Step2 CS PATIENT NOTE OVERVIEW

5/12/2016 12:44:33 PM
Once you complete any encounter, you’ll be given at least 10 mins to compose a PN.
I will start by saying for practice purposes try as much to be completing your PN in 8-9 mins( may be challenging initially but keep practicing).
You need to strategize how to flow, navigate and complete this task. After you exit the patient’s (SP’s) room, try to take a few seconds to review the information you gathered, prepare your mind.
Be confident that you can compose the best note; trust yourself (very important).
Decide on the PN style you will use: ‘’narrative ‘’or ‘’Bullet’’ style.

Chief complaint: CC, onset, freq, it’s progression, main presenting symptoms (a lot of mnemonics everywhere choose what works for you: ‘LIQORAAA’ for location, intensity, onset, radiation, aggravating factors, alleviating/relieving factors, associated symptoms).
Now that you’ve explored this case, then R/O differential diagnosis ( Neg. for : blah blah blah, or No: blah, blah , blah, or Denies blah, blah , blah)
Document other key points:

PAMHUGSFOSS:
Previous episode, PMH/PSH, Allergy, Meds, Hospitalization, Urinary habits, GI habits, Sleep, FH, OBGYN, Sex, SOCIAL: Smoking, ETOH, Illicit drugs, occupation, diet , exercise, relationship status(married, single) , living condition etc..


​PHYSICAL EXAM: key physical findings, includes pertinent positives and negatives
Pt. is in or no acute distress
VS: WNL
HEENT: NC/AT, EOMI, PERRLA, no cyanosis, no icterus, no pallor
NECK: supple, Thyroid wnl, no LAD, no nuchal rigidity
MOUTH AND PHARYNX: clear, moist, no erythema, no exudates, no lesions
CHEST/RESP: CTAB, no rales, rhonchi, wheezing, or rubs, no tenderness on palpation
CVS: RRR, S1/S2 WNL, no murmurs, rubs, or gallops, no JVD , PMI not displaced
ABD: soft, NT, ND, BS+ in all 4Q, no HSM. Neg. for: rebound tenderness, psoas etc..
MSK: motor strength 5/5 in all 4 ext. full ROM at joints.., sensation intact to sharp and dull bilaterally, special tests..
Extremities: pulses(radial or Dorsalis pedis....) +2 b/l, no cyanosis, clubbing or edema .
NEURO: Mental status(Alert &Oriented x3...), CN’s , DTRs, special tests..

DIFFERENTAIL DIAGNOSIS DDX: closest possible 2 or 3 DDX with pertinent history or physical findings

WORK UP PLANS;
Physical exam for all Peds cases
Pelvic, genital exam for all OBGYN cases
Start with simple inexpensive, affordable tests first for all cases ( such as ultrasounds, CXR, TSH, electrolytes).

Integrity usmle: Score high in ICE: Good luck guys
edited by on 5/12/2016
edited by on 5/12/2016


5/13/2016 12:41:00 PM
Thanks for sharing
Sara
tqno665899 wrote:
Once you complete any encounter, you’ll be given at least 10 mins to compose a PN.
I will start by saying for practice purposes try as much to be completing your PN in 8-9 mins( may be challenging initially but keep practicing).
You need to strategize how to flow, navigate and complete this task. After you exit the patient’s (SP’s) room, try to take a few seconds to review the information you gathered, prepare your mind.
Be confident that you can compose the best note; trust yourself (very important).
Decide on the PN style you will use: ‘’narrative ‘’or ‘’Bullet’’ style.

Chief complaint: CC, onset, freq, it’s progression, main presenting symptoms (a lot of mnemonics everywhere choose what works for you: ‘LIQORAAA’ for location, intensity, onset, radiation, aggravating factors, alleviating/relieving factors, associated symptoms).
Now that you’ve explored this case, then R/O differential diagnosis ( Neg. for : blah blah blah, or No: blah, blah , blah, or Denies blah, blah , blah)
Document other key points:

PAMHUGSFOSS:
Previous episode, PMH/PSH, Allergy, Meds, Hospitalization, Urinary habits, GI habits, Sleep, FH, OBGYN, Sex, SOCIAL: Smoking, ETOH, Illicit drugs, occupation, diet , exercise, relationship status(married, single) , living condition etc..


​PHYSICAL EXAM: key physical findings, includes pertinent positives and negatives
Pt. is in or no acute distress
VS: WNL
HEENT: NC/AT, EOMI, PERRLA, no cyanosis, no icterus, no pallor
NECK: supple, Thyroid wnl, no LAD, no nuchal rigidity
MOUTH AND PHARYNX: clear, moist, no erythema, no exudates, no lesions
CHEST/RESP: CTAB, no rales, rhonchi, wheezing, or rubs, no tenderness on palpation
CVS: RRR, S1/S2 WNL, no murmurs, rubs, or gallops, no JVD , PMI not displaced
ABD: soft, NT, ND, BS+ in all 4Q, no HSM. Neg. for: rebound tenderness, psoas etc..
MSK: motor strength 5/5 in all 4 ext. full ROM at joints.., sensation intact to sharp and dull bilaterally, special tests..
Extremities: pulses(radial or Dorsalis pedis....) +2 b/l, no cyanosis, clubbing or edema .
NEURO: Mental status(Alert &Oriented x3...), CN’s , DTRs, special tests..

DIFFERENTAIL DIAGNOSIS DDX: closest possible 2 or 3 DDX with pertinent history or physical findings

WORK UP PLANS;
Physical exam for all Peds cases
Pelvic, genital exam for all OBGYN cases
Start with simple inexpensive, affordable tests first for all cases ( such as ultrasounds, CXR, TSH, electrolytes).

Integrity usmle: Score high in ICE: Good luck guys
edited by on 5/12/2016
edited by on 5/12/2016


5/13/2016 9:40:31 PM
Nice stuff. Hey guys this is the deal. I just started using the online note grader and can't say enough how super cool.. the feedback is like the most detailed PN ever. Really recommended for anyone aiming for high performance in ICE. check: iusmlecourse.com


5/14/2016 12:10:59 AM
Thank you


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