Step 2 cs patient note overview
Once you complete any encounter, you would be given at least 10 mins to compose a patient note.
I will start by saying for practice purposes try as much to be completing your PN within 8-9 mins (may be quite challenging initially but you'll improve with practice).
You need to strategize how to 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 would use: Narrative or Bullet style.
Chief complaint: CC, onset, frequency, it's progression, main presenting symptoms (a lot of mnemonics everywhere choose what works for you: LIQORAAA for; location, intensity, quality, 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
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
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, 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., special tests..
Extremities: pulses(radial or Dorsalis pedis....) +2 b/l, no cyanosis, clubbing or edema .
NEURO: Mental status (Alert & Oriented x3...), CNs , DTRs, Sensation tests (sharp and dull b/l), special tests..
DIFFERENTIAL DIAGNOSIS DDX: closest possible 2 or 3 DDX with pertinent history or physical findings
WORK UP PLANS
Physical exam for all Peds cases
Pelvic or genital exam for all OBGYN cases
Mental Status exam for all Depression, LOC, Forgetfulness and certain Fatigue cases
Pregnancy Test (bHCG) for all premenopausal OBGYN cases
Rectal exam for all GI cases + FOBT for GI bleeding or suspected GI bleeding
Start with simple, inexpensive, affordable tests first for all cases (such as CBC, ESR, TSH, electrolytes, ultrasound, Xrays etc).
Be careful with invasive and very expensive tests such as MRI and Biopsy, only when necessary
Keep in touch with us for any Step 2 CS questions, we have 4 well experienced MDs to offer you help or evaluate your patient notes: http://iusmlecourse.com/patient-note, email us: firstname.lastname@example.org or call us + 1 407 247 7153 to secure your seat in our Live workshop Aug 8-12th
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