Вы находитесь на странице: 1из 2

I did the EXACT same thing with EVERY single patient and went through First Aid CS once

for 1
week- sorry it is long
Hello Mr./Mrs ***, how would you like me to refer to you? (If gender diff say "I am sorry. Excuse my
ignorance, I'll make sure your chart is updated accordingly."
my name is Student Dr. Uzoagu Okonkwo I am a senior medical student working with your care team
today.

What brings you in today? Then do the whole:


Duration,
Onset,
Course (constant, relasp/remit, with certain things),
characterization,
location,
radiation,
aggravating features,
relieving features,
associated symptoms, previous hx of sxs,
prev phys seen
target their CC with q's related to that complaint (abd pain - assoc w/ meals, movement, prev abd
surg, consti/diarrhea etc) Just try and tease it out some more and clarify it.

ROS: ask this exact list every time and VERY QUICKLY (yes/no) - nausea, vomiting, fever, chills, SOB,
CP, changes in hearing/vision, changes in bowel/bladder function (change in frequency,
pain/burning, blood mixed in), rash/skin changes, trauma, falls, LOC, swelling, vag discharge (not in
males), NEW numbness/tingling/weakness, confusion, recent illness, changes in medications pain
anywhere else.

PMH
Meds
Fam hx
Surg hx
social Hx
Allergies

PE: EVERYONE gets heart 4 spots/PMI, lung ausc (6 spots: left, right down; left, right down; left, right),
abdomen (look, listen, light palpate, deep palpate) --> add more based on sxs: be prepared for
simple shoulder PE (empty can, spurinling, ROM, motor, sensa, etc),
NEURO EXAM SHOULD BE ABLE TO BE COMPLETED IN 1-2 MIN!!!! Get FAST at CN 2-12 PRACTICE
PRACTICE PRACTICE, then "squeeze my fingers, pull me to you, push me away from you" rub arms
"feels same on both sides"? if not explore nerve distribution. "push your feet down like stepping on
gas, toes up, kick leg out, pull in, raise leg up, rub legs and ask for sensation". "touch your nose with
pointer finger, touch my finger, now go back and forth, now other hand." rub heel against shin and
go up and down like this (show them), walk them a few step. QUICK REFLEXES - you don’t have to do
it right just do it (quickly) and they WILL GIVE YOU A POSITIVE OR NEG EXAM. neuro done.
WRAP UP- ok mr/mrs *** i understand youre here for CC and you have had blah blah for 7 days,
intermittent but now constant, no prev history, worse with movement better with rest and not
relieved with meds. No prev med hx or surg.

ARE THERE ANY OTHER SYMPTOMS OR QUESTIONS YOU HAVE THAT YOU WANTED TO DISCUSS
BEFORE I LEAVE THE ROOM???
Ok well I plan on talking with the team and ordering: STUFF and then explain the stuff like they are 5
YEARS OLD (ekg - a test that looks at how your heart is doing, if it is beating funny or normal). DO
YOU UNDERSTAND WHAT WE PLAN ON DOING FOR YOU? ARE YOU COMFORTABLE WITH THAT
PLAN? IF YOU HAVE ANY OTHER QUESTIONS OR CHANGES AFTER I LEAVE YOU ONLY NEED TO ASK
FOR YOUR NURSE OR US AND WE WILL BE BACK TO HELP YOU? IT WAS A PLEASURE TO MEET YOU,
IM SORRY IT WAS NOT UNDER BETTER CIRCUMSTANCES BUT I CAN ASSURE YOU WE ARE DOING
OUR VERY BEST TO MAKE YOU BETTER. WE WILL BE BACK SOON TO DISCUSS THE PLAN FURTHER.
I always tried to "lay it on thick" be overly nice, overly understanding, overly patient. And keep
refocusing on the patient's comfort level and understanding of what is happening.

For the note just practice writing concise H&P: CONDENSE - if you can say in 5 words what the
patient said in 20 CONDENSE IT!!!! "pt with PMH DM (non-insulin dep), HTN, HLD, CAD s/p stents
2008 presents w/ CP. CP began this afternoon while mowing lawn, hx of cp with exertion, relieved
with rest but now CP constant despite 2 rounds nitro and rest. Pain is midsternal, dull/pressure like,
7/10 in severity, rad to left arm and neck, worse with exertion, better with rest, with assoc N, V, tactile
F, sweats, generalized weakness. Pt not followed by cards.
ROS (always ask same stuff): Pt states: +ROS
Pt denies: -ROS

VS: use listed


PE: Gen
HEENT
Heart
Lung
Abd
Ext
skin
Neuro

DDx: BE BROAD
CP - cardiac ischemia, PE, tension pneumo, pneumoniae, tamponade, cholecystitis, pancreatitis,
anxiety,
Work-up: CBC, CMP, CXR, trop, EKG, whatever the hell else

I got CS results back today I did WAY ABOVE the "borderline performance" area for all 3 criteria.