Piepaiation Notes foi

USMLE Step 2 CS
T0 BE EBITEB!
By XAK & MTA
1) knock! knock! (knock and enter.don't walt lor the S to say come ln!)
2) Cood Mornlng Mr. x?Z, l am ur. A8C, lt's nlce to meet you! (now shake hand!)
3) l am your physlclan here today. l am golng to ask you a lew questlons about your health and perlorm a brlel
physlcal examlnatlon, ls that Ck wlth you?
4) 8elore that, let me drape you llrst so that you leel more comlortable. (now put the drape on the patlent!)
3) (Whlle draplng, say.) l hope you won't mlnd ll l make my notes whlle talklng to you.
6) (So let's get started ,) Pow can l help you today?
7) atlent wlll start telllng you about the C/C, SA: Can you p|ease te|| me more about your
cond|t|on]comp|a|nt?
8) C = Cnset: When dld lt start?/Pow dld lt start? (Sudden or Cradual)
9) I = Irequency: ls lt contlnuous or does lt comes and goes?
a) ll Cont|nuous: Pas lt been the same or progresslvely worsenlng wlth tlme? (Covers #10 = rogresslon)
b) ll Comes & Goes]Interm|ttent: Pow many eplsodes do you have ln a day? Pow long does each eplsode
last? When was the last eplsode?
10) D = Durat|on: lor how long you're havlng thls problem?
11) = rogress|on: Pas lt been the same or progresslvely worsenlng wlth tlme?
12) L = Locat|on: Can you show me where exactly are you havlng thls paln?
13) I = Intens|ty: Cn a scale ol 1-10 where 1 belng the mlnlmum and 10 belng the maxlmum lntenslty ol paln,
how wlll you grade your paln?
14) = ua||ty: Can you please descrlbe your paln? ls lt sharp.burnlng.cuttlng.throbblng.?
13) k = kad|at|on: uoes your paln go to any other part ol your body?
16) A = Aggravat|ng Iactors: ls there anythlng that makes your paln worse?
17) A = A||ev|at|ng Iactors: ls there anythlng that relleves your paln?
18) A = Assoc|ated Sk: ls there anythlng assoclated wlth your paln? Ask separately about: (Make your own
mnemonlc lor them!) l1 WlLL ALSC CCvL8 ?Cu8 kCS
|) Iever:
||) neadache:
|||) Stress:
|v) S|eep:
v) 1rave|:
v|) 1rauma:
v||) 1|ck b|te:
v|||) W|ght |oss:
|x) Appet|te:
x) 1emperature Into|erance: Ask.uo u leel abnormally cold when others don't or do you leel
abnormally hot when others don't? (5omet|mes tb|s m|qbt be tbe ooly pos|t|ve f|oJ|oq |o o pot|eot
w|tb tbyto|J J|seose.)
ln case ol 8ACk AIN don't lorget to
ask:
Pave you ever passed urlne
wlthout your knowledge?
Pave you ever passed stool
wlthout your knowledge?
ou moy osk obout
|mpoteoce os well
19) lor a [olnt paln case, ask CI1kUS
|) C = Chest a|n]Cough]Con[unct|v|t|s
||) I = Insect 8|te
|||) 1 = 1rave|]1rauma
|v) k = kash
v) U = U|cers |n mouth]Ur|nary D|scharge
v|) S = St|ffness]Sore 1hroat
20) now ask about the past hlstory. Mnemonlc
AM nUGS ICSS
1k4N5l1lON 5N1Nc
Mt./M|ss \2, oow l woulJ l|ke osk you o few uest|oos obout yout post
meJ|col b|stoty, |s |t Ok w|tb you?"
|) = Mn
(a) Pave you ever had any slmllar problem/complalnt ln the past?
(b) Are you currently sullerlng lrom any dlagnosed medlcal lllness?
(c) Any chronlc condltlons llke ulabetes, Plgh blood pressure.? ll yes, ask
Pow long have you been dlagnosed wlth thls condltlon?
ot
When were you dlagnosed wlth thls condltlon?
Are you currently taklng any medlcatlon lor your complalnt (ulabetes, hlgh blood
pressure.)?
ls your blood pressure/blood sugar level under control?
uo you check lt regularly?
When dld you last vlslt your doctor / last checked wlth your physlclan?
Pave you been compllant wlth your medlcatlon?
Pave you notlced any slde ellects ol your medlcatlon?
DCN'1 ICkGL1 1C CCUNSLL SIMUL1ANLCUSL!!!
(lt w|ll sove yout couosel|oq po|ots |f you fotqet tbese po|ots ot tuo out of t|me |o tbe eoJ!)
||) A = A||erg|es
(a) Are you allerglc to anythlng or any medlcatlon?
(b) ll yes e.g. enlclllln, ask:
What happens when you're glven enlclllln?
ot
What happens when u r stung by a bee?
(c) SA?: Ck, l'm maklng a note ol lt and l'll make sure you wlll never be glven enlclllln ln luture.
Ot oJv|ce tbe pot|eot to ovo|J qo|oq to ploces wbete be/sbe coulJ bove oo |octeose t|sk of o
bee st|oq.
|||) M = Med|cat|on nx
(a) Pave you taken any medlcatlon lor your current complalnt?
(b) ll yes, ask: WPA1/WPlCP?
(c) Are you taklng any medlcatlon apart lrom thls?
|v) n = nosp|ta||zat|on nx
(a) Pave you ever been hospltallzed ln the past lor anythlng?
(b) ll yes, ask: WPLn? and lC8 WPA1?
(c) uld everythlng go llne at that tlme?
v) U = Ur|nary nx (|f you haven't asked ear||er!)
(a) uo you have any problem wlth urlnatlon?
v|) G = GI nx (|f you haven't asked ear||er!)
(a) uo you have any problem wlth your bowel movements?
v||) S = S|eep nx (|f you haven't asked ear||er!)
(a) Pow ls your sleep?
1k4N5l1lON 5N1Nc
Mt./M|ss \2, oow l woulJ l|ke osk you o few uest|oos obout yout
fom|ly b|stoty, |s |t Ok w|tb you?"
v|||) I = Iam||y nx
(a) uoes anyone else ln the lamlly have a slmllar complalnt?
(b) Are your parents allve?
(c) ll yes, SA?: lts nlce to hear that!"
(d) Pow's the health ol your parents?
(e) ll parents have dled or have somethlng, SA?: l am really very sorry to hear that!"
1k4N5l1lON 5N1Nc
Mt./M|ss \2, oow l woulJ l|ke osk you o few uest|oos obout yout post
qyoecoloq|col b|stoty, |s |t Ok w|tb you?"
|x) C = Gyn]Cb nx
(a) When dld you have your llrst perlod?
SMCklnC, ALCCPCL & lLLlCl1
u8uC uSL CCunSLLLlnC
lt ls always better to llrst
ask about thelr hlstory and
then counsel at thls polnt
about all ol them.
lt wlll save you a lot ol luss
ln the end.
& you wlll never lorget to
counsel about them!
(b) When was your last menstrual perlod?
(c) Are your cycles regular?
(d) Pave you ever been pregnant?
(e) Pow many chlldren do you have?
1k4N5l1lON 5N1Nc
Mt./M|ss \2, oow l woulJ l|ke osk you o few uest|oos obout yout
sexuol b|stoty. uoot wotty evetytb|oq w|ll be kept coof|Jeot|ol, |s |t Ok
w|tb you?"
x) S = Sexua| nx
(a) Are you sexually actlve?
(b) ll no, ask: WP??
(c) ll yes, ask: Wl1P WPCM? (Cne partner/Pusband =uon't ask any lurther questlons!)
(d) uo you have any other partner?
(e) uo you use any contraceptlve measures?
(l) ll no, CCunSLL lC8 uSlnC CCn18ACL1lvL MLASu8LS
ou must use cooJoms os tbese oot ooly pteveot ftom uowooteJ
pteqoooc|es but olso ftom mooy sexuolly ttoosm|tteJ J|seoses os
well."
(g) Pave you ever been tested or dlagnosed lor any sexually transmltted dlsease?
(h) Pave you ever been tested lor AluS?
(l) ll no, CCunSLL & ASk lC8 CCnSLn1 1C CL1 PlM/PL8 1LS1Lu lC8 Plv!
1k4N5l1lON 5N1Nc
Mt./M|ss \2, oow l woulJ l|ke osk you o few
uest|oos obout yout soc|ol b|stoty, |s |t Ok w|tb
you?"
x|) S = Soc|a| nx ( SCDA )
(a) Smok|ng:
uo you smoke?
lor how long you have been smoklng?
Pow many clgarettes do you smoke ln a day?
ll yes then counsel llke thls
be|oq yout coocetoeJ pbys|c|oo l oJv|se u tbot u must u|t smok|oq
os smok|oq moy couse mooy J|seoses sucb os beott ,luoq ooJ
stomocb J|seoses ooJ mooy coocets |o tbe boJy os well..|f u woot to
u|t |t, l om olwoys bete to belp you out."
(b) A|coho|:
uo you drlnk alcohol? lf yes.olwoys osk obout tbose 4 olcobol JepeoJeoce
uest|oos! (CAGL quest|ons!)
lor how long you have been drlnklng?
Ask about lrequency!
Counsellng as well [ust llke glven lor smoklng.
(c) I|||c|t Drugs:
uo you use any sort ol recreatlonal drugs?
ll yes, ask: SlnCL WPLn? & l8LCuLnC??
(d) Cccupat|on:
What do you do lor a llvlng?
ls your [ob stresslul?
LkAMINA1ICN
1k4N5l1lON 5N1Nc
1book you fot ooswet|oq me tbese uest|oos. Now l woulJ l|ke to
exom|oe you, fot tb|s l oeeJ to wosb my booJs f|tst ooJ tbeo come bock
to you. xcuse me fot o m|oute!"
1bete |s o Jebote tbot you sboulJ be Jo|oq some l|qbt coovetsot|oo w|tb tbe 5l wb|le youte
wosb|oq yout booJs. lo my expet|eoce, |ts bettet to keep u|te Jut|oq tbot s|oce o cbolleoq|oq
uest|oo m|qbt come Jut|oq tb|s t|me. ou coo eveo osk tbe 5l ls tbete ooytb|oq you woulJ l|ke
osk ot tb|s po|ot?" but Jo |t ooly wbeo yout booJs ote wet!
21) now l am golng to examlne you. uurlng examlnatlon, l need to touch you several tlmes. l wlll try to be very
gentle. uo let me know ll you leel any paln or dlscomlort, l wlll stop rlght away.
22) Iudge accord|ng to case and t|me |eft |n the encounter (wh|ch you w||| guess from the |ast f|ve m|nute
announcement!) from where you have to start.
Out tule of tbumb bos beeo, |f youte Jooe wosb|oq yout booJs ooJ bove tolJ tbe 5l youte qo|oq
to stott tbe exom|oot|oo, you sboulJ bove omple t|me |o tbe eoJ fot couosel|oq ooJ ptopet
closute!
23) Pere ls a brlel revlew ol all examlnatlon steps. uo not conslder lt as llnal and read the examlnatlon
lrom uSMLL World. uurlng the real patlent encounter, you normally do not have that much tlme
ll you get a CnS or Cl1 case,
never lorget to llsten to heart &
lung sounds.
Always do lt at the end when you
have completed the rest ol the
relevant examlnatlon.
uoot fotqet to ossess |f you bove
eoouqb t|me fot closute, s|oce |t
cott|es mote motks!
Proceed to cN5 exom from this point if its o cN5 cose!
to do every step ol systems' examlnatlons. 4/woys do the chief comp/oint re/oted exoms first ond
never forqet to do the 6enero/ Physico/ xom or nN1 {it wi// just toke 20-l0 seconds!).
|) nLLN1
(a) Start wlth hands. Say.
Can you please show me your hands llke thls? (Show the S your palms
laclng upward)...
l am looklng at your hands lor any sweatlng or abnormallty. jtoucb pts
booJ w|tb yout f|oqet to cbeck fot sweot|oq]
Can you please turn your hands lor me.
l am looklng lor any color changes ln your nalls.
l am looklng lor your pulse and comparlng wlth the other slde as well and lt
seems normal to me. jleel fot tbe 5ls pulse fot 5 secooJs!]
(b) Say.now l am golng to examlne your eyes.
Can you please look down lor me.l am looklng lor any yellowness ln your
eyes!
Can you please look up lor me.now l am looklng lor any pallor ln your eyes!
.and they seem normal to me.
Cet tbe Oln1nAlMO5cOl, |ts l|qbt w|ll tuto oo outomot|colly.
uoot fotqet to sw|tcb off tbe toom l|qbt befote Jo|oq
fuoJoscopy. 1bete |s oo oeeJ to sw|tcb off l|qbt just fot otol
exom|oot|oo!
(c) lunuCSCC?: uo |t wbeo you qet o b|stoty of u|obetes Mell|tus, nypetteos|oo ot o
cose of sttoke jcvA] Ok ooy eye ptoblem!
(d) Say.now l would llke to examlne the lnslde ol your mouth (oral cavlty), lor thls l
need to shlne llght ln your mouth.
Can you please open your mouth lor me.
.stlck your tongue out. checklng CN kII
.and say a blg AAP. checklng CN Ik & k
Wh||e say|ng th|s, sh|ne ||ght |nto h|s mouth
(e) AuSCuL1A1lCn Cl nLCk (fot cotot|J 8tu|ts): uo |t wbeo
you qet o b|stoty of u|obetes Mell|tus, nypetteos|oo ot o cose of sttoke jcvA] ot ooy
cose of u|zz|oess.
Say.now l am golng to llsten lor any abnormal sounds ln your neck. jlut tbe
stetboscope oo eocb s|Je of tbe oeck fot 1-2 secooJs!]
(l) 1P?8Clu LxAM: 1be sceoot|os |o wb|cb |t sboulJ be Jooe ote ooy cose of fotique,
depression, forqetfu/ness ooJ o c/eor cose of thyroid.
Say.now l would llke to look lor any abnormal swelllng ln your neck, can
you please swallow lor me (or drlnk a slp lrom the glass ol water).
jMeoowb|le, ploce yout booJ ooJ polpote tbe oteo of tbyto|J ooJ Jo
commeot |o tbe eoJ tbot |t looks ootmol to me]
Say.now l am golng to llsten lor any abnormal sounds ln your neck. jlloce
tbe bell (oot oecessot|ly |o c5 |f youte tuoo|oq out of t|me)of yout
stetboscope oo e|tbet s|Je of ftoot of oeck]
||) GI1
(a) now l would llke to examlne your belly, lor thls l need to expose your belly and
drape you properly.
(b) 1wo very lmportant thlngs to remember here, whlle the S ls slttlng:
#1 6o behind the 5P open the /ower knot of the 5Ps qown [better to open
the upper os we//]. lf you let tbe 5l l|e Jowo w|tbout opeo|oq tbe lowet koot,
you w|ll oot be oble to pull up tbe qowo to expose 5ls obJomeo.
#2 ne/p the 5P /ie down [whi/e p/ocinq your hond behind 5Ps heod] ond
s/ide the foot rest out from the foot-end of the bed soyinq.l am golng to
pull the loot rest to make you more comlortable.
(c) lull tbe Jtope up to tbe obJomeo well obove tbe umb|l|cus ooJ sl|Je tbe ftoot of tbe
qowo beoeotb |t to expose tbe obJomeo. 1beo pusb tbe Jtope bock t|ll tbe |l|oc ctest.
(d) Say.Can you me exactly where you're havlng paln? [4/woys osk this question for
every cose of poin, before stortinq your exominotion!]
(e) lnSLC1lCn: Say.now l am looklng at your belly lor any abnormallty, abnormal
swelllng, strlae, scars or vlslble pulsatlons.
(l) AuSCuL1A1lCn: Say.now l am golng to llsten to your bowel sounds and other
abnormal sounds ln your belly. jlloce tbe stetboscope ot just 2 po|ots t|qbt ooJ left
of tbe umb|l|cus fot 2-J secooJs!]
(g) ALA1lCn: Say.now l am golng to touch your belly, llrst llghtly and then a blt
deeper. uo let me know ll lt hurts or you leel uncomlortable, l wlll stop rlght away.
jllCn1 lAllA1lON.Iust fotm o vety supetf|c|ol 5" oo tbe obJomeo. ul
lAllA1lON.uo oot poke yout f|oqets. 8e vety qeotle |o Jeep polpot|oo os well.]
Always keep looklng at the S's lace. lmmedlately stop ll you see any dlscomlort
on the S's lace or the S complalns ol paln.
Alwoys ouscultote
tbe obJomeo f|tst
befote toucb|oq tbe
belly!
uo tb|s step ooly |o o
cose of tbyto|J
teloteJ b|stoty!
1nL LkAMINA1ICN CI 1nL CnLS1 (kLSIkA1Ck & CVS) SnCULD 8L DCNL A1 1nL SAML
1IML! 1nL S WILL nAVL A CnLCk LIS1, CU CAN kCCLLD WI1n AN CkDLk CU MA LIkL.
(h) L8CuSSlCn: Say.now l am golng to tap your belly to look lor any extra alr or lluld
ln lt! jletcuss ooly ot 2-J po|ots!]
(l) Say.1hank you, now let me help you slt up!
l. Close the loot rest.
ll. Pelp the S slt up.
lll. 1le the lower knot.
|v. ltoceeJ to cbest exom!
|||) kLSIkA1Ck SS1LM
(a) Say.now l have to examlne your chest. lor thls, l have [need] to untle your
gown.. ls |t Ck w|th you? juot|e tbe top koot ooly ooJ expose tbe cbest of tbe 5l,
botb |o moles os well os femoles. uoot let |t foll Jowo!]
(b) lnSLC1lCn: Say.now l am looklng at your chest lor any abnormallty, scars or
vlslble pulsatlons.
(c) ALA1lCn: lo my op|o|oo, ooly Jo tbese steps |f you qet o tesp|tototy system cose!
?ou can make an S and leel the chest lrom back wlth the palm ol your hand and
ask ll lt hurts.
lor vocal lremltus.?ou can leel wlth the ulnar slde ol your hand at any polnt on
the chest you want, lt should lnclude two polnts on lelt and 2 on rlght slde up
and down, where ever you llke.
(d) L8CuSSlCn: Say.now l am golng to tap on your back wlth my llnger to look lor
any abnormal alr or lluld ln lt. l wlll try to be very gentle jletcuss J ploces oo eocb
s|Je oo tbe bock!]
(e) AuSCuL1A1lCn:
Say.now l am golng to llsten to your lung sounds, can you please take
some nlce deep breaths lor me? NLVLk ASk AN S CCMLAINING CI
CnLS1 AIN (whatever the sca|e |s!) Ck DIIIICUL1 IN 8kLA1nING 1C
1AkL DLL 8kLA1nS, and te|| h|m that you are not ask|ng h|m to take
deep breaths because of h|s]her chest pa|n or d|ff|cu|ty |n breath|ng.
.now can you please say 99 lor me, whenever l say yes jby ploc|oq tbe bose
of stetboscope oo b|s bock].
|v) CAkDICVASCULAk SS1LM
(a) ALA1lCn:
lor Apex 8eat, Say.now l have to leel lor your heart beat. (, can you please
lllt up your lelt breast lor me... ln case ol a lemale S!)
Always palpate lor the apex beat, even ll lt's not a CvS case! jMy owo
petsoool except|oo to tbe tule wos.A5555 1n 1lM kMAlNlNC.|f you
tb|ok you coo moooqe, qo fot |t, otbetw|se leove |t!]
(b) AuSCuL1A1lCn: Say.now l am golng to llsten to your heart sounds, can you please
hold your breath lor me? jAuscultote ot pulmoooty, oott|c, tt|cusp|J ooJ m|ttol
oteos fot 1-2 secooJs eocb!] DC NC1 ASk 1nL S 1C nCLD nIS]nLk 8kLA1n IN
CASL CI CnLS1 AIN.
At tbe eoJ, Jo commeot tbot yout beott souoJs seem f|oe to me!
v) CLN1kAL NLkVCUS SS1LM
(a) C8AnlAL nL8vLS: kefet to tbe nN1 sect|oo of tbe exom|oot|oo fot cN lx, x 8 xll!
CN II & III: uo lt only ll you there ls somethlng ln hlstory or chlel complalnt,
do lt belore checklng the oral cavlty and don't forget to turn the ||ght off!
Say.now l am golng to check the lunctlon ol the nerves comlng lrom the
braln (uC ALL 1PL C8AnlAL nL8vLS LxAM A1 1PlS Cln1 1PLn!) j1btow
l|qbt |o tbe eyes ftom beb|oJ!]
CN III, IV & VI: Say.Can you please lollow my llnger wlthout movlng your
head. jlotm tbe n" w|tb yout f|oqet ooJ tbeo move yout f|oqet close to 5ls
oose to cbeck fot occommoJot|oo!]. 1hen comment.your eye movements
look normal to me ot you bove some J|ff|culty |o mo|oto|o|oq yout eye
movemeots |f tbete |s o ptoblem |o teol.
CN VII: Say.
l. Can you please lrown lor me?
ll. Can you please blow your cheeks out lor me?
lll. Can you please close your eyes and don't let me open them. jlloce
yout tbumbs oo 5ls eyes ooJ vety qeotly tty to opeo b|s/bet eyes!]
lv. Can u please smlle/whlstle lor me?
v. l am rubblng my llngers ln lront ol your ears, let me know ll you
hear the sound equally on both sldes or ll there ls dlllerence. jkub
yout f|oqets ooJ tbumb s|multooeously |o ftoot of botb eots of tbe
5l]
CN V: Say.now l wlll touch your lace llke thls jtoucb tbe 5ls foteotm qeotly
w|tb yout f|oqet.], you have to close your eyes and tell me ll you can leel lt
ln case ol a lemale
S, say.Can you
please lllt up your
lelt breast lor me?
.belore palpatlng
lor apex beat and
auscultatlng the
mltral area!
and ll lts equal on both sldes, ls lt Ck? jNow toucb tbe foce of 5l vety qeotly
ot fotebeoJ, cbeeks ooJ jow s|multooeously w|tb yout |oJex f|oqets!]
keep on asklng.Can you fee| th|s.every tlme you touch the
lace ol S.
1hen ask when you're done and the S has opened hls/her
eyes.Were they equa| on both s|des?
CN kI: Say.Can you please shrug your shoulders lor me? jlloce botb booJs
oo 5ls sboulJets!]
CN VIII: Ooly cbeck tb|s oetve |f you qet o cose of beot|oq loss ot 5l q|ves you
sometb|oq |o tbe b|stoty.
WL8L8'S 1LS1: Say.now l would llke to check the lunctlon ol your ears. lor
thls l would use thls tunlng lork. l would llrst strlke lt wlth a rubber pad llke
thls and then l wlll place the base ol thls vlbratlng lork on the top ol your
head. uo let me know ll you hear equally on both sldes or ln whlch ear you
hear the most.
8lnnL'S 1LS1: lace the base ol tunlng lork behlnd the ear on the mastold
promlnence and say.l wlll place the base ol thls tunlng lork at back ol your
ears, please let me know when you stop hearlng. jwbeo tbe 5l stops
beot|oq, ploce tbe tuo|oq fotk |o ftoot of b|s eots ooJ osk |f be/sbe coo st|ll
beot tbe v|btot|oo].
ln exam, you wlll not have tlme to explaln ln detall about the result ol
thls test.
(b) SLnSC8? S?S1LM: Say.now l would llke to touch you llke tb|s jtoucb 5ls fotebeoJ
w|tb tbe t|p of yout f|oqet], klndly close your eyes and say ?es" whenever you leel
my llnger.
now touch the lollowlng polnts slmultaneously on both sldes:
Pands
lorearms
Arms
1hlghs
Shlns
leet
keep on asklng.Can you fee| th|s.every tlme you touch the S.
1hen ask when you're done and the S has opened hls/her
eyes.Were they equa| on both s|des?
(c) MC1C8 S?S1LM: Say.Now I am go|ng to check the power of your musc|es.
Pold my llngers and don't let lt go. Ok Can u please squeeze my llngers?
now place your arms llke thls. j5bow tbe 5l to ploce b|s/bet otms flexeJ by tbe s|Je
of cbest] Can you move your arms out lor me? jlloce yout booJs oo tbe Jotsol s|Je
of tbe foteotms!]
jNow ploce yout booJs oo tbe veottol sutfoce of botb foteotms] Say.Can you move
your arms ln lor me?
Can you move your arms out lor me? jlloce yout booJs oo outet otms!]
jNow ploce yout booJs oo tbe |ooet sutfoce of otms] Say.now can you move your
arms ln lor me?
Can you move your leet up lor me? jlloce yout booJs oo top of 5ls feet!]
jlloce yout booJ oo soles oow!] Say.now can you move them down lor me?
Can you klck your legs out lor me? jlloce yout booJs oo tbe sb|os!]
jlloce yout booJs oo tbe colves oow!] Say.now can you move your legs ln?
Case of "8ACk AIN": Say...now l would llke to evaluate lor your paln ln the
back.do let me know ll lt hurts, l wlll stop rlght away.
l. lnSLC1lCn: Say.now l have to look at your back lor any abnormallty
jNow opeo tbe lowet koot ooJ look ot tbe bock] Say.everythlng seems
llne juoless tbey bove put some po|ot tbete! uo wotcb out fot sucb k|oJ
of tb|oqs!]
ll. Say.Can you exactly show me where the paln ls? j5l w|ll po|ot out!]
lll. ALA1lCn: Say.now l am golng to touch your back, let me know ll you
leel any paln. jNow polpote oo tbe sp|oe ot J-4 po|ots!]
lv. now Say.Let me help you lle down. jOpeo tbe foot test ooJ belp tbe 5l
l|e Jowo!]
v. Ask the S to abduct and then adduct hls/her legs to check the power ln
the same way.
v|. S18AlCP1 LLC 8AlSlnC 1LS1: now l would llke to check lor any problem
ln your backbone by llltlng your leg. keep your rlght leg stralght whlle l
lllt up your lelt leg. lease let me know whenever you start leellng paln
at your back, l wlll stop rlght away.jlloce ooe booJ obove tbe pt koee
ooJ yout otbet booJ uoJetoeotb 5ls beels ooJ keep|oq tbe leq stto|qbt,
l|ft tbe 5ls leq to tbe po|ot wbeo be/sbe feels po|o]
vll. now repeat lor the other leg as well. jveo |f 5lk |s pos|t|ve |o tbe f|tst
leq!]
vlll. Say.1hank you lor your patlence, now let me help you slt up!
Close the loot rest.
Pelp the S slt up.
(d) CAl1: Say.now l would llke to check your galt.
1oke tbe steps out ooJ belp tbe 5l qet off tbe beJ.
S1CCL CuLS1lCnS
Amount
Color
Conslstency
Smell
Say.Can you please walk a lew steps lor me, turn around and get back.
uon't worry, l won't let you lall down.
Now belp tbe 5l qet oo tbe beJ oqo|o!
CLCSUkL
24) 1hank you lor your patlence and co-operatlon. now let me summarlze what you have told me so lar.
5ummot|ze oll tbe b|stoty ooJ ooe ot two s|qo|f|coot f|oJ|oq |o ooe ot two l|oes mox|mum. 1be 5l
bos to cbeck o box tbot you summot|zeJ.oot bow elobototely you summot|zeJ.
.8ased on your hlstory and physlcal llndlngs, l am conslderlng a number ol posslbllltles here
llke.yout u/u bete.but l am not sure rlght now, lor thls, l need to carry out some test llrst llke C8,
x-ray ol splne and even an M8l (e.q. |f teu|teJ |o tbe cose). When the results ol these tests wlll be
avallable, we'll meet agaln and dlscuss your management and treatment optlons. 1hen l wlll be ln a
better posltlon to comment on your dlagnosls.
Meanwhlle, you should take care ol. jAll tbe oJv|ce oeeJeJ fot tbe cose ooJ olso oJv|se obout
J|et ooJ tequlot exetc|se!]
23) Do you have any concerns before I |eave?
26) 1hank you.Pave a good day.8ye lor now!
CnALLLNGING ULS1ICNS
?ou wlll llnd a lot ol materlal related to challenglng questlons ln uSMLL World / llrst Ald
(whlch ever you preler!)and neera[ notes.
nLL8A! nC1LS: ay speclal attentlon to all the 6 cases ln neera[ notes (especlally plcky eater,
whlch comes ln 3 to 6 dlllerent ways, but the questlons asked should be the same whlch ls
mentloned ln the neera[ notes]
CnILI CCMLAIN1 kLLA1LD ULS1ICNS
1P?8Clu SLClllC CuLS1lCnS
Sleep
Stress
Appetlte
Welght loss
Palr changes
Sweatlng
Skln changes
volce changes
Swelllng over leet
Swelllng around neck
ullllculty ln ad[ustlng to
temperatures
USLIUL 1IS:
never lorget to counsel about colonoscopy ln a S whose age ls more than 30.
ll you enter the room and the S ls lmmedlate dlstress (e.g. Coughlng, actlng to vomlt
wlth a kldney tray ln hand or ln paln), say.Mr./Mlss x?Z, lt seems that you're a blt
dlstressed, ls there anythlng that l can do to make you leel more comlortable. jlf |ts
yout uocoopetot|ve pot|eot, you coo olso oJJ.Let me assure you that l am here to help
you out and to solve your problems.]
lf you eotet |o o toom ooJ pot|eot stotts yell|oq ot you tbeo you must soy.Mt./M|ss \2,
l koow you must be wo|t|oq fot me fot o looq t|me, l teolly opoloq|ze fot tbot ooJ l teolly
opptec|ote yout pot|eoce, octuolly l wos w|tb oootbet pot|eot ooJ oow lts yout tuto ooJ
l om teoJy to belp you out!
ll the S ls coughlng, oller water!
never glve water ln case ol abdomlnal paln.
ln case ol cough, oller a napkln ll the S lsn't holdlng one.
ll a napkln does get lnvolved, don't lorget to take lt ln the end tell the S that you need
lt to get phlegm examlned.
PLAuACPL CASL:
Always swltch oll the llght alter taklng S's permlsslon.
never lorget to ask about the locatlon ol paln ln case ol headache.
never lorget to rule out slnusltls. Ask the lollowlng questlons:
l. uo you have any paln ln your lace?
ll. uo you have paln anywhere else?
lll. uo you have lever
lv. ury or productlve cough
v. Sore throat
vl. Peadache at whlch partlcular tlme ol the day
vll. Lye dlscharge, redness ol eyes
vlll. 8unny nose
lx. ulscharge lrom ears
x. Change ln the quallty ol volce
xl. ostnasal drlbbllng [ l am not sure how can you descrlbe thls]
never lorget SL8 ln a case ol back paln.
never lorget to mentlon rectal exam ln all abdomlnal cases.
never lorget to mentlon pelvlc exam ln all lemales ln abdomlnal or pelvlc [Cyn/Cb]
cases.
1ry to summarlze all the detalls ol hlstory once agaln ln the end ln a telephonlc case or
ln a case where exam ls not requlred (when a S ls slttlng ln the room wearlng regular
clothes, not a gown).
1ry to call the pt wlth hls or her name. 1ry not to pronounce lt lncorrectly, ask hlm ll you
are pronounclng hls/her name ln a wrong way ln the beglnnlng ol your case.
ln an abdomlnal exam, always make proper posture ol the pt ll he ls lylng to one [rlght
or lelt] slde ol the bed belore startlng your exam.

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