PBL

1/27/14

This is the form you use for a HPI:

CC: Chief Compliant
HPI: History of Presenting Illness

ROS: Review of Systems

All: Allergies (what was your reaction?)
MED: Medication (how many mg per day? How many times per day?)
PMH: Past medical History
FH: Family History (Diabetes, HTN, Cancer)
SH: Social History (Employed, Education, Married/single, children, smoke, illcit drugs, drinks- think CAGE,
Sexually Active)
PE: Physical Exam
Heart
Lungs
ABD
ExT
Neuro

Labs:

Hbb (Hemoglobin)
- glucose
WBC Platelets Na Cl
Hct (Hematocrit) K CO2 BUN Creatine

1/31/14

Complete Chest Exam:

- inspection
- palpitation
- Respiratory
- Tactile fremitus
- Percussion Auscultation

SIQORAAA:
S- Site (Location)
I- Intensity (1-10, 1 being the least, 10 being the worst pain)
Q- Quality (Sharp, throbbing, burning, tingling)
O- Onset (When did it start)
R- Radiates ( Travel around, stay the same)
A- Aggravating ( What makes the pain worse)
A- Alleviating ( What relieves the pain)
A- Associating Symptoms ( Associated with anything else)

Ask personal questions:

- Drink?
- If yes, ask CAGE questions
- Smoke
- Drugs

If yes to drugs/alcohol:
- How often?
- When was your last drink/smoke?

CAGE:
C- Tried to cut down
A- Do you ever get annoyed?
G- Do you ever feel guilty?
E- Do you need an eye opener?

-Summarize the Situation

WASH HANDS AND APPLY GLOVES

2/5/14

Differential Diagnosis for Confusion/ Memory Loss:

-Alzheimers
- Dementia
- B12 Deficiency
- Hypothyroid
- Delirium
- Chronic Alcohol
- CJD
- Normal Pressure Hydrocephalus
- Depression

Instrumental Activities of Daily Living:

S- Shopping
H- House Keeping
A- Accounting (Finance/Bills)
F- Food Preparation
T- Transportation

ADLs- Activities of Daily Living:

D- Dressing
E- eating
A- Ambulating
T- Toileting
H- Hygiene

2/7/14

Differential Diagnosis for Headache:

- Migraine
- Cluster
- Temporal Arteritis
- Encephalitis
- Tension
- Sinusitis
- Meningitis
- Subdural Hematoma
- Psuedotumor Cerebri

Differential Diagnosis for Depressed Mood:

- Depression
- Bipolar I/II
- Schizoaffective Disorder
- Normal Beareavment
- Dysthymic Disorder
- Substance induced mood disorder

Psychosis:
- Schizophrenia/Schizophreniform/ Schizoaffective Disorde
- Psychotic Disorder
- Brief Psychotic Disorder
- Substance induced psychosis
- Psychotic disorder (Gen. Medical condition)

2/10/14

When interviewing patients write these Mneumonics:

PAM HITS FOSS
P- past medical history/previous episodes
A- Allergies (what were the reactions)
M- Medication- prescriptions, oral, vitamins, herbals
- if patient is taking a prescription, ask them:
- What do you take it for?
- Do you take it regularly?
- If not, how often?
- Do you supplement it with a diet?

H- Hospitalization
I- Major Illness/ Immunizations
T- Significant Trauma
S- Surgeries

F- Family history (family members with the same problem? Diabetes, cancer, HTN in family)
O- Ob/GYN
S- Social history
S- Sexual History

Depressed Mood Differential:

- Major Depression
- Bipolar I/II
- Schizoaffective disorder
- Normal Bereavement (<6 mos.)
- Dysthymic Disorder

EX:
72 year old male presents with memory loss, gait, disturbance and urinary incontinence for the past 6
months.
- Normal Pressure Hydrocephalus
- Alzheimers
- Vascular dementia
- Chronic subdural hematoma

70 year old insulin dependent diabetic male presents with episodes of confusion, dizziness, palpitation,
diaphoresis, and weakness.
- hypoglycemia
- TIA- Transient Ischemic Attack
- Delirium
- Angina

55 year old female presents with altered mental status and headache. Two weeks ago she slipped and
hit her head on the ground and last consciousness for 2 minutes.
 - subdural hematoma
- SIADH
- CJD- Creutz- Jabob Disease
- Intracranial Neoplasia

2/12/14

Past Medical History:

R-UGS:

R- Review of Symptoms Transitional Phrases:

U-Urinary - How often do you urinate? Burn when urinating? Go to bathroom at night?
G- Gastro Intestinal - Regular Bowel Movements? Weight Issues? Diet?
S- Sleep - hours of sleep? Change sleep pattern?
- Increase sleep: depression, hypothyroidism, substance abuse
- decrease sleep: bipolar disorder

Obstetrical History: Example:

G- Gravida (how many times have you been pregnant) 5

P- Para (how many alive children) 3
A- Abortions/ Miscarriages 2
G5/P3/Ab2

Other questions to ask:

When was your last menstral cycle?

Is there any change in your cycle?
On a heavy day how many pads/tampons do you use?
Any mood swings or irritability during your period?
Regularity?
Cramps/ Pain?
Flow?
Cycle of Length?
Age of menarche/Menopause?
Spotting?
Vaginal Discharge?
Last pap smear?

Are you sexually active?

How many partners?
Men/Women/ Both?
Have you ever been tested for HIV?
Do you use contraceptives? Which ones?
Have you ever had/been treated for an STD?
Do you have any questions about regular sexual function?

Right way to ask:

Tobacco- Have you ever used tobacco?

Wrong way to ask:

Do you smoke?

Pack Years: (# of packs per day) x ( # of years)

Recreational Drugs:

Do you use recreational drugs?

What do you use?
How do you take it?
When did you last use?
Also ask them if they are willing to quit?
Find out what method they use to quit in the past?

ALCOHOL

Question to ask:
Do you drink alcohol?
How much do you usually drink?
When did you last drink?
If the persons drinking is a problem then you go with CAGE questions. If they have more than one drink
per day then ask the CAGE questions. (One for the women, two for men)

*Use CAGE questions to find out if they are a binge drinker

C-Cut down
A-Annoyed
G-Guilt
E-Eye Opener

Alternate Names:
Alcohol: Brewski, Juice, Goodstuff, Johnny, Booze
Marijuana: Ganga, spliff, goodstuff, mary jane, weed, kush, grass, bud, reefer
Cocaine: crack, powder, nose candy, toot, blow
Heroine: horse, brown sugar, smack
PCP: Angel Dust, sherm sticks
Rhoids: steroids, aggressive
Cocaine Abuse:
Angina
Dilated Cardiomyopathy
MI
Death

Pediatric Subparts:
Prenatal: Health during pregnancy, regular checkups, smoke/drink during pregnancy, HTN/Diabetes
Birth: full term, C-Section, labor problems, babys weight
Neonatal: 2 days, how long did you and the baby stay in the hospital after delivery, problems with
breathing, any problems with bile movement, medical problems or yellow
Feeding: breast fed, bottle fed, Problems breast feeding, how many ounces does the baby drink, how
often and the schedule. When did the child start eating solid food how is the childs appetite, they taking
any pediatric vitamins and does the child have any food allergy.
Development: child gain weight normally, loose of physical growth, Age of milestone- at what age did
the baby start to say a few words, smile, roll over, walk, talk, crawl, toilet train
Routine Care: immunizations for child up to date, child getting routine checkups, if the mother has
immunization papers in her purse, ask to see it.

2/14/14

Follow up Visit:
S: subjective- why theyre visiting the clinic, compliant, etc.
O: objective- P.E findings, vital signs, studies, labs
A: diff. diagnosis, diagnosis
P: (1.) treatment (2.) plan of action (3.) advice to return to clinic

How have you been since the last visit?

No change/ side effects of new medication?
No effects to the medication that were stopped?

2/17/14

PEDIATRIC EXAM

1) Prenatal
2) Birth
3) Neonatal
4) Feeding
5) Development
6) Routine care (1) Checkups , 2) Immunization)

Sample questions to ask

1) How was your health during pregnancy?

2) Do you get regular prenatal check ups
 3) Do you smoke or drink during pregnancy
4) Was there any problems with swelling or HBP?

Calculating smoke years

Number of packs per day x number of years

ROS for GI: There are two questions you need to asked:

1) Any recent weight changes?

2) Are you on any special diet?

DIZZINESS

1) MENIERE DISEASE
2) VESTIBULAR NEURONITIS
3) BENIGN POSITIONAL VERTIGO
4) LABYRINTHITIS
5) ACOUSTIC NEUROMA
6) ORTHOSTATIC HYPOTENSION DUE TO DEHYDRATION
7) VERTEBROBASILAR INSUFFICIENCY
8) DRUG INDUCE HYPOTENSION
9) VERTIGO ASSOCIATED WITH CERVICAL SPINE DISEASE OR INJURY

LOSS OF CONCIOUSNESS

1) Complex chronic tonic seizure

2) Compulsive syncope
3) Substance abuse/ overdose
4) Malingering
5) Hypoglycemia
6) Cardiac arrhythmia
7) Syncope
8) Stroke
9) MI
10) Pulmonary Embolism

NUMBNESS/WEAKNESS DIFFERENTIAL
 1) Guillain Barrie Syndrome
2) TIA (Transient ischemic attack)
3) Hypoglycemia
4) Seizure
5) Facial nerve palsy
6) Multiple Sclerosis
7) Mystania gravis
8) Diabetic peripheral neuropatic
9) Alcoholic Peripheral neuropathy
10) B12 deficiency
11) Horners syndrome
12) Todd paralysis- a paralysis that dissolves within a few hours

Annual physical or periodic physical

1) How much do you exercise?
2) Do you work?

HOME LIFE:
1) Who do you live with?
2) Is there any stress at home?

SUICIDAL DEPRESSION:
Does your child seem sad or hopeless?
Does your child seem to unharmed

Physical maneuvers you are not allowed to do at the Step II CS

1) You do not do a female breast exam

2) No internal pelvic exam
3) No rectal exam
4) No genitals or rectogenital exam or inguinal exam
5) No corneal reflex exam

ABDOMINAL EXAM

You will do an abdominal exam when the chief complain includes abdominal pain, vomiting, diarrhea,
jaundice, urinary tract problems and pelvic pain.

ASPECTS OF ABDOMINAL EXAM

 1) You will do an inspection first. You see a make up
2) After inspection it is auscultation. Listen for 3 secs of each of the four quadrants
3) Percussion is next. Three taps in on the 4 quadrants. Tap out the liver side when you see a
jaundice case, CHF case and liver problem
4) Palpation is nxt. Palpate all 4 quadrants on the epigastric area for three secs each

Special tests
Murphys sign for coloncistitis
CVA for kidney and appendicitis

Auscultation you have to warn the pt. first that you are warming it before using it.

CHEST EXAM
Do a complete chest exam when the CC includes cough, SOB, chest pain, respiratory tract infection and
sputum production

ASPECTS OF CHEST EXAM

Inspection: Check the pt. hands for clumping and sinuses.
Respiratory Excursion: Stand behind the pt Flip the gown open, make sure to tell the pt. you are going
to touch them
Palpation: Check the chest wall for tenderness
Tactile Fremitus: Please speak out 99.
Percussion: I am going to touch your chest
Auscultation: I am going to check your lungs. Please breathe in and out. You will hear the eeee

PERSONALITY DISORDER
Obsessive Compulsive Disorder (OCD)
Histrionic (those are the drama queens and kings. Mostly women)
Narcissistic (they have a very self-inflated ego)
Borderline (It is usually females)
Paranoid
Antisocial