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-- 作者： JuanFe
[這篇文章最後由JuanFe在 2018/06/05 11:02pm 第 3 次編輯] 15 INSOMNIA 30 BACK PAIN
-- 作者： JuanFe
[這篇文章最後由JuanFe在 2018/05/11 07:12pm 第 1 次編輯] Doorway information about patient The patient is a 22 years old woman who comes to the clinic for follow up of asthma. Vital signs Approach to the patient Asthma should be specific as intermittent (daytime symptoms <=2 days a week , nighttime symptoms <=2 times a month) or persistent . Persistent asthma can be further specific as : . Mild: Symptoms 2-6 days a week with minimal limitation in activity. . Moderate : Daily symptoms wit noticeable limitation in activity. . Severe ; constant o near-0 constant symptoms with significant limitation in activity The evaluation should focus on identifying patient at risk for exacerbation and varying that they are taking appropriate preventive measures. The patient encounter has 4 primary components: . Assessment of current symptoms . Object evolution of disease status (eg.peak expiration flow rate ) . Risk stratification based o the patient’s history and current status. . Interventions , including medications , vaccines , and education , to mitigate the risk. Review the patient’s current treatment and discuss whether it is working , is well tolerated , and is appropriate to the patient;s risk. In general , asthma with only mild , Intermittent symptoms can be managed with a short- acting beta agonist as need . patient with persistent symptoms should also receive a low-dose inhaled glucocorticoid (at a minimum). Different diagnosis The diagnosis may need to be reconsidered if the patent’s condition is worsening despite appropriate treatment . Possibilities include : . The origginal diagnosis is incorrect or incomplete . . the diagnosis is correct , but the treatment is inappropriate of inadequate for the patient . The diagnosis and chronic treatment are correct , but an acute problems has caused decomposition in the patient’s condition. Asthma symptoms may be exacerbated due to acute infection or enviromental triggers , such as smoking or seasonal pollen . Also patent may be noncompliant with therapy or using inhalers incorrectly. History and physical examination Patient with chronic conditions are often well educated on their condition and familiar with the questions the physicians is likely to as . begin with a broad , open-ended questions and give the patient time to answer without interrupting History History of present illness . how are you doing with your asthma ? Past medical history . What other medical conditions have you had ? Social history . Do you smoke ? When didi you start and how much do you smoke ? The physical examination for patient with chronic illness is often very brief . however , if the patient is doing poorly a more extensive examination is warranted. Physical examination . Examine body habits. HEENT . Examine ears with otoscope Cardiovascular . Auscultate heart. Pulmonary . Evaluate respiratory rate & depth as well as accessory muscle use . Closing the encounter The wrap up discussion should being with a summary of your findings and assessment of the patient’s risk for a severe asthma exacerbation . Encourage the patient to discuss any concerns about current management , and review plans for addressing any exacerbation they may experience between office visit (asthma action plan) . Discuss whether the asthma is table and the current management is adequate or whether it is unstable and management should be changed. If the patient smokes , assess readiness to quit. Diagnostic studies All patients with asthma should have as objective assessment of physiologic lung function . In most cases , this is accomplished with bedside measurement of peal expiratory flow ate . Spirometry is not performed at every visit but should be considered if the patient has ongoing symptoms or has responded to therapy as expected. other test may include; . pulse oximetry (if no provided ) or arterial blood gas analysis Advanced imaging (eg. CT scan ) ind invasive studies (eg. bronchoscopy ) are not usually performed in the initial assessment.
-- 作者： JuanFe
[這篇文章最後由JuanFe在 2018/05/11 07:13pm 第 1 次編輯] doorway information about patient Patient is a 25-year-old woman who comes to the clinic due to vomiting vital signs . Temperature : 36.7’C Approach to the patient Vomiting is the involuntary , forceful expulsion of gastric contents . when evaluating a patient with vomiting ,, first clarify the patient is not expecting reflux (non forceful retrograde passage of gastric contents) or regurgitation (pharyngeal return of esophageal contents ) Chronic or severe vomiting can impair adequate intake of food an fluid m and lead to complications . However , many cases of acute vomiting are self-limited and may require minimal or no diagnostic testing . Therefore , the objective of the evaluation is to identify associated symptoms (eg. abdominal pain , fever , gastrointestinal bleeding ) or complications (eg, dehydration , acidosis) that may necessitate additional evaluation. Be ware of that the evaluation of vomiting differs significantly by the setting of care. Patient with chronic or mild intermittent vomiting are more likely to be seen in the clinic whereas with severe , acute vomiting are more likely to come to the emergency department. Differential diagnosis Acute vomiting with diarrhea is usually due to either acute (vial ) gastroenteritis or food-borne enteric illness (eg. staphylococcal or Bacillus cereus food poisoning) . However , vomiting can be due to disorders in virtually any system , and a detailed medical history and review of system any be needed to identify the sources . other common darers that cause vomiting in adults include : . Gastrointestinal : gastric outlet or intestinal obstruction , cholecystitis , appendicitis , pancreatitis , peptic ulcer , liver disease. . Cardiovascular : acute myocardial ischemia , mesenteric ischemia . respiratory : legionnaire’s disease . Genitourinary/ reproductive : pyelonephritis , kidney failure , pregnancy . Endocrine : adrenal insufficiency , diabetic ketoacidosis . Ophthalmic : ankle - closure glaucoma . Vestibular : motion sickness , vestibular neuritis . Psychiatric ; anxiety , eating disorders . Multisystem : toxin ingestion , medication History an physical examination . please describe what you are experiencing . PAST MEDICAL HISTORY . Have you been diagnosed with any other medical conditions? MEDICATIONS . Do you take any medications (prescription and over-the counter)? SOCIAL HISTORY . Do you smoke ? at what age did you start, and how much do you smoke ? PHYSCIAL EXAMINATIONS General . Assess level of alertness Vital signs . Check for orthostatic hypotension if not already given in vital signs. HEENT . Examine oropharynx for dry mucous membranes . Heart . Auscultation for murmurs , gallops , and rubs Abdomen . Inspect ofr distension Colin the encounter Diagnostic studies Stable patients with gastroenteritis or otters benign cases of vomiting (eg, migraine ) may require no diagnostic testing . Woman of child-bearing potential should have pregnancy test .other studies to consider include:
-- 作者： JuanFe
[這篇文章最後由JuanFe在 2018/05/11 07:13pm 第 1 次編輯] Doorway information about patient The patient is a 20 - year - old woman who reports abnormal vaginal bleeding. Vital signs . Temperature 36.7’C Approach to the patient Abnormal uterine bleeding (AUB) is bleeding that is heavy , lasts > 7 days , or occurs more than every 21 days or less than every 35 days . AUB may be heavy bleeding during a normal cycle (eg, uterine leiomyomas ) , bleeding between menses (eg, endometrial hyperplasia ) , or irregular bleeding ( eg, polycystic ovarian syndrome) . AUB should be differentiated form bleeding form other sources ; heavy bleeding is usually form the endometrium , wheres light spotting can be form either the endometrium or other genitourinary sites(eg , cervix , vagina ) . Postcoital bleeding is usually form the cervix or vaginal mucosa . Occasionally , woman who report vaginal bleeding actually have hematuria or rectal bleeding . Prolonged oligomenorrhea suggest chronic an ovulation and increase the risk of abnormal endometrial proliferation . Endometrial hyperplasia or malignancy is a concern with AUB in patient age >=45 , especially postmenopausal woman (>12 months since the last menstrual period [LMP]). Different diagnosis Causes of abnormal uterine bleeding in non pregnancy women STRUCTURAL CAUSES Polyp(eg, endometrial polyp) NONSTRUCTURAL CAUSES Coagulopathy pregnancy and pregnancy- related complications (eg, placenta; abruption , ectopic pregnancy ) should be considered in all premenopausal woman with AUB . After pregnancy is ruled out , AUB may be classified according to structural or nonstructural causes. History and physical examination HISTORY HISTORY OF PRESENT ILLNESS . when did the bleeding start ? —sexual history — . Are you sexually active now ? in the past ? PAST MEDICAL HISTORY . have you ever had abnormal bleeding ? MEDICATIONS . Are you taking medications (eg . aspirin , nonsteroidal anti inflammatory drugs, anticoagulants ?) FAMILY HISTORY . Do you have a family history of bleeding disorders? SOCIAL HISTORY . Do you smoke ? All patients with AUB should have a pelvic examination . However , pelvic examinations are not permitted in the USMLE step 2 CS exam , but should be listed in the Diagnostic Studies section of our cases documentation. PHYSICAL EXAMINATION General HEENT Skin Abdomen Closing the encounter Diagnostic studies Transvaginal ultrasound should be done in most cases to evaluate for structural lesions. indicators of endometrial biopsy include age >=45 with suspected anovulatory bleeding and age < 45 with ovulatory dysfunction and risk factors for unopposed estrogen ( eg, obesity , polycystic ovarian syndrome ) screening for cervical cancer (i.e., Pap test ) should be ordered , if indicated.
-- 作者： JuanFe TERMIANL CANCER Doorway information about patient The patient is a 69-year-old man with terminal lung cancer who comes to the clinic requesting pain medications . Vital signs . Temperature : 37 ‘C Approach to the patient PALLIATIVE CARE ASSESSMENT Source of distress . Pain Support & resources . Family . close loved ones Setting goals . Expectation of disease course Flow up . Care coordination Evaluation pf pain at the end of life should address the Characteristic of the pain itself (eg,location , serenity , modifying factors ) as well as other sources of distress and the patient’s overall well-being. High-quality pain management should take into account the patient’s understanding of their illness , including natural history and potential sources of pain . Individual patients defer widely in priorities and goals; some desire complete pain relief , even at the cost of diminished alertness or other side effects , whereas others prefer only nominal pain relief with a minimum of cognitive impairment . Input form family members (if present ) should be encouraged . Differential diagnosis In palliative care , the primary diagnosis is not usually in doubt . However , be alert for decompensation in comorbid conditions (eg, worsening , heart failure due to cancer treatment) as well as any new cognitive or psychological disorders (especially depression ) History and physical examination history History of physical illness . I understand that you have been diagnosis with cancer ,. How can I help you today ? Past medical history .Have you been diagnosed you with any other medical conditions ? Medications . Do you take any medications (prescription and over- the -counter )? Social history . Who do you live with ? The physical examination amy be limited . The primary symptomatic body system and adjacent system should be examined briefly , alone with an assessment of nutrition and hydration . During the interview , observe the patient’s affect , speech , alertness and psychomotor activity. Closing the encounter To close the encounter , begin by summarizing the status of the patient’s disease , pain love; , and prior interventions . Collaborate with the patient to set treatment goals and discuss what the patient would consider an objective measure of success (eg, “The pain is under control well enough that I can walk my dog in the evening and sleep at least 6 hours a night”.) Be positive and empathetic , but avoid setting unrealistic goals or giving false hope. Treatment is not tested in the USMLE step 2 CS exam . However , you should be ready to discuss patient’s current treatment an counsel them on the purpose and primary side effects of any medications they are taking. Diagnostic studies Most patients coming to discuss pain due to known malignancy will not require diagnostic testing. However , limited imaging or laboratory studies may be appropriate in individual cases , especially if there are new or unexpected symptoms.
-- 作者： JuanFe
[這篇文章最後由JuanFe在 2018/05/11 07:14pm 第 1 次編輯] Doorway information about patient Approach to the patient To begin a telephone encounter , press the yellow speaker button.Introduce yourself to the patient (or caregiver) and conduct the medical history as yo would in a regular encounter . Physical examination is not possible m but you should obtain enough information to formulate a differential diagnosis and determine the appropriate next steps in patient care. Do not dial any numbers and do not press any other buttons on the phone as these amy disconnect the call . When you are finished , end the call by press ion the yellow speaker button ago an . Once you disconnect the call (intentionally or unintentionally) , you are not permitted to call patient again. Different diagnosis The most common cute of vomiting in children age >1 year is viral gastroenteritis . Suggestive factors includes sudden onset , contact with similar cases , abdominal cramps , and diarrhea . Moderate fever is common . Blood in the emesis or stool warrants additional concern. Other causes of vomiting in children include toxic ingestion , upper respiratory illness (eg, otitis , pharyngitis ) ,obstruction , increased intracranial pressure ,(eg, tumor , hydrocephalus ) . and ,metabolic disorder (eg, diabetic ketoacidosis , adrenal insufficiency). HISTORY History of present illness . How old is your child ? Past medical history . Has he ad similar problems previously ? Medications/ allergies . Dose he take many medications (prescription and over -the -counter )? Family history . How old are you and dos father ? Social history . Who dose he live with ? Closing the encounter Clinical features that may indicate a potentially serious cause of vomiting in children include . Prolonged course (>48 hours in children age > 2 years ) Disposition (eg, admit to hospital ) is not tested as part of USMLE Step CS exam. However , any of the above warning sign warrant additional evaluation , including an in-person clinical assessment . the patient should be advised to have the cild evaluation as soon as possible .If the child is stable , you can counsel the parent to encourage fluid intake with continued observation . Explain that the parent should call again (or you will call the parent) at a specified time.
-- 作者： JuanFe
[這篇文章最後由JuanFe在 2018/05/11 07:14pm 第 1 次編輯] Doorway information about patient The patient is a 55-year-old man who comes to the clinic due to passing out. Vital signs .Temperature : 37’C Approach to the patient Comparison of syncope & seizure - Seizures - Circumstances invoked by : Clinical clues . Aura(eg,olfactory hallucinations) Sequelae . Delayed return to baseline - Syncope (typically vasovagal) - Circumstances Invoked by: Clinical; clues . Symptoms of presyncope(eg,lightheadedness) Sequelae . Immediate spontaneous return The initial step in evaluation a patient with loss of consciousness is to differentiate among the primary types of events: . Syncope/presyncope : Transit loss of consciousness with spontaneous recovery , usually due to decreased cardiac output or vascular tone. . Seizure : Disorganized cerebral activity , typically associated with uncontrolled motor activity . Dizziness/vertigo : Abnormal sensation of motion or disequilibrium without true loss of consciousness . Anxiety/ panic : sudden fear or apprehension , often with prominent adrenergic symptoms (eg, sweating , palpations ) . other psychological phenomena: Nonepileptic seizure , altered attention , behavioral disturbances. The patient’s medical history is often helpful unmaking a determination. patients with prior brian injury are more likely to have a seizure . Cardiac arrhythmias are most common inpatient with a history of conduction system or structural heart disease . Patients with nonepileptic seizures often have a history of psychologic illness. Brief myoclonic activity during syncope can be mistaken for a seizure . Features that suggest true seizure include a prolonged postictal state, tongue biting , head /eye turning to one side , and hypersalivation. Brief loss of consciousness is often labeled incorrectly as a transient ischemic attack (TIA). Damaged or ischemic tissue for a prior stroke acne serve was a nidus for seizure , but a true TIA rarely present as loss of consciousness. Differential diagnosis 1: Vasovagal or neurally medicated syncope 1: Situational syncope 1: Orthostatic syncope 1: Aortic stenosis , HCM , anomalous coronary arteries 1: Ventricular arrhythmias 1: Sick sinus syndrome , Bradyarrhythmias , atrioventricular block 1: Torsades de points (acquired long QT syndrome) CAD = coronary artery disease ; EF = ejection fraction ; HCM = hypertrophic cardiomyopathy ; MI= myocardial infarction The most common type of syncope i.es neurocardiogenic (vasovagal) syndrome , which is due to an alteration in autonomic drive leading to decreased cardiac output . It is often triggered by prolonged standing , emotional stress , or pay full stimuli and is sometimes preceded by prodrome of nausea, diaphoresis , or generalized warmth . These syndromes amy briefly persist after the episode and can help differentiate neurocardiogenic syndrome form more serious etiologies . HISTORY AND PHYSICAL EXAMINATION history history of present illness . Describe what happened. Past medical history . Have you been diagnosed with other medical conditions (eg. diabetes , heart disease )? Medication/allergies . Do you take nay medications, especially blood pressure , anti epileptic , or diabetes (eg, insulin) medications? Family history . Has anyone in your family had heart disease , arrhythmias , or seizures? Social history . Do you smoke? At what age did you start & how much do you smoke ? PHYSICAL EXAMINATION Vital signs . Check for orthostatic hypotension if not included in Doorway information. Neck . Auscultate for carotid bruits. Heart . Auscultate for murmurs, gallops , rubs Neurologic . Determine level of consciousness & mental status.
Unless an ECG is provided , it s unlikely that you will have a firm diagnosis to the end of the patient encounter, Discuss with the patient the most likely possibilities and any significant abnormalities you noted on examination. If additional testing is indicated, explain what gets you plan to order and what disorders you are ruling out. If you think the patient is at risk of future events , ask about what support is available at home and discuss steps to take if there is another event. Diagnostic studies All patient with syncope should have an ECG , which may not be diagnostic but can identify abnormalities (eg, conduction blocks , infarcts , ventricular hypertrophy) that predispose to serious arrhythmias . A young patient with a typical vasovagal event and normal ECG may not need further evaluation. Additional studies to consider based on the clinical presentation and risk factors include: . Glucose
-- 作者： JuanFe SMOKING CESSATION Doorway information about patient The patient is a 55-year-old woman who comes to the clinic for counseling on smoking cessation Vital Signs . Temperature : 36.7’C Approach to patient 1 Precontemplation : Not really to change : patient does not acknowledge negative consequences . Encourage patient to evaluate consequence of current behavior 2 Contemplation : Think of change : patient acknowledge consequences but is ambivalent . Encourage evaluation of pros & cons of behavior change 3 Preparation : Ready to change : patient decides to change . Encourage small initial steps 4 Action : Making change : patient makes specific , overt changes . Help identify appropriate change strategies & enlist social support 5 Maintenance : Changes integrated : into patient;s life ; focus on relapse prevention . Follow-up support; reinforce intrinsic rewards 6 Identification : Behavior is automatic : changes incorporated into sense of self . Praise to change The initial assessment in smoking cessation can be summarized with the “5 As” : . Ask about smoking at each visit Most agent who smoke desire to quit and may have attempted it many times. In light of this , it is important to be patient , empathetic , and nonjudgemental when interviewing a patient who smokes. Lectures or glib pronouncements (eg, “if you don’t stop song you are going to kill yourself”) are rare helpful. Differential diagnosis The diagnosis of nicotine abuse is not usually doubt . however , be alert for other substances abuse disorders (eg, alcohol, illicit drugs ) and psychiatric illness (eg, depression , anxiety disorder ) that may complicate management. HISTORY AND PHYSICAL EXAMINATION History history of present illness . When did you start smoking ? Past medical history . Do you have nay otters medical problems (eg, cancer, cardiovascular disease )? Social history . What kind of work do you do ? They physical examination may be very limited . However , you should make observations about the patient’s psychological states (eg, mood/affect , alertness , psychomotor activity) during the interview .A brief cardiopulmonary examination may also be appropriate , in addition to examination of any symptomatic body system. Closing the encounter Motivation Interviewing 1 Indications 2 Principles 3 Technique (OARS) Treatment is not tested as part of the USMLE Step 2 CS exam. However , a brief counseling intervention regarding quitting is appropriate. Help patient identify factors that might make quitting more or less difficult .Allow them to express any preference on quitting strategies and treatments (eg,prescription medications). Be positive and encouraging about their desire to quit. If the patient is ready to quit , encourage setting a “quit date”. The idea quit date is a low -stress day (eg, a weekend ) with no significant social engagement that might make patient’s first day without nicotine more difficult . the date should be soon enough that the patient dose not lose motivation but still has adequate time to prepare (eg, purchase nicotine patches) without feeling rushed. Diagnostic studies Diagnostic studies testing is not often needed in smoking cessation . You can consider basic screening tests for any significant complications you suspect (eg. chest x ray , spirometry for chronic obstructive pulmonary disease), but these should be kept to a minimum . Toxicology testing (eg, urine nicotine or cotinine levels 0 is not usually helpful. If no tests are necessary , write “No studies indicated “ in the Diagnostic Studies section of your documentation.
-- 作者： JuanFe SHOULDER PAIN Doorway information about patient The patient is a 56 - year - old man who comes to the clinic due to shoulder pain. Vital signs Approach to the patient Shoulder pain can be categorized based on the following factors: . Acute (<2weeks) or chronic The clinical history in shoulder disorders is often fairly straightforward , but a though examination amy require an extended time . Physical examination for should pain , as for many orthopedic disorders , benefits form a variety of standardize , validated maneuvers (eg , painful arc test , Neer impingements test ). Be sure to allow adequate time for examination and an appropriate wrap-pup discussion. Differential diagnosis Common causes of shoulder pain 1 Rotator cuff impingement or tendinopathy 2 Rotator cuff tear 3 Adhesive capsulitis (frozen shoulder) 4 Biceps tendionpathy/rupture 5 Glenohumeral osteoarthritis Most pasting with shoulder pain have an intrinsic musculoskeletal disorder of the shoulder . however , features suggesting referred pain form the internal organs (eg, heart , gallbladder) include pain not related to motion or position , nomusculoskeketal system (eg, cough , nausea), vague or diffuse location, and significant medical risk factors(eg , heavy smoking) The most common cause of shoulder pain in a primary care setting is -subacromial impingement syndrome- , group of disorder (eg, subacromial bursitis , rotator cuff tendinitis , tedinitos of the long head of biceps),characterized by worsening of pain with lifting the arm overhead or lying on the affected side. HHISTROY AND PHYSCIAL EXAM History History of present illness . Tell me about your pain. Past medical history . Have you ever had a similar problem? Social history . What kind of work do you do? As your examine the shoulder , try to visualized the underlying musculoskeletal anatomy. Additional information on examination of the shoulder can be found in the physical Examination section. physical examination Musculoskeletal . Inspection for swelling , deformity , or redness. Skin . Examine ofr rash (eg, Herpes zoster). Neurologic . Check reflexes. Closing the encounter In the warp-up discuss with the patient , explain your differential diagnosis and the significance of abnormal finding form the physical examination . Encourage the patient to discuss how the problem is affecting activities. In most musculoskeletal conditions , diagnosis and management is heavily dependent on the acuity and course over time . Patient with acute trauma or with prolonged symptoms that have not improved as expected warrant a more aggressive evaluation , whereas patient with subacute symptoms that are slowly improving may benefit form symptomatic management and close follow-up .
-- 作者： JuanFe PREEMPLOYMENT EXAMINATION Doorway information about patient The patient is a 25 -year-old man who comes to the clinic for a pre-employment evaluation Vital signs Approach to the patient Pre-employment medical evaluations generally fall into one of a few categories: . To assess fitness in a worker whose job is unusually strenuous or in whom a medical condition could put the public at risk (eg,truck drivers, air traffic controllers) .To provide aggressive preventive care for a high-level employee in whom unexpected absences could jeopardize the company at large (“executive physical “) .To screen for substance abuse or other mental health disorders (often requires as a condition of employment for an individual with a history of substance abuse) .To provide general preventive care as a non monetary benefit for the employee(“wellness examination”) In most cases , patients coming to the office for a pre-employment visit have explicit instructions (often on a preprinted form)listing what must be done during the visit . If the patient requires additional examinations , You may do those as time permits , but the required services should be complete first .If the patient dose not provide specific instructions , conduct a routine preventive visit. HISTORY AND PHYSICAL EXAMINATION The pre-employ,meant visit should address the following topics : . Past medical , family , and social histories , include medications , drug allergies , and tobacco/alcohol/illicit drug use . Occupational history . Age-appropriated history . Vaccine history . Occupational health exposures(eg,toxins, blood-borne pathogens) . Personal protective equipment(as appropriate) . General multi system examination, including vital signs if the form asks you to measure blood pressure , perform the measurement yourself . This differs from most other encounters in the USMLE Step 2 CS exam , in which you should rely on the vital signs provided in the Doorway information . Closing the encounter If the patient has given you a form to complete and time is short , advise the patient that you will fill out the form after leaving the room and mail it to the patient’s home. Note in your documentation if the patient has an obvious disqualification for the job that would put the patient or the public at risk or if the patient is unable or unwilling to use personal protective equipment or follow appropriate safety practices. Diagnostic testing The patient will usually notify you want diagnostic tests are required. common test include : The patient should also be offered age-appropriate screening tests. Additional tests(eg, blood counts , serum chemistries ) are recommended only of the patient encounter reveals specific indications for them or the patient has certain high-risk exposures (eg, chest x-ray and pulmonary function tests for patient with inhalation exposure to hazardous particulate).
-- 作者： JuanFe PALPITATIONS Doorway information about patients The patient is a 28-year-old man who comes to the clinic sue too palpitations. Vital signs Approach to the patient Palpations can be defined simply as an awareness of the heart beat and can be uncomfortable or disconcerting to the patient . Palpations may be fleeing or sustained ,and can be described as rapid , irregular , forceful , or as a strange “flip-flopping” sensation in the chest . The character of the palpations can give clues to the cause(eg,ventricular premature contractions amy present as isolated , forceful beats occurring at rest ), but historical features alone are rarely sufficient for diagnosis. Although palpations are typically though of as a cardiac phenomenon , patients with anxiety or hyperadrenergic states may experience palpations in the absence of intrinsic cardiac abnormalities. Conversely, recurring palpations can be a source of anxiety and become self-perpetuating . In light of this , it is important to be sensitive to any underlying anxiety a patient may have , but do not allow the presence of anxiety to preempt a thorough evaluation. Differential diagnosis Differential diagnosis of palpations 1 Structure heart disease : Valvular heart dies , cardiomyopathy 2 Cardiac conduction disease : Atrial fibrillation , supraventricular arrhythmia /ectopy , ventricular arrhythmia / ectopy 3 Metabolic disorders : Hyperthyroidism , pheochromocytoma , hypoglycemia , anemia. 4 Neuropsychiatric disorders : Anxiety disorder , insomnia. 5 medications : Stimulants , vasodilators , bronchodilators , anticholinergics 6 other substances : caffeine , alcohol(abuse or withdrawal) , cocaine , amphetamines. Cardiac source of palpitations is more likely in a patient who was a sensation of irregular heartbeat , prolonged symptom(>5 min) or underlying heart disease . Some patient may learn to terminate the symptoms by vagal maneuvers (eg, coughing , valsalva), which suggest a supra ventricular tachycardia. -Syncope or pre syncope _ suggests possible malignant arrhythmias(eg. non sustained ventricular tachycardia ). Occasional “skipped beats “ that occur at rest and disappear with activity in an otherwise healthy , well-conditioned patient are common and usually represent benign ectopy . A cardiac cause iOS more like in patients presenting to the emergency department , whereas a psychiatric cause is more common in a ambulatory clinic setting. HISTORY AND PHYSICAL EXAMINATIONS The cardiovascular examination for a patient with palpations should be through and will likely require examination in multiple positions (upright , supine 45 degree). Be sure to allow adequate time for a proper examination. History of present illness . Please describe what your palpations feel like. Past medical history . Have you been diagnosed with any others medical conditions( eg, heart disease , hypertension, asthma)? Medications/ allergies . Do you take any medications (prescription or over-the-counter)? Family history . Are there any heart conditions in your immediate family? Social history . Do you smoke ? At what age did you start & How much do you smoke ? PHYSICAL EXAMINATION Neck Lungs Heart Neurologic Extremities Skin Closing the encounter Following the physical examination , mist patient with palpitations may need only a brief wrap-up discussion . Review the most important findings in the history and physical examination, and discuss your differential diagnosis and any anticipated diagnostic studies . However , patients having significant anxiety regarding the symptoms may require extra time . Encourage them to express their concerns (eg, “what are you concerned may be causing your symptoms ?”) and provide reassurance as appropriated but avoid minimizing their concerns or giving false reassurance . Diagnostic studies A resting - 12 -lead -ECG - should be performed on almost all patients with palpitations or other symptoms that are potentially due to cardiac condition disease . In the Step CS exam , an ECG ,ay be provided for you in the patient room , and you should review common ECG abnormalities prior to the exam . More advanced cardiac diagnostics (eg , echocardiogram , exercised stress test ) are usually not ordered as a first step unless there are oath specific indications (eg , prominent heart murmur). Ambulatory monitoring (eg, Holter monitor )can be considered if the patent is having frequent symptoms and the resting ECG is non diagnostic . Laboratory studies are worthwhile in most cases but the initial testes are usually limited to basic markers : Chest - x -ray ,may helpful to assess the cardiac silhouette , advanced imaging studies (eg , CT scan , MRI ) are usually not needed.
-- 作者： JuanFe OBESITY Doorway information about patient The patient is a 40-year-old woman who comes to the clinic due to weight gain Vital signs Approach to the patient initial assessment of obesity History&symptoms of obesity & obesity-related complications Biometric measurements Laboratory studies Patient may come for evaluation of obesity due to cosmetic reasons , social discomfort , weight-related comorbidity (eg , diabetes , osteoarthritis), or concern for an underlying metabolic disorders (eg , hypothyroidism) . The evaluation has 3 parts : Ruling out any - underlying disorders - causing weight , identifying - complications - of obesity (eg, back pain , obstructive sleep apnea), and screening for - comorbid conditions _ that occur in association with obesity(eg, diabetes) Obesity is categorized based on BMI (weight in kilograms/ height in meters squared): The term ‘mobbed obesity “is often used interchangeably with severe obesity , but should generally be reserved for patient with weight -related complications. Different diagnosis In most cases . obesity is due to nonmediacal causes , such as sedentary lifestyle or overeating . Other common causes include pregnancy , menopause , smoking ,cessation , sleeping deprivation , and medications (eg, oral contraceptives , sulfonylureas , tricyclics) . Less often , an endocrine disorder (eg , hypothyroidism, Cushing syndrome )is responsible. History and physical examinations The following sections list the most common items that should be included in the evaluation of a patient with weight gain. HISTORY History of present illness Past medical history Medications / allergies Family history Social history If a tape measure is supplied , measure waist circumference (however , bringing a tape measure or any additional items to the USMLE Step 2 CS exam , other than a standard stethoscope , is not allowed). Physical examination General HEENT Neck Lungs Heart Extremities . Examine ofr peripherial edema. Closing the encounter The wrap-up discussion should be guided the patient primary concerns (eg, cosmetic issues, wight -related comorbidity) . Start by restating and clarifying the patient’s concerns (eg, “So you have noted a significant weight gain , and you are concerned your may have a thyroid disorder. Is that right ?”). Review the severity of the patient’s obesity , any complications or comorbidities, and any additional findings noted on examination. Treatment is not tested as part of the Step 2 CS exam . However , if a patient inquires about wight loss treatment , acknowledge the request and reassure the patient you will follow up to address appropriate options. Finally , be aware that most patients seeking medical attention for obesity have already attempted multiple diet and exercise programs . In light of this , remain empathetic and nonjudgemental . Condescending lectures and gilt pronouncements (eg “ You would lose weight if you didn’t eat so much”) are never appropriate. Diagnostic studies Extensive laboratory testing is not usually necessary , but a basic assessment
-- 作者： JuanFe NIGHT SWEATS Doorway information about patient The paint is a 22-year-old man who comes to he clinic due to night sweats. Vital signs Approach to the patient Night sweats can be defined as sweating that requires the patient to change their bed clothes and is not due to elevated ambient temperature or humidity. Night sweats can arise form disorders in virtually any system and form multiple disease modalities within those systems (eg , infection , malignancy , metabolic derangements). The evaluation should focus n features in the history and physical examination that might identify the primary system. Features that increase the likelihood of significant disease include : . Additional system symptoms (eg, weight loss , fever) Different diagnosis Menopause and male or female hypogonadism can cause - hot flashes - ( a sudden sensation of warmth in the upper body), but true night sweats may or may not be present . - Flushing - (vasodilation and redness in the face and upper body ) can also be due to menopause as well as certain medications (eg , niacin ) and carcinoid tumors. Idiopathic - hyperhidrosis - typically affects the axillae , palms , and soles and is generally worse during the day. Important causes of night sweat include: . Idiopathic (begin ) night sweats HISTORY AND PHYSICAL EXAM As noted previously , the initial goal is to identify the primary system involved. Therefor , in addition to the general questions listed here , the history should include a detailed review of system History History of present illness Past medical history Family history Social history If the patient dose not have localizing symptoms , an extended examination will be required ./ the spleen and lymphatic system , in particular , warrant attention , an all major lymphatic chains should be palpated . Physical examination HEENT Neck lymphatic lungs Heart Abdomen Neurologic Skin Closing the encounter Begin by discussing any significant findings form the history and examination, If you have narrowed the cases to a specific organ system , discuss that with the patient as well . Asking the patient for - specific concerns - (eg, ‘ What do you think may be the cause of your symptoms?” “ What are you concerned it might be?”) is often helpful for clarifying the differential diagnosis and ensuring that the patent’s concern are addressed. Diagnostic studies When evaluating a patent with nonspecific symptoms such as night sweats , focus on the most likely diagnosis and the mist straightforward tests. you may need to screen multiple organ systems , but avoid taking a “ shotgun” approach of ordering many low-yield tests to rule out unlikely possibilities. Be diplomatic in discussing sensitive subjects (eg, HIV test) Tests to consider in the evaluation of night sweats include: Advanced imagine and testing (eg, CT scan ,echocardiogram , bone marrow analysis ) are not usually ordered in the initial assessment unless specific findings are found on history or examination.
-- 作者： JuanFe CARAPL TUNNEL SYNDROME (HAND PAIN) Doorway information about patient The patient is a 41 -year-old woman who comes to the clinic with hand pain. Vitals signs Approach to the patient Evaluation of hand symptoms should address 2 interrelated aspects: Chronic orthopedic disorders are common ,,and you may encounter a patient who has characteristic findings of a certain condition (eg- Heberden nodes of osteoarthritis-) but whose pain is actually due to unrelated case (eg, -Raynaud phenomenon-) Different diagnosis The diagnosis should first note any trauma that might indicated a fracture , sprain , or ligament avulsion . For atraumatic pain , the differential diagnosis is strongly influenced by location : . Osteoarthritis typically affects the proximal and distal interphalangeal joints. Associated symptoms also are helpful in the diagnosis . for example , joints swelling and prolonged morning stiffness suggest in inflammatory arthritis. HISTORY AND PHYSICAL EXAMINATION In addition to a general medical history , the following list some of the mist important questions to ask a patient with hand pain. History History of present illness Past medical history . Have you had bone , muscle , or joint disorders in the past? Medications/allergies . Are you taking any medications , especially pain medications ? Social history . What kind of work do(did) you do? Physical examination in orthopedic disorders benefits form having a broad selection of well-validated maneuvers (eg, -Phalen test - carpal tunnel syndrome, -Finkelstein maneuver for de Quervain tenosynovitis ) In most cases , you should examine the joints immediately above the below the symptomatic area to avoid missing additional injuries. physical examination General Neck Cardiovascular Musculoskeletal Neurologic Coshing the encounter During the wrap-up discussion , allow the patient to express their concerns and ask questions regarding their fictional limitations . Specific workplace modifications need not be discussed , but a discussion of functions; status os important for understanding the overall impact of the disorder . In addition , a patient who is unable to perform household or occupational tasks may warrant a more aggressive workup than a patient who is not limited by the symptoms. Diagnostic studies Subacute overuse injuries (eg, de Quervain tenosynovitis ) or conditions with pathognomonic examination findings (eg,palmar contracture ) may not need any diagnostic tests . If no testing is needed m write , “ No studies indicated “ in the Diagnostic studies section of the patient note. - Inflammatory markers - (eg , erythrocyte sedimentation rate or c-reactive protein)can gauge disease activity in systemic inflammatory disorders (eg , rheumatoid arthritis) . - Serologic markers - (eg, cyclic citrullinated peptide antibody) can also be considered ; markers with high sensitivity (eg , antinuclear antibody) are ordered before less sensitive but more specific markers (eg, anti-double-stranded DNA antibody).Also , consider screening for metabolic disorder that might contribute to the condition (eg, hypothyroidism in carpal tunnel syndrome). Most patients with trauma or arthritic symptoms should have a plain film x-Ray . Advanced imaging ( eg, MRI ) is usually considered only of the X -ray is non diagnostic. Electrodiagnostic studies can confirm compressive neuropathies (eg, carpal tunnel syndrome) ,but are not usually ordered in the initial evaluation unless evidence of significant neurologic compromise (eg thenar atrophy and weakness) is present.
-- 作者： JuanFe MENOPAUSE Doorway information about patient The patient is a 52-year-old woman who comes to the clinic due to hot flashes. Vital signs Approach to the patent Menopause Clinical features . Vasomotor symptoms Diagnosis Treatment Menopause is the permanent cessation of menses due to the exhaustion of ovarian follicles and loss of ovarian function . It is diagnosed clinically in woman age > 45 who have a 12 - month history if amenorrhea without evidence for other causes of amenorrhea . the manage of menopause is 51. Woman often experience irregular menstrual bleeding for several years prior to the cession of menses(often termed the menopausal transition , or perimenopause). Menstrual cycles are considered irregular if the do not occur every 28+ - 7 days . Ovrail failure veofre age 40 is considered premature. Menopausal woman can have vasomotor (eg, hot flashes) and hypoestrogenic (eg, vaginal dryness) symptoms , which are most often reason for seeking medical care. Occasionally , woman may come to discuss prospect for fertility to to discuss long-tern complications of menopause (eg, osteoporosis). Different diagnosis Menopause and thyroid disorder have similar clinical manifestations. Features suggesting hyperthyroidism include heat intolerance , tremor , weight loss , hyperreflexia , and palpitations . Pituitary disorders are suggest by disruption of menses with additional endocrine (eg, galactorrhea ) or mass effect symptoms (eg, headache , visual field defects). Finally , pregnancy should be considered , especially in woman age <45 or who are sexually active without reliable contraception . HISTORY AND PHYSICAL EXAMINATIONS The history should be directed to excluding other causes of abnormal menstruation and assessing the impact of menopausal symptoms on the patient’s quality of life. History History of present illness Past medical history Medications/ allergies Social history Remember that genital and pelvic examination are not permitted in the USMLE Step 2 CS exam . If these examinations are indicated , list them in the Diagnostic Studies section of your documentation. Physical examinations General Neck Abdomen Psychological Closing the encounter Patient may have different concerns ranging from distressing perimenopausal symptoms , impacts on fertility , or risk for long-tern complications. Some women may simply want reassurance that what they are experiencing is normal . Although treatment is not tested as part of the Step 2 CS exam, treatment options will differ depending on the patient’s most bothersome symptoms , os this should be discussed as well . If the patent is having significant hot flashes, note wherever she has an intact uterus or any contraindications to systemic estrogen therapy (eg ,smoking , history of breath cancer ). Diagnostic studies Menopause is usually diagnosed clinically , and the pattern of menstrual bleeding is a more reliable indicator the hormone levels . Serum FSH may be useful for woman with cessation of menses age <45 to in older woman whom he diagnosis is uncertain (eg, hysterectomy), but it is not necessary for most women . - Estradiol and progesterone levels - decrease gradually during the menopausal transition but are highly variable and not a reliable indicator of menopause. Patient with symptoms suggest hyperthyroidism should have a - serum TSH -. A - serum prolactin level -0 should be considered for patient with features suggesting a pituitary etiology (eg, galactorrhea ). Finally , a - serum hCG - should ordered for younger women with irregular menses and any women in whom pregnancy is a possibility.
-- 作者： JuanFe INSOMNIA Doorway information about patient The patient is a 45-year old man who comes to the clinic with insomnia Vital signs Approach to the patient Insomnia can occur as a primary disorder or as a manifestation of an underlying condition (eg, restless legs syndrome , generalized anxiety disorder). the diagnosis of insomnia requires 4 key findings: Normal sleep latency ( the time for transition from full wakefulness to sleep )is < 20-30 minutes, and most patient with insomnia report sleep latency > 30 minutes (or periods of waking > 30 minutes in duration ) . How ever , patient estimators of sleep latency are imprecise , and the diagnosis should be based primarily on subjective finding rather than a numerical value of sleep latency. Different diagnosis Insomnia can be categorized as - short -tern- (< 3months ) or -chronic -(> 3months). Insomnia can also be characterized as -initial insomnia - (difficulty falling asleep ) or -terminal insomnia-(difficulty maintaining sleep or waking to early) . Initial insomnia is often associated with anxiety , poor sleep hygiene , or use stimulates , wheres terminal insomnia is often a manifestation of depression or alcohol abuse. Lack of sleep without daytime drowsiness may be an indication of bipolar disorder. However , the amount of sleep an individual needs is variable and generally declines with age. Insomnia must be distinguished form disorders in which the patient has adequate but -nonrestorative sleep- (eg , obstructive sleep apnea ), or- altered sleep schedule- (eg , circadian rhythm disorder) HISTORY AND PHYSICAL EXAMINATION Address quanta and quality of sleep , daytime symptoms , possible triggers(eg, food , caffeine ) ,and comorbid conditions (eg , thyroid disorder , chronic pain) .In addition , review patient’s sleep habits : when of they go to bed and wake uno , what of the do just before and after lying down , how often do they take naps , eft, A though history may take most encounter , but the physical examination is often brief. History History of present illness Past medical history Medications / allergies Social history Physical examination General HEENT Neck lungs heart Extremities Psychiatric Closing the encounter Patient with insomnia often have significant affective distress and may have additional stressors that are impacting their quality of life . in light of this , much of the wrap-up discussion may focus on how the patient’s insomnia is affecting well-being , functional status , and social interactions. it is often helpful to counsel patient to keep a daily “sleep dairy “ (eg , time going to bed , how long to fall asleep , number /duration of awakenings , estimated hours of sleep , daytime symptoms , dietary and exercise habits). Treatment is not tested as part of the USMLE Step 2 CS exam . however , you may be able to counsel the patient briefly on nonpharmacologic management of insomnia. Diagnostic studies The diagnosis of insomnia is based primarily on clinical features . However , a limited diagnostic workup may be needed for nay underlying medical condones tat might contribute to the symptoms. Diagnostic studies include:
-- 作者： JuanFe HEMOPTYSIS Doorway information about patient The patent is a 45-year-old man who comes to the clinic with a cough and blood in his sputum. Vital signs Approach to the patient Hemoptysis is the expectoration of blood form the lower respiratory tract can can range form minimal blood streaking in sputum to frank blood and /or clots . Massive hemoptysis is defined as acutely life-threatening hemoptysis , typically > 100 ml/hr or >500 ml/24hr For the step 2 CS exam , the possible diagnosis should be listed in order likelihood rather than acuity or severity . However , the acuity of hemoptysis and free of respiratory distress are often helpful in identifying the likely cause . Frank blood or massive hemoptysis usually indicates bleeding form the bronchial artery distribution (high-pressure systemic circulation) rather than the alveolar circulation (low-pressure pulmonary circulation). Differential diagnosis Causes of hemoptysis Pulmonary Cardiac Infectious Hematologic Vascular Systemic disease Other pulmonary airway disorder (eg. chronic bronchitis , bronchogenic carcinoma , bronchiectasis) are the most common causes of hemoptysis . -Bronchogenic carcinoma- is suggested a heavy smoking history and associated system symptoms (especially weight loss). - Chronic bronchitis - is defined as a chronic productive cough for >=3 months in 2 successive years, and cigarette smoking is the leading cause. - Bronchiectasis - is irreversible dilation and destruction of bronchi, resulting in chronic cough and impaired mucus clearance . compared with chronic bronchitis m bronchiectasis is more likely associated with recurrent respiratory tract infection and production of copious mucopurulent sputum. Other movable causes of hemoptysis include: HISTORY AND PHYSICAL EXAMINATION In addition to the standard general medical history and physical examination , the following sections include many of the most common items that should included in the evaluation of patient wth hemoptysis History history of present illness Past medical history Medications/ allergies Family history Social history Physical examination HEENT Neck Lungs Heart Extremities Closing the encounter In most cases of hemoptysis , it is not possible to make a definitive diagnosis solely on history and examination findings . Even apparently minor or intermittent hemoptysis can signify a serious underlying disease .Before leaving the room , discuss with the patient the importance of the diagnostic evaluation. It may be helpful to assess the patient’s own concerns before launching into a detailed discussion of the differential diagnosis. Diagnostic studies A plain -chest radiograph- is the initial test of choice and is indicated for almost all patients with hemoptysis . chest -X -ray can identify the site and causes of bleeding (eg, cavitary lesion , lung mass , sign of mitral stenosis ) in over a third of patient, Laboratory studies are also ordered for most patients with hemoptysis , but the test indicated depend on the specific clinical scenario. Common options include: . Complete blood count(infectious, platelet disorders) The need for invasive studies (eg, fiberoptic bronchoscopy ) and advanced imaging ( eg- high-resolution CT scan ) is usually determine after the initial test have been completed . However , these studies may be done earlier in patient with massive hemoptysis.
-- 作者： JuanFe HEEL PAIN Doorway information about patient the patient is a 35-year-old man who comes to the clinic due to 1 week of left heel pain. Vital signs Approach to the patient Physical examination in orthopedics benefits form having a broad selection of specific , well-validated -maneuvers -(eg, Lachman test for anterior cruciate ligaments injury , Thessaly test for meniscal tear)/ In most cases , it is worthwhile to examine the joints immediately - above and below- the symptomatic area to avoid missing additional injuries and rule out referred pain. Different diagnosis Differential diagnosis of heel pain Plantar facilities Ruptured plantar fascia Bone infection/ Metastasis Calcanea stress fracture Tarsal tunnel syndrome For heel pain , the differential diagnosis is driven primarily by location . Chronic pain at the plantar aspect is usually due to -plantar fasciitis-. Risk factor include obesity , running /jogging , dancing , prolonged standing , and yes plants (flat feet). The pain is usually worst when first stepping out of bed and may improve as the day progresses. Examination shows point tenderness at the insertion of the plantar fascia on the calcaneus and increased pain with dorsiflexion of the toes. HISTORY AND PHYSICAL EXAMINATION The following section include many of themes common items that should be included in the evaluation of heel pain. History History of present illness Past medical history Physical examination Musculoskeletal Cardiovascular Neurologic Skin Closing the encounter Follow the history and physical examinations , the diagnosis of musculoskeletal conditions his often apparent ( especially if there are positive findings on specific maneuvers .) however , your discussion should address the need for any additional testing . As musculoskeletal disorders are frequently discussed in popular culture and the ay media , you should allow adequate time for patient to ask questions and to tactfully counsel them on any misconceptions they may have . Diagnostic studies Patient with acute trauma warrant an expedited evaluation including imaging , as do those with chronic symptoms the are not improving as expected. However , if patient are experiencing gradual improvement , it may be best to simply counsel hem on appropriate measures (eg, activity modification) and defer additional testing . For the USMLE step 2 CS , if no additional testing is needed , write , “No studies indicated” In the diagnostic studies section of the documentation. Most evaluations in orthopedics begin with plain film x-rays , which can identify acute fractures and many chronic disorders (eg, osteoarthritis) . X-rays have low sensitivity for soft -tissue injuries , but may reveal bony deformity that predispose the patient to chronic complications . For plantar fasciitis specially , x-rays are rarely helpful and the diagnosis is usually made based on clinical features . Imaging frequently identifies nonspecific abnormalities (eg, ligamentous calcification) that do not correlate with symptoms and are not useful for clinical decision making . Other studies that can be considered for musculoskeletal disorders include:
-- 作者： JuanFe HEADACHE Doorway information about patient the patient is a 40-year-old woman who comes to the clinic due t headaches. Vital signs Approach to the patient headache are usually diagnosed based on historical features . Examination is normal in most patients , and is primarily focused on ruling out uncommon diagnosis. Differential diagnosis Types of headaches Migraine Sex predilection - Female> male Cluster Male>Female Tension Tension -type headache is the most common headache syndrome. It begins slowly over several hours and may act for days if not treated . Characteristic feature include a bilateral squeezing or pressure sensation , particularly at the temporal or occipital area . Associated symptoms (eg, nausea , visual changes ) are rare. Sure migraine headaches are usually unilateral , have throbbing quality , and may e associated with nausea and visual disturbances .Migraines generally have a rapid onset and recognizable triggers such as caffeine , food/beverages (eg, chocolate, red wine) , or menstruation . migraines can be categorized as -without aura-(common migraine) or -with aura-(classic migraine) . An -Aura- is a transient neurologic (usually visual) symptom at the beginning of the headache . A history of “flashing lights” or “ wavy lines ‘ in the visual fields flooded by a throbbing unilateral headaches is virtually pathognomonic for migraine . Atypical migraines are common , and many nonstandard headache types(eg , sings headache ) actually represent migraine variants. Secondary headaches are less common than primary headache syndromes but usually more ominous . major syndromes include: HISTORY AND PHYSICAL EXAMINATION In addition to the standard general medical history and physical examination , the following sections include the most common items that could be include in the evaluation of headaches. History history of present illness Past medical history Family history Physical examination HEENT Neck Musculoskeletal Neurologic Closing the encounter Older patients or patients with atypical symptoms amy need additional diagnostic testing . in such cases , explain the possible causes and the goals of the tests. Give the patient an accurate assessment of the diagnostic uncertainly (eg “ Your symptoms suggest benign migraines , but it its usual for someone your age to have headaches for the first time. I would like to do additional testing to be sure .”) Explain that there are no tests to confirm migraine or tension-type headaches, but tests are done to rule out other disorders. Diagnostic studies Patients with focal neurogenic symptoms ( other than a stereotypical aura) or any off the “ SNOOP” criteria should be considered for -neuroimaging- . Patient with suspected -subarachnoid hemorrhage- or signs of elevated intracranial pressure usually undergo an urgent -CT scan- . For less urgent indications , MRI has greater sensitivity. -Lumbar puncture(LP) - may be considered in the evaluation of atypical or potentially serious headache syndrome . LP can confirm subarachnoid hemorrhage , but CT is done first . Otters indications for LP include-bacterial meningitis - and idiopathic intracranial hypertension (pseudo tumor cerebri) Patients with possible -giant cell arteritis- should have -erythrocyte sedimentation rate or C-reactive protein- tests . Patients with fever or otters systemic symptoms should have a -complete blood count- . Patient with severe hypertension should have an -ECG- and -renal function studies- (blood urea nitrogen , creatinine , urinalysis).
-- 作者： JuanFe FORGETFULNESS Doorway information about patient The patient is a 70-year-old woman who comes to the clinic due to episodes of forgetfulness. Vital signs Approach to the patient Cognitive impairment in elderly patients Normal aging Mild neurocognitive disorder (mild cognitive impairment) Major neurocognitive disorder (dementia) Major depression The first in evaluation of possible -dementia- is to assess the - acute and severity- of the impairment . Severity should be rate with objective tests (eg , Mini -Mental State Examination) and a subjective discussion of how the problem affects the patient’s activities of daily living. Second , determine whether the symptom s involve only learning and memory , or additional -neurocognitive domains- (eg, complex attention , perceptual-motor-function, language , executive function, social cognition) , Finally , use the physical examination and diagnostic testing to identify and -underlying medical conditions -or reversible causes of impairment. Different diagnosis Alzheimer disease Vascular dementia Frontaltemporal dementia Normal pressure hydrocephalus Prion disease The primary types of -dementia- are listed in the table . Alzheimer dieseae is most common . Other -neuropsychiatric disorders- amy manifest as memory impairment (eg, major depression, multiple sclerosis) . -Metabolic disorders- (eg, hypothyroidism, vitamin B12 deficiency0 should be considered and screened for initial testing. Finally , -medications -(ego tricyclic antidepressants, benzodiazepines) and -alcohol abuse- are major causes of cognitive dysfunction. HISTORY AND PHYSICAL EXAMINATION \Be sure to pay attention to the time when interviewing a patient with memory loss, as the clinical examination may be lengthy. History History of present illness Past medical history Medications/ allergies Social history Physical examination General Neck Cardiac Neurologic - Mini-Mental state Exam - Psychiatric Closing the encounter Explain that you will be looking for treatable disorders (eg, hypothyroidism) that can masquerade as dementia , and that even if the patient has dementia there may be treatment available to improve the symptoms or slow the progression of the disease . Also discuss what family support and community resources are available to the patient. Diagnostic testing Most patients with memory impairment should have a -TSH- and -vitamin B 12- assay, Additional tests are based on the patient’s clinical features . Possible test include: . Electrolytes and glucose In addition , the status of chronic disease should be assessed (eg, hemoglobin A1c for diabetes ) , and therapeutic drug levels (eg, digoxin) should be checked . -Neuroimaging-(eg, CT scan, MRI) is ordered in mist cases but is not mandatory . lumber puncture and more obscure tests (eg,heavy metal screen) are not typically done in the initial workup.
-- 作者： JuanFe ENURESIS Doorway information about patient You will be speaking with mother of a 5-year-old boy who wets his bed frequently. Approach to the patient -Enuresis- is nocturnal urinary incontinence in children age >=5 years . It occurs in up to 15 % of children at age 5 years and is more common in boys . Enuresis can be categorized as -primary- (patient has never had a sustain period of nocturnal continence0 or -secondary-(incontinence after the patient has had a period of dryness lasting >= 6 months) and -monosymptomatic- (isolated incontinence) or -nonmonosymptomatic- ( nocturnal incontinence associated with additional symptoms [eg, daytimeincontinence , urinary hesitancy , feeling of incomplete emptying , abdominal pain]). Secondary enuresis is often due to -psychological stress- or an underlying -medical problem-. Differential diagnosis Causes of secondary enuresis Psychological stress : Behavior regression , mood lability Urinary tract infection : Dysuria , hesitancy ,urgency , abdominal pain. Diabetes mellitus : Polyuria , polydipsia , polyphagia , weight loss , lethargy , candidiasis Diabetes insipidus : Polyuria , polydipsia Obstructive sleep apnea : Snoring , dry mouth , fatigue , hyperactivity , irritability the patient (and child ) should be queried about additional symptoms that may suggest a neurologic disorder (eg , spinal dysraphism). urinary tract infection , encopresis / constipation , or metabolic disorders (eg, diabetes mellitus , diabetes insidious). recent psychological stressors should be noted . Enuresis can also be associated with abnormal fluid intake (eg, psychogenic polydipsia ) , obstructive sleep apnea , and irritative lower gastrointestinal disorders (eg, pinworms). Genitourinary cause of enuresis are often associated with daytime incontinence , holding maneuvers , abnormal voiding (eg, interrupted micturition , weak stream ) , and frequent small-volume voids. HISTORY AND PHYSICAL EXAMINATION Practice pediatricians often have the parents keep a log of the child’s daily fluid intake and voiding habits (i.e., timing , volume , voiding symptoms). In the Step 2 CS exam , such follow-up is not possible ,m but you may ask about the patient’s recollection of these factors. History History of present illness Past medical history Social history Most children with enuresis have normal findings on physical examination, Remember that you are -not permitted- to perform genitourinary , rectal , pelvic , or inguinal hernia examinations (if these are necessary , you may include them in the Diagnostic Study/ Studies section of your documentation). Physical examination General HEENT Gastrointestinal Musculoskeletal Neurologic Closing the encounter Although psychological stress is a common cause of enuresis , be careful to remain non-accusatory and non-judgmental . If you identify signs of an underlying medical disorder , these should be discussed with the parent , but explain your degree of uncertainty and the need for confirmatory tests (eg, “Excessive fluid intake with frequent , large-volume urination may be a sign of diabetes or a kidney problem , but there are other possible explanations as well . We will need to do additional tests before I can give you a definite diagnosis”) Keep in mind that parents may be more anxious about health problems in their children than they would be for a similar problem in themselves. Avoid giving false reassurance , but sure them that you will work with them to identify the problem and provide appropriate care . It may be helpful to note that enuresis is common and often resolves spontaneously. Diagnostic studies Depending on the clinical findings , the initial evaluate may include a -urinalysis- on first -morning void . Additional studies that may be considered include :
-- 作者： JuanFe DOMESTIC VIOLENCE Doorway information about patient The patient is a 45-year-old woman who comes to the clinic due to bruises on her arms and face after fall Vital signs Approach to the patient Assessment of intimate partner violence Concerning signs . location of injuries (genital , breasts , abdomen , head , neck , teeth) Interview strategies . Ensure privacy(ask others to leave for interview) Recognition of intimate partner violence is commonly addressed in the USMLE Step 2 CS exam. The simulated patient may come ostensibly for evaluation of some other problem with the violent behavior apparent only after extensive discussion . For this reason , you should be alert for signs of domestic violence in the simulated patients you see thought the test day. Different diagnosis Intimate partner violence should be considered in the differential diagnosis of acute chronic trauma., It should also be considered in case in which the cause of symptoms in uncertain , or if the patient’s symptoms and examination findings are not consistent with the reported mechanism off injury. In addition to the primary injury , the physical should be aware of any comorbid conditions , disabilities , and substance abuse issue (in the patient or partake ) that should affect the ability of he patient to respond to the abuser . In particular , individuals with intellectual disabilities are more likely be be victims of violence and may be less able to escape or report their injuries. HISTORY AND PHYSICAL EXAMINATION The medical history should be open and direct , but empathetic and nonjudgmental . Do not pressure the patient to disclose details of abuse . Extra times should be allowed to explore psychiatric and social history , and patients should be queried for suicidality and risk for self-harm. History History of present illness . I noticed that you have a number of bruises . ow did these occur? Social history . Who loves at home with you now? The physical examination of a patient with intimate partner violence is not significantly different from a patient with similar injuries but without a history of violence . However , unusual wounds , wounds in unusual locations ,and wounds in multiple -stages of healing- should be noted and suggest possible abuse. Patient who are victims amy refuse to disrobe or allow examination of certain body parts . If the patient refuses examination , explain the reason you need to do the examination . If the patient is still resistant , abide by these wishes move on . Remember also that you are -not permitted- to perform genitourinary , rectal , pelvic , inguinal hernia, or female breast examinations in the USMLE Step 2 CS exam (if examination is necessary you may indicated this in the diagnostic workup section of the documentation). Closing the encounter Individuals in abusive relationships may minis or deny abuse due to shame , fear or partner retaliation , believing that there is no alternative , or feeling that the abuse is deserved. the physician should affirm that nay abuse is wrong but avoid counseling the patient in a directive way. Confrontation of denial , pressuring the patient to report the abuse , or urging the patient to l;eave the partner is inappropriate . Physicians also should confront of discuss suspected abuse with the partner as this can endanger the patient. physicians should assess the immediate and future safety of patients with intimate partner violence . the most important initial intervention is identification of an -emergency safety plan- (eg, “Where is a safe place that you can go when you are afraid?”) . In addition , discuss community resources , including domestic violence shelters and counseling services. Diagnostic studies Diagnostic studies are primarily used to guide patient management but may also occasionally be used in the course of subsequent legal proceedings. You should bot order tests that are not otherwise medically indicated “ just in case “(eg, x-ray of asymptotic body parts). However , it is appropriate to have lower threshold for ordering tests that can provide contemporaneous evidence of any injuries you do note . In most cases , plain film radiographs are adequate m although CT scan should be considered for craniofacial injuries. Incase of -sexual assault- , additional studies may include:
-- 作者： JuanFe DIZZINESS Doorway information about patient the patient is a 65-year-old woman who comes to the clinic for episodes of dizziness Vital signs Approach to the patient Dizziness encompasses a variety of syndromes involving different organ systems. The most common causes include vestibular dysfunction , cardiac / hemodynamic instability , sensor dysfunction , and psychiatric disorders . Although the patient interview can often identify the cause, even classic descriptions can be nonspecific or misleading (eg, a patient with anxiety may describe syndromes as “spinning”) Begin by allowing patients to describe the sensation in -their own words- before asking about specific types of dizziness . Clarify the onset and course over time , associated symptoms , triggering factors , and underlying medical conditions (eg , cardiovascular , neurologic , psychiatric disorders). Confirm whether the patient lost consciousness during an episode : if so , specify the duration , time to recovery , and whether the patient suffered any injuries. Differential diagnosis Common causes of dizziness Category Vertigo . -Benign paroxysmal positional vertigo- Presyncope . -Cardiac arrhythmias- Disequilibrium . Peripheral neuropathy Nonspecific . Anxiety & other psychiatric disorders -Vertigo_ is an abnormal sensation of motion (eg , spinning, tilting ) . The most common causes is -benign proximal positional vertigo-(BPPV) , which is provoked by change in head position . Vestibular neuritis cases prolonged vertigo . Often following a viral illness . vertigo with tinnitus , hearing loss, and a feeling of fullness in the ear suggests -Meniere disease- . -Vertebrobasilar stroke- causes debilitating vertigo , often with other neurologic deficits. -Presyncope- is lightheadedness lasting seconds to a few minutes . it is often associated with visual disturbances and usually occurs in an upright position . Pre syncope with sweating and nausea usually represents a vasovagal event and is common in young , healthy patients. Sudden onset in a patient with cardiac disease suggests an arrthymia . Exertion symptoms suggest valvular heart disease (eg , aortic stenosis). Orthostatic symptoms are common in individuals with neuropathic conditions or taking certain medications(eg , diuretics , beta , blockers). -Disequilibrium_ is a sense of imbalance with walking . It is typically seen in patient with sensory disorders(eg, loss of peripheral vision , peripheral neuropathy) , neuromuscular disorder, and certain central nervous system disorders (eg , Parkinson disease,, normal -pressure hydrocephalus). HISTORY AND PHYSICAL EXAMINATION The following sections list items that should be addressed in a patient with dizziness . Note that historical features (including the character of the dizziness and the patient’s medical history) are usually more helpful than the physical examination. History History of present illness . How long have you had this spells? Past medical history . Have you had a similar problem before ? Social history . Do you smoke? Physical examination General . Alertness, orientation & level of distress HEENT . Whisper , Rinne , Weber tests Cardiovascular . Auscultation ofr murmurs , rubs , or gallops Neurologic . Cranial nerves The -Dix-Hallpike maneuver- is specific test for BPPV. The patient is seated on the table. the head is turned 45 degrees to one side , and the patient lies back quickly . Watch the eyes for nystagmus and ask if the patient feels dizzy. In the Step 2 CS , the simulated patient may not have any objective findings , but subjective vertigo suggest BPPV Closing the encounter During the wrap-up discussion , review the possible diagnosis and any test that may be needed . In addition , patient with dizziness should have an assessment of safety prior to being released . Ask about any falls or injuries they may have suffered during their episodes of dizziness , and make sure their gait is stable. Also , ask what assistance they may have at home and who can help them if their symptoms worsen. Diagnostic workup Diagnostic testing should reflect the underlying health of the patient . A young patient with peripheral vertigo may require no testing at all , whereas an elderly patient with nonspecific dizziness may need an extensive workup . Focus on the most likely system rather than taking an unfocused , “shotgun”approach. An ECG should be ordered in all patients with suspected arrhythmias or other cariogenic causes. . Fasting glucose
-- 作者： JuanFe DIABETIC DRUG REFILL Doorway information about patient The patient is a 50-year-old man who comes to the clinic for a refill of his diabetes medications. Vital signs Approach to the patient Oral anti diabetic agents Class 1 Insulin secretagogues . Sulfonylureas (eg, glimepiride) . Hypoglycemia 2 Biguanides . Metformin . Gastrointestinal upset 3 Thiazolidinediones . Pioglitazone . Weight gain 4 DDP-4 inhibitors . Sitagliptin . Headache 5 GLP-1 receptor agonists . Eventide . Nausea/vomiting 6 Alpha-glucosidase inhibitors . Acarbose . Diarrhea SGLT2 inhibitors . Canagliflozin . Polyuria DPP4=dipeptidyl peptidase-4 ; GLP-1=glucagon-like peptide-1 ; SGLT2=sodium-glucose coteransporter-2 There are 2 primary objectives in chronic medication management: . Determine whether the medication regimen is -safe-. The physician should review whether the patient has -contraindications- to the medication and whether there are potential -interactions- with the patent’s other medications. Ask if the patient has any 0side effects-, and perform a physical examination to assess for disease-related complications. Outcome measures are followed to determine whether the patient is meeting -treatment targets- and to assess the disease -course over time-(i.e., stable, better, worse). For diabetes , the main outcome measure os glycemic control , which is assessed with fasting glucose , hemoglobin A1c, and home glucose monitoring. Patient with diabetes should have periodic examination of the feet , including monofilament testing for sensory neuropathy . They also should have a dilated eye examination for retinopathy(usually performed by an ophthalmologist). neuropathy screening is typically performed with a urine micro albumin assay. Because diabetes is a major risk factor for cardiovascular disease , other risk factors (eg, blood pressure, smoking) should be addressed. Differential diagnosis In a visit for disease management , there may not be a question about diagnosis. however , reman alert to indications that the conditions is -out of control- , to potential secondary -complications- of the condition , and to signs that the original diagnosis is -incomplete or erroneous- (eg, diabetes secondary to underlying hypercortisolism). HISTORY AND PHYSICAL EXAMINATION History History of present illness . When were you diagnosed with diabetes? Past medical history . Have you ever been hospitalized for diabetic complications or for any other reason? Social history . Do you smoke ? when did you start & how much do you smoke? Physical examination General . Assess alertness, orientation HEENT . Perform ophthalmoscopic examination Cardiovascular . Auscultate heart Neurologic . Assess light touch(monofilament if available ) & joint position sense in the feet Extremities . Examine feet for deformity , ulcerations , calluses (Ask patient to remove sho&socks: if a pad or extra drape is available , place this under the patient;s bare feet.) Closing the encounter Before leaving the room , summarize your findings with the patient . Be sure that the patient understands the medication regimen. Discuss what gets need to be performed to monitor therapy and how the results may later management. Finally , counsel the patient on a personalized care plan, including diet , exercise , home glucose monitoring , and sick-day recommendations. Diagnostic studies Common tests to evaluate diabetes include: . Fasting glucose and Hemoglobin A1c (An oral glucose tolerance test is used in the initial diagnosis but not for follow-up)
-- 作者： JuanFe DEPRESSION Doorway information about patient The patient is a 40-year-old woman who comes to the clinic stating that she feels “Down.” Vital signs Approach to the patient Patient with depression may feel uncomfortable discussing emotional symptoms with an unfamiliar physician. Avoid rushing thought the interview , and allow the patriot to describe their symptoms in their own words .Remember to convey empathy using verbal and nonverbal cues. Complicating factors , such as substance abuse or psychotic features , should be noted . It is also important to identify patients with a history of -manic or hypomanic episodes- suggesting -bipolar disorder-,as management may be significantly different for these patients . In addition , all patients with depression should be evaluated for -suicidality- . If the patient is at risk , explain that you awful need to work with the patient to obtain an expedited evaluation form qualified mental health professional. ————————————————————————————— -Manic or hypomanic episodes- Manic episodes Clinical features . >= 1weeks of elevated or irritable mood & increased energy/activity Severity . Impaired psychosocial function ———————————————————————————————— Different diagnosis Major depressive disorder . >=2 weeks Persistant depressive disorder (dysthymia) . Depressed mood >= 2 years Adjustment disorder with depressed mood . Onset within 3 months of identifiable stressor Substance abuse . Alcohol Metabolic disorders . Hypothyroidism Neurologic disorders . Dementia SIG E CAPS History and physical examination Taking a history in a patient with depression usually requires more time than the physical examination. However , much of the psychiatric examination is performed during the history , While interviewing the patient , observe the patient’s -mental status- , fluidity and organization of -speech-, -affect-, and psychomotor activity. Begin with an open-ended question (eg, “Tell me about how you have been feeling”) follows by additional specific questions as necessary . the SIG E CAPS mnemonic is helpful for conducting a structured interview for patient with depression . Sleep disturbance (“Are you having trouble falling asleep or staying asleep?”) History History of present illness . How long have you been feeling this way? Past medical history . Have you had a similar problem before ? Medications/allergies . Do you take any medications(prescription or over -the -counter)? Social history . Who do you live with? Physical examination General . Alertness, orientation Neck .Examine the thyroid Neurologic . Check reflexes , noting any delayed relaxation phase Psychiatric . Mood & affect Closing the encounter At the conclusion of the interview , assess the patient’s -insight-(i.e., how well one understands their own condition). Simple , empathetic questions (eg, “So what do you think may be causing you to feel this way?”) can be very helpful . Although treatment is not tested in the USMLE Step 2 CS exam , you should also briefly discuss the patient’s -readiness- to consider treatment options ( eg “Would you be willing to talk with a counselor?”) Diagnostic studies Diagnostic testing is not always needed , especially in young patient with classic depression symptoms. A-complete blood count- and -TSH- are commonly performed but are not mandatory. However , additional tests are indicated if the diagnosis is uncertain , if there is a possibility of substance abuse , of if there are comorbid medical conditions that may be contributing , Possible tests include: . Electrolytes and glucose Imaging is not indicated unless there are additional neurologic findings or suspicion for dementia. MRI should be considered if the history suggests multiple sclerosis (eg, episodic neurologic symptoms in multiple distributions).
-- 作者： JuanFe DARK URINE Door way information about patient The patient is a 20-year-old man who comes to the clinic due to dark urine for 5 days . Vital signs Approach to the patient Patients may report unusual or undifferentiated symptoms that could be due to disease in multiple systems . In some cases , this may represents a -cardinal manifestation- of an uncommon condition (eg, the “ target shaped “ rash of Lyme disease). Alternately , unusual symptoms may be an -atypical manifestation- of a common disorder (eg, systemic lupus erythematous presenting as migratory mononeuropathy). Dark urine can represent either an unusually concentrated urine , gematria , or an -abnormal pigment- in the urine. Abnormal urine color is usually due to disorders of the renourinary tract, hepatobiliary system, blood/hematologicc system , or musculoskeletal system. If the patient otherwise feels well, abnormal urine color is usually benign. Differential diagnosis The color of the urine can guide the differential diagnosis: . -Red- ; Blood , food pigments (eg, beets , rhubarb) , medications (eg, phenazopyrudine, rifampin), porphyrins. -Hematuria- can be categorized by the patten though urination . Blood at the start of voiding that clears is usually from a urethral source . Blood at the end of voiding suggests a bladder or prostate source .Visible blood thought voiding may represent an upper tract (kidney and collecting system) source. -Biliary obstruction- May cause dark-yellow/orange wurine with jaundice , pale stool m and right upper quadrant pain . Hematuria in a patient with a history of heavy smoking is a common presentation of -bladder cancaer- . Dark urine following a crush injury or extreme physical exertion suggests -rhabdomyolysis- . In addition , -hemolysis- may case dark urine with fatigue , jaundice m and back or abdominal pain . HISTORY AND PHYSICAL EXAMINATION In addition to the standard general medical history and physical examination, the following sections include the most common items that should be included in the evaluation of a patient with dark urine. History History of resent illness . What color is your urine? Psst medical history . Have you had a similar problem before? Medical /allergies . Do you take any medications? Social history . What kind of work do you do? Physical examination General . Observe level of alertness & hydration HEENT . Examine the oropharynx. Skin . Observer pallor or jaundice Abdomen . Auscultate bowel sounds. Closing the encounter In the warp-up discussion , the first step is to discuss the likely diagnosis along with an assessment of the diagnostic uncertainly . If a patient has pathognomonic findings for a particular disease , you should explain the significance of them, if you are uncertain about the diagnosis , say so clear, but pressure the patient that you will work with them to identify the cause. Regarding diagnostic tests, If invasive studies are necessary (eg, cystoscopy in an elderly smoker with hematuria), explain the rational for the test. Allow time for questions , and assess the patient’s readiness to undergo the studies you recommend. Diagnostic workup Patients with an abnormal urine color should have a urinalysis with microscopic analysis of urinary sediment (i.e., for casts , crystals , etc) . Note that patients with myoglobinuria amy have a positive test for hemoglobin on chemical(‘ dipstick”) urinalysis without red blood cells microscopic analysis. . Electrolytes , blood urea nitrogen, creatinine {Patient with hematuria should have evaluation of both the upper and lower urinary tract. Typical studies include CT urogram and cystoscopy , but the specific evaluation may be individualized. If hemolytic anemia is suspected , start with a complete blood count , reticulocyte count , and peripheral smear . Supportive findings include elevated lactate dehydrogenase, low haptoglobin, and elevated unconjugated bilirubin , These should be performed before specific testing (eg, hemoglobin electrophoresis , glucose-6-phosphatase dehydrogenase , osmotic fragility)
-- 作者： JuanFe CONFUSION Doorway information about the patient The patient is a 65-year-old man who is brought to the clinic by his wife for 2-3 months of confusion. Vital signs Approach to the patient Changes in mental status are most noticeable when they have an abrupt onset : patient with a slow progressive decline in function may not be brought for medical attention until the problem is far advanced and is noticed by a family member or friend who has not seen the patient for a long time. Impaired mental status can be ,infestation of visually any disease process if severe enough .Be alert for sign and symptoms that can point to the -primary body system- (eg, abdominal pain, productive cough) . Also , be aware that elderly patients who develop an acute medical illness may present with delirium but without the more characteristic symptoms of the illness(eg, urinary urgency and dysuria in acute cystitis). Although vital signs may be normal , subtle abnormalities may be an important clue too the diagnosis (eg, mild tachycardia in alcohol withdrawal) Different diagnosis Causes of delirium Predisposing risk factors: . Dementia Precipitating factors . Drugs (eg, narcotics , sedatives , antihistamines, muscle relaxers, polypharmacy) The differential diagnosis of confusion can be subdivided into chronic/progressive (i.e., -dementia-) and acute/fluctuating (i.e.,-delirium-) causes , patients may have manifestations of both , and patients with underlying dementia are more likely to develop delirium during an acute illness. Alcohol , illicit drugs , and perception pharmaceuticals are common precipitating factors for delirium. A history of mental illness is also helpful in identifying the cause of confusion , but it is often not known at the time of presentation. Before formulating a differential diagnosis , male sure that the patient has a true cognitive rather than a sensory deficit(eg, hearing loss) or aphasia that may be interpreted as confusion .Also patents with affective disorders may develop alterations in behavior that are difficult to distinguish form dementia. HISTORY AND PHYSICAL EXAMINATION Ask questions to narrow down the primary system , than follow with more detailed questions to identify a specific cause within a system . Also , try to understand the patent’s -baseline mental status- , relying on family members if possible (eg, “When was the last time your spouse seemed normal to you ?”). If the patient becomes irritable or uncooperative , it is usually better to make your clinical determinations based on the information you are able to obtain in the available time arther than rush the patient. History
. Your spouse is concerned about you being confused . Do you feel unusual? Social history . Who do you live with? Physical; examination General .Observe hygiene, posture & psychomotor activity HEENT . Palpate for thyroid enlargement Lungs . Examine for signs of consolidation Abdomen . Palpate for masses & tenderness (especially suprapubic tenderness) Neurologic . Cognition . Examine cranial nerves Closing the encounter The history and physical examination for a patient with confusion amy be lengthy ; stay aware of the time and allow adequate time for warp-up . Patients9ad their family members) with declining mental function may be understandably anxious . Encourage them to express their concerns , both to enhance the physician-patient relationship and potentially to marrow the differential diagnosis If the diagnosis is not clear by the end of the encounter , state your uncertainty honestly. Do not provide false reassurance , but assure patients that you will work with them evaluate their condition and that you will inform them of your findings in a timely manner. Diagnostic studies As with the medical history , diagnostic testing should begin with a broad assessments of system , with more specific tests done later to rule in or rule out individual disorders . Brain imaging should be considered if there is impaired arousal , history of trauma , focal neurologic findings , or correctable cause identified on initial assessment . Test to consider include: . Electrolytes, glucose , renal function markers
-- 作者： JuanFe CHRONIC DIARRHEA Doorway information about patient The patient is a 34-year-old man who comes to the clinic due to 4 weeks of diarrhea. Vital signs . Temperature: 36.7’C (98.1F) Approach to the patient Acute diarrhea is usually a self-limited illness . Unless bloody stools , systemic symptoms (eg , fever), or signs of dehydration are present, most cases are manages conservatively and do not need an extensive investigation. However , patient with chronic(> 4 weeks) diarrhea are less likely to have spontaneous resolution and warrant additional workup . Patient with usually soft but otherwise normal stools may use the term ”diarrhea” so the interview should begin by clarifying the frequency , volume , and consistency of stools. Different diagnosis Most patients who comes for evaluation of chronic diarrhea have one of the following: . Functional diarrhea: loose stools without additional symptoms . Malabsorption : Increased stool volume , weight loss, steatorrhea , flatulence , possible association with foods(dairy products , gluten) Patient with chronic diarrhea should be queried for foreign travel and risk factors for -HIV-, which would broaden the differential diagnosis significantly . Waterlyt diarrhea following exposure to rural or wildness water resource suggests -giardiasis- ; parasitic causes of chronic diarrhea are otherwise uncommon in the United States. HISTORY AND PHYSICAL EXAMINATION The following section include the most common items that should be included in the evaluation of a patient with diarrhea . In patients with chronic diarrhea , the history is usually more helpful than the physical examination. History History of [resent illness . Please explain what you mean by “ diarrhea” Past medical history . Have you had abdominal surgeries? Social history . Are you sexually attire ? Have you been active with men , women , or both? Physical examination General . Assess fluid & nutritional status (eg, tachycardia, orthostatic hypotension, decreased subcutaneous fat) HEENT/Neck . Examine oropharynx for ulcers , thrush. Abdomen . Inspect for scars & distension. Closing the encounter The closing conversation should review the most likely diagnosis and any clinical features that suggest serious illness . Discuss whether an aggressive evaluation is warranted or whether you should order tests in a stepwise fashion, If endoscopy is considered , provide basic education about the procedure and obtain the patient’s consent before proceeding. Diagnostic studies Virtually all patients with diarrhea should have a rectal examination ; this is not allowed in the USMLE Step 2 CS exam but should be listed in the Diagnostic studies section. Also , most patients warrant basic laboratory studies (eg, electrolytes , urea nitrogen, creatinine , blood counts , fecal occult blood) to assess serious and identify dehydration or other potential complications of the diarrhea. Patient with bloody diarrhea or fever need an expedited evaluation with early colonoscopy . in contrast , patient with non bloody diarrhea and no systemic symptoms may warrant only a few basic laboratory tests and a trial of dietary modification before invasive studies. Diagnostic tests to consider in chronic diarrhea include: . Total protein , albumin(possible malabsorption)
-- 作者： JuanFe CHRONIC COUGH Doorway information about patient Vital signs Approach to the patient Subacute ( 3-8 weeks) and chronic(>8weeks) cough is common reason for physician visits. Whereas patients with acute cough(<3 weeks) often present with a characteristic constellation of symptoms (eg , influenza presenting with subbed -onset fever, myalgia , headache , and cough) those with only a nonproductive cough may avoid coming to the clinic until the symptoms have been present for an extended period. Patients with a prolonged cough should be queried for risk factors (eg, smoking) , chronic medical conditions (eg,seasonal allergies ), or subtle symptoms (eg , night sweats, weight change) that may suggest the likely causes. Differential diagnosis Common etiologies of chronic cough Upper airways disorders . Upper airway cough syndrome (postnasal drip) Lower airway & parenchymal disorders . Asthma Other causes . Gastroesophageal reflux -Postnasal drip- (upper -away cough syndrome) , - Gastroesophageal reflux disease-(GERD) , and -asthma- causes > 90% of chronic cough in nonsmokers without known pulmonary disease . Wheezing or atopic history (eg , seasonal allergies , eczema) suggest asthma . Increased sputum production is nonspecific but suggests postnasal drip or lower airway disease (eg, chronic bronchitis, bronchiectasis). In smokers , an early-morning cough suggests chronic bronchitis. Adult pertussis and post infectious cough often begin with unremarkable upper respiratory symptoms . Systemic symptoms (eg , fever , weight loss) may indicated malignancy or chronic infection (eg, tuberculosis) . note that the dry cough caused by- ACE inhibitors- can begin up to a year or more after initiation of therapy. HISTORY AND PHYSICAL EXAMINATION In addition to the standard general medical history and physical examination , the following sections include the most common items in the evaluation of a patient with chronic cough. History history of present illness . When did the cough start? Past medical history . Have you had heart or uno problems in the past? Family history . Is there anyone in your family with asthma? Social history . What kind of work do you do?(Ask industrial workers about asbestos exposure) Physical examination HEENT/neck . Oropharynx: Erythema, drainage, lesion. Cardiac . Auscultate for murmurs, rubs, or gallops. Lungs . Inspection : Chest wall abnormalities ,accessory muscle use. Abdomen . Upper abdominal tenderness Extremities . Peripheral edema Closing the encounter Following the history and physical examination , the diagnosis may be apparent . However , diagnostic testing may be needed before the cause can be confirmed . In such cases , explain the most likely causes and the goal of the specific tests. in addition, ion the patient smokes , inquire about readiness to quit and offer to provide support to help them quit. Diagnostic studies Diagnostic testing in pulmonary dies can be subdivided into -structural tests-(eg , chest X-ray, CT scan) and -functional tests- (eg , pulmonary function tests, arterial blood gas analysis). The tests chosen will be influenced by the mist likely cause; patient with undifferentiated symptoms often require both structural and functional tests. Tests to consider for patients with chronic cough include: . Plain film chest x-ray (most patients with a chronic cough should receive a chest x-ray) Although chronic cough may have an allergic etiology, allergy tests are rarely helpful in the initial assessment. Bronchoscopy and nasal endoscopy are also not usually part of the initial workup
-- 作者： JuanFe CHEST PAIN Doorway information about patient The patient is a 65-year-old man who comes to the clinic with 1 day of episodic chest pain Vital signs Approach to the patient Patients with a variety of disorders raining form being musculoskeletal pain to myocardial ischemia may report chest pain . Most causes have a distinct -profile of historical features- (eg, location , quality , aggravating / relieving factors ) but clinical characteristics car rarely specific enough for a firm diagnosis (eg, pain that is worse with meals is usually due to a gastroesophageal source but can occasionally be due to cardiac angina). In addition , some causes of chest pain are notoriously difficult to identify based on clinical characteristics alone (eg, pulmonary embolism). Although the evaluation of chest pain in clinical settings is oriented to first rule out life-threatening disorders , the differential diagnosis in the USMLE Step 2 CS exam should formulated based only on liked , without regard to seriousness ., Also , some scenarios in Step 2 Camay incorporate images , such as ECG or chest-x-ray ; you should review common abnormalities on these tests prior to the exam. Differential diagnosis Differential diagnosis & features of chest pain Coronary artery disease 1 Substernal Pulmonary / pleuritic (pleurisy , pneumonia pericarditis , PE) 1 Sharp . stabbing pain Aortic (dissection , intramural hematoma) 1 Sudden , severe “tearing” pain Gastrointestinal / esophageal 1 Nonexertional , relieved by antacids Chest wall / musculoskeletal 1 Persistant &/or prolonged pain the most common causes of chest pain are listed in the table , alone with clinical features that are characteristic of each other , In addition , be aware of disorders in adjacent structures 9eg, neck/thyroid, liver , gall bladder , shoulder) that may cause pain in the chest. Also , herpes zoster (shingles) is a very common and frequently overlooked cause of chest pain HISTORY AND PHYSICAL EXAMINATION The following sections include the most common items to address in the evaluation of chest pain. History History of present illness . Have you had pain like this before? If so , what was the outcome? . For active chest pain . For resolved or intermittent chest pain? . Point to where the pain is . Do you feel it anywhere else? Past medical history . Have you been diagnosed with any other medical conditions (eg , high blood pressure , diabetes , heart problems , high cholesterol)? Family history . Is there anyone in your immediate family with heart disease?(Note : Cornily artery disease is very common & is usually relevant to family members only of it occurs early in life.) Social history . Do you smoke ? At what age did you start & how much do you smoke? Review of system . Pulmonary : cough , dyspnea , wheezing , hemoptysis Physical examination General . Patient position & body habitus Cardiac . Carotid pulse , carotid bruits; jugular venous pressure Lungs . Work of breath/ accessory muscle use Gastrointestinal . Epigastric tenderness Extremities . Peripheral pulses Closing the encounter Patients with chest pain are frequently concerned about potentially serious causes. They may also have ha previous similar (diagnosed or undiagnosed ) episodes . Asking the patient what they think may be the cause of the pain (eg “What do you think your pain is due to , or what are you concerned may be the cause of it?”) is often helpful in evaluating chest pain , both to improve patient communication and to clarify the differential diagnosis. In most cases , the diagnostic test will be simple and familiar to the patient (eg , chest-x-ray , ECG ), but you should explain more complex tests (eg , echocardiogram , ventilation /perfusion scan) and get the patient;s permission before proceeding . Reassure the patient that the result should be available quickly and you will explain the results as soon as possible. Diagnostic studies Common diagnostic studies that should be considered for patients with chest pain include: . ECG
-- 作者： JuanFe BACK PAIN the patients is a 60-year-old woman who comes to the clinic due to 2 months of back pain Vital signs Approach to the patient most patient with acute (<4-6 weeks) , uncomplicated low back pain have etiology and will have spontaneous resolution . However , patients with chronic or atypical symptoms are more likely have to require diagnostic and therapeutic intervention. For this reason , the evaluation of patients with back pain should give careful attention to duration of symptoms and other features that might suggest a poor prognosis. Inanition , patients with possible infection , malignancy , or bony injury (eg , compression fracture 0 may require more aggressive evaluation . These -red flag- features include: . Age > 50 Different diagnosis Causes of low back pain Musculoskeletal 1 Mechanical (eg, muscle strain) . Normal neurologic examination 2 Radiculopathy (eg, herniation disk) . Radiation below the knee 3 Spinal stenosis . Pseudoclaudication 4 Compression fracture . Osteoporosis Malignancy 1 Metastatic cancer . Age>50 Infectious Osteomyelitis, discitis , abscess . Recent infection of intravenous drug use The differential diagnosis os heavily dependent on age , comorbid and historical conditions (eg, history of malignancy) , and risk factors ( eg , intravenous drug use for infectious causes, menopausal status for osteoporosis) . the most common cause son back pain and the major clinical clues are listed in the table. HISTORY AND PHYSICAL EXAMINATION Inanition to the standard medical history and physical examination , the following sections , include most common items should be included in the evaluation of a patient with back pain. History History of present illness . When did the pain start? . Nerve root compression / radicular pain: . Have you had any injuries to your back? Past medical history . Do you have a history of cancer ? Any recent infections? Social history . Do you smoke ? Review of systems . General : weight loss , fever , night sweats Physical examination General . Posture , body habits , pain behaviors neurologic . Lower extremity strength Musculoskeletal . Visible deformity of spine (scoliosis, loss of lumber lordosis) Genitourinary . Costoverterbral od suprapubic tenderness Extremities . Lower extremity pulses Closing the encounter Treatment is not tested as part of Step2 CS , but diagnostic testing for a patients with back pain is oriented toward identifying which patients can be managed conservatively with simple analgesics and which will need more aggressive treatment. In light of this , discuss the factors in the history and physical examinations that are most relevant in guiding subsequent testing and treatment: . Patients with acute, -uncomplicated back pain- are manage conservatively , without additional testing, Advise the patient to maintain moderate activity. Diagnostic studies Imaging for uncomplicated low back pain is not recommended . If no additional testing is required , write “ No studies indicated “ in the Diagnostic Studies section of the patient notes. Diagnostic tests that can be considered for patients with back pain include: . X-rays : Reduced range of motion , suspected malignancy , compression fracture
-- 作者： JuanFe ALCOHOLISM Doorway information about patient The patient is a 55-year-old man bought in by his wife to discuss ways for his to stop drinking alcohol Vital signs Approach to the patient Patients should be evaluated for -unhealthy alcohol use- if they have: . -Excessive intake- (men>14 drinks /week or > 4 drinks /day ; woman: > 7 drinks/week or > 3 drinks /day) The evaluation of alcohol use disorders should address -current alcohol intake- , personal and family history of alcohol -abuse and treatment- , and medical any psychological -complications- of alcohol intake . Patients should also be screened for abuse of -other substances- ( eg, tobacco , illicit drugs , prescription medications) and for comorbid -psychiatric illness-. Different diagnosis The differential diagnosis for alcohol use disorders is usually straightforward . however , patient amy have additional problems that need to be identified and addressed . the following disorders should be considered when evaluating a patient with alcohol abuse: . Polysubstance abuse HISTORY AND PHYSICAL EXAMINATION The initial screen for unhealthy use can utilize single-item screen , or the AUDIT or AUDIT-C test. the CAGE questions are helpful in further characterizing alcohol use un patients who are positive on the initial screen. Alcohol use (abuse) screening 1 Single-item screening . How many times in the past year have you had (5 for men) ( 4 for women) or more drinks in a day? 2 AUDIT-C . How often do you drink alcohol ? 3 AUDIT . 10-items screen assessing frequency , number of drinks &psychosocial consequences CAGE . Have you felt you should -Cut down- on your drinking? The following section include additional items hat may be useful in evaluation of a patient with alcohol abuse. History History of present illness . At what age did you start drinking alcohol? Past medical history . Have you had any seizures? Family history . Do you have any family members with alcohol or drug problems? Social history . Are you facing any stressful situations in your home? Review of system . General : weight changes , change in appetite Physical examination General . Diaphoresis Skin / breast . Signs of cirrhosis : telangiectasia, jaundice, gynecomastia Heart . Tachycardia, ectopy /arrhythmia Abdomen . Signs of cirrhosis, ascites , spider angioma , caput medusae Neurologic . Tremor Psychiatric . Impaired level of consciousness Closing the encounter Diagnostic studies The diagnosis of alcohol use disorder is based on clinical findings . Additional testing is ordered only as necessary to evaluate potential medical complications ( , eg , alcoholic liver disease ) and comorbidities . The following studies should be considered as the individual case warrants: . CBC
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