PATIENT NOTE

PATIENT NOTE
Examinee's Name
Patient's Name
Miss: Use “Miss” when addressing young girls and women under 30 that are unmarried. Ms.: Use “Ms.” when you are not sure of a woman’s marital status, if the woman is unmarried and over 30 or if she prefers being addressed with a marital-status neutral title. Mrs.: Use “Mrs.” when addressing a married woman.
Case number
DIAGNOSES

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DIAGNOSTIC REASONING: Based on what you have learned from the history and the physical examination. Enter the positive or negative findings from the history and the physical examination (if present) that support your diagnosis. At the end of each encounter, you will be expected to tell the patient about your findings, offer your medical opinion (including a concise differential di- agnosis), describe the next step in diagnosis, and outline possible treatments. In doing so, you should always be clear and honest.
HPI

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(The source of information is the patient's XXXX) XXXXX yo F c/o intermittent, burning/cramping/stabbing, non-radiating/radiating pain that started for the first time XXXX weeks ago. The pain occurs at least once/twice/three times a day, usually 2/3/4 hours after meals/medication/strenuous work. It is exacerbated by XXXXXXXX and XXXXX and is alleviated by XXXXXXX, and XXXXX. It reaches XXXX/10 in severity and then diminishes to XXXXX/10. It is sometimes accompanied by XXXXXX. The patient vomited once/twice/three times yesterday, an acidic, yellowish/greenish, non-bloody/bloody fluid. No diarrhea or constipation? No changes in weight or appetite? No changes in the color of the stool?
ROS

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The review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease. Negative except as above? Negative except for fatigue? Residual weakness in left arm after a stroke?
OB/GYN

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LMP? Regular periods? Menarche? Uncomplicated NSVD? At full term? Early term: Your baby is born between 37 weeks, 0 days and 38 weeks, 6 days. Full term: Your baby is born between 39 weeks, 0 days and 40 weeks, 6 days. Late term: Your baby is born between 41 weeks, 0 days and 41 weeks, 6 days. Post term: Your baby is born after 42 weeks, 0 days.
Allergies

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NKDA? Yes? Which drug? Which reaction?
Medications

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The patient who doesn’t know the names of his medications or is taking medications whose names you don’t recognize: Ask the patient if he has a prescription or a written list of the medications he is currently taking. Renal artery stenosis: A patient with hypertension who is not respond- ing to multiple antihypertensive medications. Do not be surprised if you hear an abdominal bruit.
PMH

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PSH

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Many examinees run out of space while writing this section. One way to save both time and space is to make ample use of abbreviations. Train yourself to use the abbreviations that are listed in the USMLE Step 2 CS exam orientation materials. (Please see inside back cover.) You will find a copy of this list on each desk. You are allowed to use any abbreviations that are commonly used in U.S. hospitals. If you are un- sure of the correct abbreviation, it is better to spell out the word or phrase.
SH

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Tobacco? Illicit Drugs? Alcohol Sexual life? CAGE questions? Hypoactive sexual desire disorder (HSDD)? Inconsistent condom use?
FH

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Contributory or non contributory?
Birth History

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40-week vaginal delivery with no complications?
Dietary History

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Breast-feeding and supplemental vitamins?
Immunization history

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UTD?
Developmental history

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Last checkup? Weight, height, hearting, vision norma? Milestones?
Physical Examination

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Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of examination you performed in this encounter. Is the patient in acute or no acute distress? When you enter the examination room, for example, the patient may hand you an insurance form requesting that only certain systems be examined. In such cases, the patient will usually tell you that you do not need to take a history. Should this occur, simply introduce yourself, proceed to examine the systems listed, and then leave the room. No PN is required under such circumstances; instead, you are required only to fill out the form the patient gave you with the appropriate findings. In such encounters, the emphasis will be on the correct performance of the physical exam maneuvers and on professional and appropriate interaction with the patient. REMEMBER: You may see real C-section, appendectomy, cholecystectomy, or other scars. Don’t overlook them. Always inquire about any scar you see. 􏰄 You may see a real nevus (mole). Ask the patient about it and advise him to check it routinely and report any change in it. You may see real skin lesions, such as pityriasis rosea in a Christmas tree pattern, seborrheic dermatitis of the scalp, or acne vulgaris. When you listen to a patient’s heart, don’t be surprised to hear a real heart murmur. A patient with a sore throat may present with real enlarged tonsils.
VS

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WNL? BP: XXX/XXX mmHg Temp: XXXXX °F RR: XXX /minute HR: XXX / minute, regular? BMI?
HEENT

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NC/AT? Nontender to palpation? PERRLA? EOMI? No papilledema? No nasal congestion, no pharyngeal erythema or exudates, dentition good?
Neck

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Bruises? Supple? Full ROM? Normal thyroid? No cervical LAD? No JVD? No bruits? Meningeal signs: Neck stiffness? Kernig, Brudzinski? Lymphadenopathy?
Chest

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Clear breath sounds bilaterally? No rhonchi, rales, or wheezing? Tactile fremitus normal? PMI, retrosternal heave, and thrills? 􏰄 Shortness of breath. 􏰄 Wheezing: This may often sound strange, as if the patient were whis- tling from his mouth. 􏰄 Decreased respiratory sounds: The patient will move his chest without really inhaling any air so that you do not hear any respiratory sounds. 􏰄 Increased fremitus: The patient will say “99” in a coarse voice, creating more fremitus than usual.
Heart

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RRR; normal S1/S2; no murmurs, rubs, or gallops? 􏰅PMI not displaced? Listening to the heart in a female patient: You can place the stethoscope anywhere around the patient’s bra and between the breasts. To auscultate or palpate the PMI, if necessary, ask the patient, “Can you please lift up your breast?” Heart murmur: Once you place the stethoscope on the patient’s heart, you will hear him saying “Hush, hush.”
Abdomen

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Soft, nontender, nondistended, BS 􏰂, no hepatosplenomegaly? Murphy's? Obturator? CVA tenderness? Rovsing's? Guarding? Psoas sign? Ascites?􏰄 Abdominal tenderness: The patient feels pain when you press on his abdomen. Remember that the patient is an actor. When you palpate the area, he will feel pain where he is supposed to feel pain regardless of the amount of pressure you exert. So don’t try to palpate the same area again; instead, move on, and consider the pain on palpation a pos- itive sign. 􏰄 Abdominal rigidity: The patient will contract his abdominal muscles when you try to palpate the abdomen. Rebound tenderness of the abdomen.
Extremities

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Clubbing? Cyanosis? Edema? Nonlocalized tenderness? Location? Pain restricted range of motion on flexion, extension, abduction, and external rotation? Pulses normal and symmetric in brachial and radial arteries? Unable to assess muscle strength due to pain? DTRs intact and symmetric? Sensation intact to pinprick and soft touch?
Skin

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No rash or lymphadenopathy?
DIAGNOSTIC WORKUP

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Lastly, list initial diagnostic studies (if any) you would order for this patient (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, Rectal exam, US, CBC, AST/ALT/Bilirubin/Alkaline phosphatase/lipase, ....)