after a few minutes)
iii.Recent (Dinner yesterday?)
iv.Distant (when married?)
g.Mood
h.Affect
i.Perception
j.Suicide
k.Judgment
6)Mini Mental
a.Follow command (paper right hand, fold in half, put on floor)
b.Registration 3 objects (same as immediate memory)
c.Recall 3 objetes (same as short memory)

THYROID FUNCTION
1)Constipation
2)Skin
3)Hair
4)Temperature
5)Sleep


FUNCTIONAL STATUS
1)Daily Activities
a.Feed
b.Ambulate
c.Toilet
d.Bathe
e.Dress
f.Grooming
2)Instrumental Activities
a.Clean
b.Laundry
c.Cook
d.Telephone
e.Write
f.Outdoor
g.Drive
h.Travel
i.Shops
j.Medications
3)Reasoning
a.Oriented
b.Concentration
c.Memory
d.Emotions
e.Judgment
f.Intelect
4)Language
a.Name
b.Command
c.Speech
d.Oriented
e.Write
f.Draw


PHYSICAL EXAM

HEENT
I)HEAD: Inspect, Palpate
II)EYES: Inspect, Pupillary Reflex, EOM, Visual Acuity, Visual Field, Ophthalmoscope.
III)EAR: Inspect, Palpate, Audition (Fingers or whisper) Otoscope, Weber, Rine.
IV)NOSE: Inspect, Palpate.
V)THROAT: Inspect, Palate movement, Tongue, Floor of mouth.
VI)NECK: Inspect, Palpate Swollen glands, Auscultate Carotids
VII)THYROID: Inspect, Palpate, Check for Associated Sx.

NEUROLOGIC
I)MENTAL STATUS
a.Oriented (Person, Time, Place)
b.Concentration (Serial 7 or “word” spell)
c.Memory (3 objects: chair, bed, pen. Repeat after few minutes)
II)CRANIAL NERVS
a.II  Vision (Snellen eye chart)
b.III, IV, VI  EOM (“H” patern)
c.V  Clench Teeth (MOTOR), Feel face (3 ares with eyes close)
d.VII  Show teeth (smile), Lift Brow, Eye lid strength.
e.VIII  same of HEENT exam
f.IX, X  Symmetrical palate movement (say AH!!!!)
g.XI  Shrug Shoulders
h.XII  Stick Out Tongue, move it side to side.

EXTREMITIES

I)MOTOR
a.Arms  Push in / Push out
b.Wrists  Pull up / Push down
c.Hands  Finger spread
d.Legs  Kick out / Pull in
e.Ankles  Push on gas / Pull up
II)REFLEX
a.Bicep
b.Tricep
c.Brachioradialis
d.Patelar
e.Achiles
f.Babinsky


III)SENSORY
a.Sharp/Dull  4 points upper-lower, distal-proximal.
b.Vibration  Tuning Fork on Toe.
c.Position Sense  move toe up/down with eyes close

IV)CEREBELLAR.
a.Finger to nose
b.Romberg (feet’s together, arms open, palms up, look up, eyes close)
c.Heel to Shin
d.Gait
V)SPECIAL
a.Kerning Bend-straight leg
b.Brudzinski  Chin toward chest

PULMONARY
1)Inspect: Rate, Pattern, Cyanosis, Clubbing
2)Palpate: Tenderness, Excursion, Fremitus (Say “99” at itch level)
3)Percuss: Front and Back of Chest.
4)Auscultate: Front, Back and Lateral Chest (Cross arms, Sit Straight, Breath mouth
5)Auscultate Heart

CARDIOVASCULAR
1)Sitting: BP (2 arms if BP ↑), Pulse, Ankle Edema, Auscultate Carotid (Hold Deep Breath), Palpate PMI.
2)Lie Back: Inspect JVD (Look Left), Palpate (PMI, Thrills, Chest, Stomach area), Auscultate 4 cardiac areas. Turn left for mitral area.
3)Sitting: Auscultate (lean forward and hear base, Palpate tender, Auscultate lungs.

ABDOMINAL
1)Inspect Skin
2)Auscultate (warm stethoscope)
3)Percussion (4 quadrants, start away from pain)
4)Palpate (start away from pain, Light/Deep palpation)
5)SPECIALS: Rebound Tenderness, Murphy, Obturator (Bend leg if hurts), Psoas (turn to left, lift leg and pull it back), Rovsing (Palpate one area-fell pain in other), CVA tenderness (tap on back)

MUSCULOSKELETAL
1)Inspect area - compare to other side
2)Inspect other joints (distal and proximal).
3)Palpate (Start with NON PINFULL ONE), Check Pulses.
4)Check Motion – Crepitus (Start in NON PAINFULL)
5)Sensation, Strength, Reflexes around affected area.
6)SPECIALS:
a.Wrist (Tinel, Phalen, Adson)
b.Knee (Drawer, McMurray: push down knee and move foot)
c.Lumbosacral (Gait, Straight leg rise, Palpate back, Babinsky, Bend to toes, Lean back, side to side)
d.Shoulder (Palpate neck, shoulder blade)


PATIENT NOTE

Use specific terminology in data, differential, Diagnostic Work up.
Write: 1-Differential (from more to less likely), 2-Work up, 3-Physical, 4-History.
Work up: write all related tests in one line
Rectal, pelvis, breast, genital exams are first line in Dx Work Up.

A)CC: Chief Complaint ( Age, Sex and reason of visit).
B)HPI: LIQOR AAA
C)PMH: PAM HUGS DWS FOSS
D)Physical exam:
a.VS: WNL
b.Comment about appereance

HEENT MN
Head: normocepahilc, atraumatic.
Eyes: EOM intact, PERRLA, (-) fundoscopy abnormalities or Papilledema.
Ears: Canal Without Abnormalities, Tympanic membrane clear.
Nose: Turbinates not congested, No pain in Sinus palpation.
Throat: No tonsilar enlargement, erythema or exudates.
Mouth: Dentition good, (-) lesion, (-) vesicles, (-) oral thrush
Neck: Supple, (-) Thyroid enlargement, (-) cervical Lymph nodes.

NEUROLOGIC
Mental status: Alert, oriented x 3, good concentration.
Cranial nerves: II-XII grossly intact.
Motor: Strength 5/5 in all muscle groups.
DTR: 2+ intact and symmetric, Babinski (-).
Sensation: Intact to Sharp and Dull.
Cerebellum: (-) Romberg sing, intact finger to nose.
Specials: (-) Kerning, (-) Brudzinski.

RESPIRATORY
Inspection: Breathing unleabored, no Cyanosis, no Clubbing.
Rate: # Resp./min.
Percussion: Clear to percussion bilaterally
Auscultation: No Rales, Rhonchi, Wheezing or Rubs.
Palpation: No tenderness to palpation
Fremitus: Tactile Fremitus WNL.



CARDIOVASCULAR
Pressure: # mmHg
Rate: # beats/min.
Pulse: 2+ bilateral
Inspection: No JVD, No Pedal Edema.
Palpation: PMI not displaced, no palpable Heaves.
Auscultation: Normal S1/S2, RRR, No murmurs, Rubs or Gallop.

ABDOMINAL
Inspection: Surgical scars, skin abnormalities.
Auscultation: (+) BS.
Percussion: Tympanic to percussion in 4 quadrants, Liver span normal (8-12 cm)
Palpation: Soft, non tender, non distended, No Palpable Masses.
Specials: (-) Rebound, Murphy, Psoas, Obturator, Rovsing, CVA tenderness.

LUMBOSACRAL
Inspection: No obvious deformities or sings of trauma.
Palpation: No spinous process or paraspinous tenderness.
Motion: Range of motion normal anteriorly.
Reflex: 2+ Patellar, Achilles, (-) Babinsky.
Sensation: Intact to Sharp and Dull.
Gait: Normal Gait.

PSYCHIATRIC MENTAL STATUS
Patient appears well groomed.
Alert
Oriented to person, place and time.
Concentration and attention good as tested by sereal sevens.
Speech is fluid and goal directed.
Recent and Remote memory intact
Mood is euthymic
Affect is consistent with mood.
Patient doesn’t have abnormal perception such as hallucinations, delusions or paranoias.
Patient denies having suicidal/homicidal ideation or intent
Judgment/insight are intact.

CLOSING
Summarize
Give 4-5 points from history and physical that lead to Dx.
Give Dx impression, express in lay terms.
Order some tests (I’ll look over it and as soon as ready whe meet again)
Ask if patient has any questions and make some Health Suggestions.
Thanks patient for coming , Shake hand, “Take Care”.

IMPORTANT POINTS


1)Wait 3 full seconds before expressing empathy. (This must been difficult for you, are you willing to share with me?
2)Never stand behind the patient
3)Look the patient comfortably to the eyes.
4)Two feet is right for personal proximity.
5)Turn your watch to inside wrist so you can see it.
6)Observe patient face for sing of discomfort and comment on this changes.
7)Never denies the patient beliefs..
8)Ask one question at a time.
9)Don’t interrupt
10)Explain everything you do on physical.
11)Introduce when changing lines of questioning.
12)Paraphrase information (repeat words to the patient)
13)Take notes in Abbreviated form for quickly writing.
14)Use phrases like “ok” and “all right”
15)Extend leg rest, pull out foot step, hold arm or back when lying down or sitting up.
16)Unfold the drape by half and cover the patient from the wait down.