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greenflower: My CS protocol
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发表时间:2010-02-04
更新时间:2010-02-04
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发信人: greenflower (greenflower), 信区: MedicalCareer
标 题: my CS protocol
发信站: BBS 未名空间站 (Thu Feb 4 00:19:54 2010, 美东)

My CS protocol:

Get my CS score today, very glad to find that I passed. I got a lot of
useful information from this forum, here is the protocol I used for my CS,
hopefully someone will find it useful in his/her preparation for CS.

I studied about four months for my CS, and practiced all FA cases once with
my LD, who has no background in medicine at all.

I stick to the protocol in all my cases during practice , in fact I repeated the same/similar questions so many time, my LD is very good at asking medical history and collecting data in the end.

During the exam, I didn’t have enough time to finish the closing statement in the first case, I had no idea what the SP had in another case. My experience is that it is very important to be confident in SP encounter, also http://csprotocol.blogspot.com/ is very useful.

Following is the protocol:

Knock three times with confidence, a smile, walk in and say:

Good morning/ Afternoon, Ms (Mr)XXXY. I am Dr. xxxx, and I am here to see
you today as your physician. -----( nice to meet you ) Shake hands----. Is
everything in the room alright for you? Let me cover you with this to make
you a little more comfortable (Cover drape) .
Ok, Ms( Mr) XXY, what caused you to come in today?
CC
I am sorry to hear that, I shall try my best to help you .could you tell me
more about ----?
(Such as how long have you had……? When did you first notice this?)

OLIQRAAA
O onset/duration/progression( every case)
Chronic complaint:
How long have you had this?
During this -----, did it get worse, get better, or just stay the same?
Did anything usually happened before that ---ago?(travel/food to diarrhea;
tax time to burning epigastric pain)

Acute complaint
When did you first notice this?
Did it start all of sudden or slowly and gradually?
What were you doing when it occurred?
Did anything unusual happen before it start?(travel/food to diarrhea;
Did it get worse, better or stay the same.


L location /site( some cases)
Would you please tell me where exactly your pain is. Show me with one finger
if possible
Do you have pain in both your knees or just left?
Vision loss in both eyes or just left
Loss of hearing in both ears or just left?
I intensity/Quantity( all cases)
On a scale of 1 to 10, 10 as the worst pain you ever had, how bad is your
pain?
How often does the stomach pain occur?(How often do you urinate? How often
do you have this?)
How many times did you vomit today? (How many bowel movements do you have
today?)
How much blood is there in your sputum?
Functional impairment: How does the fatigue affect your daily activity? (
what a patients can do for how long)
Q quality
How would you describe your pain (feeling, discomfort)? Is it a dull ache (
sharp, stabbing, burning, pulsating, cramping, pressure)
Is the pain there all the time, or on and off.
Please describe how it feel?
Tell me what it feels like?
Do you feel--- all the time, or just certain time of day? What time of day?
R radiation (pain)
Does the pain (or other symptom) move anywhere?
Do you have pain in any other parts of body?
Ischemic pain---arms, neck, back , mandible
Kidney stone--- femoral triangle, testes or vulva
Gallbladder, ruptured ectopic pregnancy—posterior right shoulder region
Spleen injury---- top of the shoulder
Testicular torsion----lower abd
Abd aortic aneurysm; pancreatitis; posterior penetrating gastric ulcer ---
back thoracic region
Sciatica------down lower limb, calf
Pharyngitis pain--- ear
A Aggravating factor
Is there anything that make your --- worse?( position, activity level,
exertion, food, time of the day , medication)
A Alleviating factors
Is there anything that makes it better?
A Associated symptoms
In addition to ---, do you have any other symptoms?
Young female with joint pain: do you have fever? Rash in your skin?
Cough : Fever, sputum, chest pain, shortness of breath, hemoptysis.
Headache (fever, dizziness, sore throat, cough , chest pain, shortness of
breath, nausea, vomiting. Weakness in your lag and arm, tingling numb
sensation, burninbg sensation, sweating)
Joint pain ( redness, swelling, warmth, tenderness, and decreased range of
motion)

PAMHUGSFOSS
Before the past medical history:
Okay, Ms Green, I would like to ask you some questions about your health in
general .is that OK with you?
P previous event
Have you ever have similar problem like this before?
Recurrent identical headache-----migraine, muscle contraction headache
New onset headache in an elderly ----cerebral vascular disease, subdural
hematoma,
neoplasm, temporal arteritis
Have you been diagnosed with -----? (diseases related to HPI)
Have you ever had ----problem? How about HTN, DM , high cholesterol, and
heart disease, and cancer?
A Allergy
Are you allergic to anything?

In cases of crash, shortness of breath, rhinorrhea, conjunctivitis,
anaphylaxis, bee sting.
Detail (medications, Foods, Plants or animals, environmental sources)
( Do you have any allergies to prescription medication, any reaction to
food? Do you have allergies to animal or plants)
M Medications
Are you taking any medications?
Do you take prescription medicines?
Do you take oral contraceptives or birth control pills?
How about over –the- count pills?
Do you take any vitamins or herbs?

What do you take that for, ?

If do not recognized what the patient is saying.
Could you spell the name for me , please ? I can read the labels if you have
the prescription with you.
Adherence to prescription instruction is important. some symptoms may be
caused by not taking the medication regularly .
D: Are you taking Lasix regularly?
P: well, no-I stopped it two weeks ago
D: when did the shortness of breath start?
P: Just in the last 3 or 4 days
DD: Non-adherence to medication regimen causing exacerbation of heart
failure.
Adverse effect should be noticed.
Saw palmetto ---BPH; Granberry juice----UTI; Echinacea: URI; Ginseng: stress
and memory:
St john’s wort: depression Zinc; Garlic, Ginkgo Biloba;
H( his)
Have you ever been hospitalized?

D: Have you ever been hospitalized ?
P: Yes, I had my gallbladder out 5 years ago. That ‘s it
D:Besides the gallbladder , have you had any other surgical operations?


Have you ever had any major injuries?
Have you ever had a surgical operations?

U:
Do you have any problems with your urination?
G:
Do you have any problems with your bowel movement?
S:
Do you have any problems with your sleep?





F family history
Before the family history:
Now, let’s talk about your family health
Does anyone in your family have similar problem as yours? What you had?
Does anyone in your family have high blood sugar ? high blood pressure?
Does anyone in your family have any serious illness?
Offer condolences if death was less than a year ago or if pt’s facial
expression suddenly become sullen
( Pt: My mother died last month. Doc: Oh, I am sorry. Pt; Thank you. Doc:
What health problems did she had? Pt; Pancreatic cancer . Doc:And how is
your father’s health .

O OB/GYN
All right, Now I need to ask you some personal questions so that I may
understand your health in general, whatever you tell me will be kept
confidential.
Anemia ---menses and pregnancy
When was your last menstrual period?
Is your period regular?
Any change in your period recently?
When did you have your first period?

Regularity; cramps/pain; Flow: cycle length; age of menarche/age of
menopause; spotting; vaginal discharge; Last pap smear.
When was your last menstrual period?
Was it normal?
Any change in your period recently?
Do you have period every month? How long between the periods?
Are you regular? How many days do you use pads or tampons;
When did you start having periods? When did you stop menstruating?
Any mood swings or irritability around your period? Anything else?

S Sexual history
STD? angina precipitated by sexual intercourse erectile dysfunction caused
by depression; diabetes, beta-blocker

Are you sexually active?
How many sexual partners have you had in the last 6 months?
Are your partners male, female, or both ?
Do you use birth control?
Have you ever been tested for HIV? Sexually transmitted diseases?
Do you have any problems with your sexual function?



S social history

Before the social history:
Thank you, now let me ask you about you work, family and social life

Before asking questions about smoking alcohol, and recreational drugs
Okay, Now I need to get some information about your lifestyle,
Do you use any tobacco products?( smoke cig, chew tobacco)
How many packs a day do you smoke? For how many years?

Pack-year = number of packs per day X number of years

IF CC is Pt want to quit smoking: when he started to smoke, how many, what
he has tried to do in the past to stop, what methods of quitting have and
have not been succeful for him.
Do you drink alcohol?
How much alcohol do you drink?
If more than two drinks /day male, one drink/day female.
CAGE:
Have you ever tried to cut down on your drinking?
Have you ever been annoyed by other people criticizing your drinking ?
Have you ever felt guilty about your drinking?
Do you drink alcohol early in the morning ?
Two positive ----alcohol abuse

DOC: Do you use recreational drugs?
Pt: yes
DOC: what do you use?
Pt: Cocaine, when I can get it
DOC: how do you take it
Pt: I smoke it
DOC: when did you last use ?
Pt: about 20 minutes ago

Exercise : if come in for general checkup, ask, Acute problem NO
What do you do for exercise?

Work life:
DOC: what type of work do you do ?
Pt: coalminer
DOC: Do you have any stress from your work ?
Home life( partner violence)
Who do you live with?
Do you have any stress at home?












Ms(Mr) XXY , thank you for answering all these questions. Now I would like
to perform a quick general physical exam, and then take a close look at your
---------. Is this OK with you? Just before exam . Is there anything you
would like to tell me which I haven’t asked you. Excuse me for a moment, I
need to wash my hand first.------- Wash hand-----


Ok let‘s begin by checking your eyes.

During the physical exam, before any maneuver:
Now, I need to look in your throat to see if there is any redness and
swelling.
Now, I need to listen to your heart, I will need to put my stethoscope on
your chest.







Closing:
Thank you, Ms Mr. XXY, I have finished my physical exam, now I would like
to sit down and talk over what I am thinking so far. Let me summarize
first, you told me that you had ----- for -----, you also had ------, and
you don’ t have any -----. Is this right? Base on what you told me, and my
physical examination. I think that you may have XXXX disease, which is ----
-----. However, there are other possibilities which may also cause your
symptoms, such as -----. To be more certain, I would like to run some tests.
I will order some blood work, stool work. Also I will order a chest x-ray,
which is just to take a picture of your chest. As soon as we get the results
of the tests back, I will come back to discuss the diagnosis and treatment
options with you. Do you have any question for me?

One more thing, as your physician, I’d like to tell you alcohol/smoking
places you at a higher risk of high blood pressure, strokes, heart diseases,
even some kinds of cancer. I would recommend you to think about stopping
drinking/quitting smoking. If you decide to quit/stop, our professional
support group will help you, and I will be glad to provide you all the
necessary information.

Do you have any more questions for me? I shall leave my contact information
with my nurse. Feel free to contact me anytime if you have any questions.
Ms(mr) XXY, Thank you very much, shake hands, Take care!







MMSE ( mini-mental status exam)
Indications: patients have hallucination, delusion, concentration/memory
impairment;
Confused or distant.


Transition sentence: “I would like to check your memory and concentration
by asking you to do a few things now “

Also check orientation, speech, attention, mood, affect; perceptions(
haluciation, delusion, paranoias, suicidal/homicidal ideation; judgement ,
insight )

Orientation---- time, place, and person.
Could you tell me what date today is ?
Could you tell me where you are now?
Could you tell me your full name?
Memory:
Immediately-----OK, please repeat the following three words” computer, dog,
tomato”
Delayed recall-----ask patent to recall the three words above? Could you
please repeat the three words for me again?
Attention and concentration :
What is 100 minus 7?
Could spell “love” backward?
Language:
Name—ask patient to name common objectives eg: pencil, watch
Could tell me what this is? Raise my pen .
Repetition—repeat the phrase” no, ifs, ands, or buts”
Show him or her the pen, what color is this?
Obeys commands_--- ask patents to close his eyes.

Recording:
Well groomed, Alert, awake, and oriented to time, place and person
(unkempt, lethargic, disoriented to time, place and person)
Speech is fluid and goal directed ( pressured/slow and tangential)
Recent and remote memory are intact ( not intact )
Attention/concentration are good ( impaired) as tested by subtracting serial
Seven.
Mood is euthymic( depressed , euphoric) Affect is/not consistent with mood
Doesn’t have abnormal hallucinations, delusions, paranoias
Denies/admit having suicidal/homicidal ideation or intent
Judgment and insight are intact( impaired)


Thyroid functions:
Have you had any change in your bowel movement habits? Constipation?
Diarrhea?
Has your skin been very dry/ very moist lately?
Have you been losing your hair lately?
Do you have problem adjusting to cold or hot temperature lately? ( do you
feel hotter or colder than usually lately)
Do you have any trouble in sleeping?


Family history :
Does anyone in your family have depression ( feel low all the time).
Does anyone in your family have problem with memory and concentration (
clear thinking)\


Willingness to seek help:

I just want you to know that you are not alone, we are here to help you,
there are also good support groups in the community. Would you like this
kind of support? If you do, I will be glad to provide you with all the
necessary information.


Suicidal idea:
Do you ever think you might want to kill yourself?
Do you actually have plan to kill yourself? Tell me about your plan.
Homicidal idea:
Do you ever think you might want to hurt anyone?



Hallucination:
Sometimes when people are under a lot of stress, they see or hear things
that others don’t . Does this ever happen to you?

Delusion:
Do people ever say that you have extremely unrealistic idea about yourself
or about life in general.




Auscultation or not auscultation, this is a question!


Auscultate the usual complete detail in Cardiac conditions or respiratory
condition.


In all other cases; with the SP in a sitting position
Quickly listen to the four heart valves area and then listen to the breath
sound at the base of lung on the front of the chest in the sitting position.


Let’s quickly listen to your heart, would you mind holding your breath for
5 seconds. That is great. Now Let ‘s listen to you lung, could you take a
deep breath”


Stroke, TIA------Carotid bruits: first use diaphragm of stethoscope, then
“Let ‘s make sure that we have not missed anything”
Bells

---------- A Doppler Dulplex scan of carotid artery. Bruit or no bruit.


Doc. is this a fracture?
It is certainly a possibility, but let’s wait for the x-ray report.
Please give me a painkiller fast
I understand that you are in a lot of pain, it is tough to endure. But I
need to ask a few questions and do a physical to find out is the problem
first , so that we can give you the most effective medications for your pain
.

Phone( diarrhea) I don’t have car to get my son to the hospital.
It is important for me to examine your son , call 911, and they will help
you with that .

Am I gone die?
I understand your anxiety, let us find out what exactly are you suffering
first and discuss the treatment options later.

Am I have heart attack?
I understand your concern, and it is certainly a possibility, however, there
are many causes of chest pain besides that. We can confirm it only after
investigation.


Patient refusing to answer questions about his/her sexual history.
Dear Ms Bush , I understand that it is a sensitive issue, but whatever you
tell me with not go out of this room. The way medicine works, this kind of
information may be important for us to finger out what causes your symptoms.
I want to do my best to help you. So Shall we try answering these questions
again?

Patient in extreme pain on the bed the moment you enter the room


1) introduce yourself with appropriate soberness.
2) Say:” I see that you are in a lot of pain, I will try my best to
help me. I shall ask you a few questions and do a short physical exam to
figure out what is causing your pain, As soon as I am done, I will had my
nurse to give you something for your pain. Is that Ok with you?( I only ask
you to bear with me for a few minutes)
3) Drape the SP
4) Start



3 systems is sufficient
ROS
Constitutional:
Do you have fever? (have you been having fever ?)
Do you feel warmer or colder than usual?
Do you sweat or have chills at night?
Has there any change in how much you sleep?

Increased sleep –depression, hypothyroidism, sleep apnea, drugs
Decreased sleep-depression, hyperthyroidism, mania, drug use.

HEENT:
Do you have headache? Dizziness?
Have you had any vision change? (eyesight, blurry vision . loss of vision).
Do you have any trouble with your ear?
Do you get nosebleeds?
Do you have any throat pain or soreness?
Do you have any difficulty swallowing?
Respiratory
Do you get shortness of breath?
Do you wheeze?
Do you cough up sputum?
Cardiac:
Do you feel that your heart is pounding in your chest? Palpitations?
Do you have any trouble with your heart?
Gastrointestinal:
Have you had any change in your bowel habits?
Do you have any trouble with diarrhea or constipation?
Has you weight changed any?
Has your eating habits changed in any way?

Diet ---B12 deficiency
Weight gain---depression; hypothyroidism; eating disorder; Cushing and
edematous states such as liver failure, heart failure; nephritic syndrome
Weight loss---depression, eating disorders, cancer, hyperthyroidism, DM,
amphetamine use , as well as many chronic diseases

Urinary
Have you had any changes in your urinary habits?
How often do you urinate?
How many times do you get up at night to urinate?
Do you have burning sensation or pain with urination? Any blood?
Is the stream weak?
Do you ever have any accidents?

If the cc is dysuria, all of the questions should be asked in the HPI.

Musculoskeletal
Do you have joint pain anywhere in your body?



The pediatric History
Infant and children
Parent, grandparent, guardian will present the child history in person or
phone cases .
Review all components of the chief complaint and HPI.
Then talk about pregnancy, delivery, and then about the child’s growth and
development. Nutrition, immunization, and progress in school.

Psychiatric diagnosis: depression/anxiety

Depression:
Depressed mood or loss of interest in carrying out pleasurable activities/
Worse in the morning, present more days than not for at least 2 weeks

Often present with somatic symptoms: headache; insomnia; abd pain;
musculoskeletal pain; or not feeling right.
Appetite and weight may increase or decrease. Insomnia or hypersomnia may be
present
Common precipitate of depression: financial problems; work issue; change in
a relationship; medical problem, loneliness; or moving.

Screen questions:
How has your mood been lately?
What is your energy level like?


If suspected :
SIGECAPS:
How is your Sleep lately?
How is your level of Interest?
Do you have any feelings of Guilty?
How is your Energy level lately?
How is your Concentration?
How is your Appetite?
Do you feel restless or slowed down? (Psychomotor)
Have you ever considered hurting yourself or someone else (Suicide)

DD:
Depression;
Anxiety (depression and anxiety are related, --if consider one, list the
other)
Hypothyroidism
Somatic symptom

Investigations:
Screen for common chronic diseases: anemia; renal failure; DM;
hypothyroidism; chronic liver disease, infection.

Antidepressant medication and referral to a therapist are first step in
management.
Arrange for a rapid return appointment for continued assessment and
management.

Suicide risk:
Have you ever considered killing yourself ( intent )?
Do you have a plan to carry it out?
Is there any weapon in your home?

Have you ever tried to kill yourself? If yes, how?


Anxiety reaction:
Too much worry or nervousness, and it becomes a problem when it interferes
with daily activity function.

Somatic symptoms:
Fatigue; muscle tension; chest discomfort, trouble catching breath;
palpitation:
Difficulty concentration at work or school, trouble sleep .
Pt nervious; jittery and worried.

Are you worrying or more nervous than usual?
What are you worrying about?
Is your worry keeping you up at night, making it difficult to concentrate,
or eat.

Panic attack : worrying accompanied by physical symptoms: palpitation;
sweating; shaking; trouble breathing; chest discomfort; lightheaded.

Anxiety overlap with depression. Always ask another:
DD:
Anxiety
Depression
Hyperthyroidism
Somatic symptoms



Investigation:
( similar to depression)
screen tests for anemia; renal failure; DM; hyperthyroidism; chronic liver
disease, chronic infection.


Medication for anxiety: benzodiazepine referral first step
Arrange for continued assessment.

--

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