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JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [¼Ó ¥D]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/06/05 11:02pm ²Ä 3 ¦¸½s¿è] 1  ASTHMA FOLLOW UP 2  VOMITING 3  VAGINAL BLEEDING 4  TERMIANL CANCER 5  TELEPHONE ENCOUNTER 6  SPELL (syncope,seizure) 7  SMOKING CESSATION 8  SHOULDER PAIN 9  PREEMPLOYMENT EXAMINATION 10 PALPITATIONS 11 OBESITY 12 NIGHT SWEATS 13 CARAPL TUNNEL SYNDROME (HAND PAIN) 14 MENOPAUSE 15 INSOMNIA 16 HEMOPTYSIS 17 HEEL PAIN 18 HEADACHE 19 FORGETFULNESS 20 ENURESIS 21 DOMESTIC VIOLENCE 22 DIZZINESS 23 DIABETIC DRUG REFILL 24 DEPRESSION 25 DARK URINE 26 CONFUSION 27 CHRONIC DIARRHEA 28 CHRONIC COUGH 29 CHEST PAIN 30 BACK PAIN 31 ALCOHOLISM 2018/05/11 06:26pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 734 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 2 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/05/11 07:12pm ²Ä 1 ¦¸½s¿è] ASTHMA FOLLOW UP Doorway information about patient The patient is a 22 years old woman who comes to the clinic for follow up of asthma. Vital signs .Temperature 36.8¡¦C .Blood pressure 118/68 mm Hg .Pulses 84/Min .Respirations : 16/min 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 ? . when was your asthma first diagnosed ? . What symptoms are you having ? Wheezing / coughing ? shortness of breath ? . How often have you had symptom during the day ? at night ? . What is your current medical program? . What treatment have you been on in the past ? Why is your treatment changed ? . How often are you using your rescue inhaler ? . Can you show me how you use the inhaler ? .Do you check your pick flow at home ? Hw do your recent readings compare with your personal best ? . What things (eg. infections , pollen, dust , cold air ) trigger your asthma ? . have you ever taken oral corticosteroids for asthma ? when was the last time ? . overall , do you think your asthma is getting better or worse ? Past medical history . What other medical conditions have you had ? . Did you receive an influenza vaccination this season ? . have you received a vaccine for pneumococcal; pneumonia ? Social history . Do you smoke ? When didi you start and how much do you smoke ? . Do you drink alcohol? How much and how often? . Have you used illicit drugs ? 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 general . Examine body habits. . Assess level of distress HEENT . Examine ears with otoscope . Examine nasal mucosa . Examine pharynx for thrush (possible complication of inhaler glucocorticoids). Cardiovascular . Auscultate heart. Pulmonary . Evaluate respiratory rate & depth as well as accessory muscle use . . Estimate time for inspiration compared with expiration (normal 2:3) . Auscultate both sides , front and back . Percuss upper , middle & lower lung fields bilaterally. 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 . complete blood count . chest x ray ( if the patient has abnormal examination findings other than wild wheezing ) Advanced imaging (eg. CT scan ) ind invasive studies (eg. bronchoscopy ) are not usually performed in the initial assessment. 2018/05/11 06:33pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5685 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 3 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/05/11 07:13pm ²Ä 1 ¦¸½s¿è] VOMITING 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 . Blood pressure 110/70 mmHg . Pulse : 80 / min . Respirations : 14/ Min 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 HISTORY . please describe what you are experiencing . . When did the vomiting start ? . Are you throwing up any blood ? are you passing any blood in your stool ? . Do you have any abdominal pain ? . Any diarrhea or constipation ? . Any fever or chills? Headache? . Any burning with urination ? . Have you lost any weight recently ? . Have you had problems like this before ? . Did you eat at a restaurant or eat leftover food prior to this illness ? Is anyone else who ate the same thing sick? . Is anyone around you sick ? . When was your last menstrual period ? is there a chance you could be pregnant? PAST MEDICAL HISTORY . Have you been diagnosed with any other medical conditions? . Have you had any surgeries (especially abdominal surgeries )? 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 ? . Do you drink alcohol ? How much , and how often ? . Have you used recreational drugs ? 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 . . Examine funds suspecting increased intracranial pressure . Heart . Auscultation for murmurs , gallops , and rubs Abdomen . Inspect ofr distension . Auscultate for bowel sounds. . Percuss for bowel gas pattern. . Palpate for tenderness . . Examine for costovertebral tendernes Colin the encounter At the conclusion of the encounter , describe any notable examination findings , discuss the differential diagnosis ,and explain the need for any diagnostic testing . If invasive studies 9eg. esophagogastroduodenoscopy) are needed. explain the procedure and obtain the patient¡¦s permission before proceeding . be sure to leave adequate time to answer patient questions . 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: . Complete bold count ( and differential ) . Serum electrolytes . Blood glucose . Blood era nitrogen and creatinine . Liver function panel . Lipase (prefer over amylase ) . Urinalysis (and culture) . Abdominal x-rays (flat and upright if obstruction is suspected ) 2018/05/11 06:38pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 4912 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 4 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/05/11 07:13pm ²Ä 1 ¦¸½s¿è] VAGINAL BLEEDING Doorway information about patient The patient is a 20 - year - old woman who reports abnormal vaginal bleeding. Vital signs . Temperature 36.7¡¦C . Blood pressure 110/70 mmHg . pulse : 80 /min . Respirations : 16/ min 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) Adenomyosis Leiomyoma(submucosal & other) Malignancy & hyperplasia NONSTRUCTURAL CAUSES Coagulopathy Ovulation dysfunction Endometrial ( eg, infection , inflammation ) Iatrogenic (eg, anticoagulants) Not yet classified 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 ? . Was the onset gradual or sudden? . Can you describe the bleeding (eg, bright red blood , brown spotting , clots) . Is the bleeding continuous or intermittent ? . How many tampons / pads do you use a day ? . Did you pass any tissue ? (eg , roar pregnancy ) . Do you have otters symptoms beside bleeding ? (* eg , abdominal pain , fever , vomiting ) ? . Have you ever been pregnant ? . Describe your typical cycle : often , regular , days , heavy (tampons / pads ) . Have you had any portions or miscarriages? . Have you noticed sores , pain , or infection around the genital area ? ¡Xsexual history ¡X . Are you sexually active now ? in the past ? . Are you using birth control ? what type ? ( Copper intrauterine devices are associated with increased bleeding ) . Have you had pain or bleeding with intercourse ? . have you ever had a sexually transmitted infection ? PAST MEDICAL HISTORY . have you ever had abnormal bleeding ? . Have you had liver or kidney disorders ? MEDICATIONS . Are you taking medications (eg . aspirin , nonsteroidal anti inflammatory  drugs, anticoagulants ?) FAMILY HISTORY . Do you have a family history of bleeding disorders? . Has anyone in your family had recurrent miscarriages? SOCIAL HISTORY . Do you smoke ? . Do you drink alcohol? . Do you use illicit drugs ? (cocaine may cause bleeding ) 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 . Body habits (eg , obesity , low body weight) HEENT . Other sites of bleeding ( eg . nasal mucosa , gums ) Skin . Petechiae or purpura . Hair distribution & quality ( eg , hirsutism , fine lanugo hair ) Abdomen . Distension . Bowel sound . Liver & spleen size . Abdominal ( including suprapubic ) masses or tenderness Closing the encounter the causes of AUB is usually not confirmed sole on clinical findings , especially in he step 2 CS exam as pelvic examination is not permitted . The wrap - up discussion should discuss the most likely causes and the tests need ed to confirm the diagnosis . Because many of these studies are either physically uncomfortable (eg, transvaginal ultrasound) or of a personally sensitive nature (eg. pregnancy test ) , allow the patient to ask questions and obtain permission before proceeding . Diagnostic studies Initial evaluation should include a     urine pregnancy test     ,    complete blood count    , and coagulation studies .  Other laboratory studies to consider include . TSH , prolactin and FSH . 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. 2018/05/11 06:46pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5356 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 5 ¼Ó]   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 . Blood pressure : 130/80 mmHg . Pulses : 80/min . Respiration ; 12 / min Approach to the patient PALLIATIVE CARE ASSESSMENT Source of distress . Pain . other somatic symptoms (eg. cause , dyspnea ) . Psychologial & spiritual distress . Functional & cognitive decline . Caregiver burden Support & resources . Family . close loved ones . Living situation . Financial & material resources . Outside supports (eg, caregiver , clergy . PT/OT[physical therapy/ occupational therapy]) Setting goals . Expectation of disease course .  Priorities & preferences . Objective to determine success Flow up . Care coordination . Medication titration schedule . Decision making & advanced directives 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 ? . please tell me more about your cancer . . I am very sorry to hear that , and I am sure that it has been difficult for you . Tell me more about your pain. . How severe is the pain ? . What makes your pain worse ? . What are you doing now for the pain , and what have you tried in the past ? . Do you have any symptoms otters than pain ? . How is your appetite ? . Have you lost nay weight ? .How well are you sleeping at night ? . How is your mood ? Past medical history .Have you been diagnosed you with any other medical conditions ? . Have you had any surgeries ? Medications . Do you take any medications (prescription and over- the -counter )? Social history . Who do you live with ? . Do you have otters family members or friends who provide assistance or emotional support for you ? . Do you smoke ? At what age did you start , and how much do you smoke ? . Do you drink alcohol ? How much and how often ? 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. 2018/05/11 06:49pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 4371 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 6 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/05/11 07:14pm ²Ä 1 ¦¸½s¿è] TELEPHONE ENCOUNTER Doorway information about patient The patient is a 5-year-old boy who has been vomiting for a day , his mother has left a phone message with the clinic . You will talk with the patient¡¦s motor on the phone 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 ? . How long has he been vomiting ? . How many times has he vomited today ? . Has he been vomiting late amounts ? . What dose the vomit contain ? . Did you notice any blood in the vomitus ? . Dose he have any pain in his belly ? . How are his bowel movements ? . Dose he have a fever ? . How is his appetite ? . Did he eat out recently , such as a party or restaurant ? . Dose he have any headaches ? . Is he usually a healthy child , or dose he get sick frequently? . Has he been exposed to any sick contacts? . Has he had all of his recommended vaccinations ? Past medical history . Has he ad similar problems previously ? . Has he had any other medical conditions or surgeries ? . Were there nay problems at brith or during the pregnancy ? Medications/ allergies . Dose he take many medications (prescription and over -the -counter )? Family history . How old are you and dos father ? . Do either of you have any medical conditions ? . Dose he have brothers and sisters ? . Do they have any medical conditions ? Social history . Who dose he live with ? . What grade is he in school ? . Is he OK in school? 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 ) . Lethargy or altered consciousness . Neurotic symptoms (eg, seizure , focal symptoms) . Symptoms of obstruction (eg, dissension , feculent vomiting) . Symptoms of increased intracranial pressure (eg, headache , vomiting without nausea , vomiting triggered by position change) 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. 2018/05/11 06:54pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 3803 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 7 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/05/11 07:14pm ²Ä 1 ¦¸½s¿è] SPELL (syncope,seizure) 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 . Blood pressure : 130/80 mmHg . Pulse 80/min . Respirations: 12 /min Approach to the patient Comparison of syncope & seizure - Seizures - Circumstances invoked by : . Sleep loss . Emotions . Alcohol withdrawal . Facing light Clinical clues . Aura(eg,olfactory hallucinations) . Can occur with sleeping / sitting position . head movements . Tongue biting . Rapid strong pulses Sequelae . Delayed return to baseline . Usually sleepy & confused afterward (postictal state) - Syncope (typically vasovagal) - Circumstances Invoked by: . Upright position . Emotions . Heat . Crowded places Clinical; clues . Symptoms of presyncope(eg,lightheadedness) . Unlikely to occur with sleeping/sitting position (except in cardiac arrhythmia) . Rarely ,several clonic jerks can occur with prolonged cerebral hypoperfusion . Pallor & diaphoresis . Weak , slow pulses 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 likely etiology 2 clinical clues to diagnosis 1: Vasovagal or neurally medicated syncope 2: Triggers : prolonged standing or emotional distress , painful stimuli    Prodromal symptoms: nausea , warmth, diaphoresis 1: Situational syncope 2: Triggers: cough , micturition, defecation 1: Orthostatic syncope 2: Postural changes in heart rate/blood pressure after standing suddenly 1: Aortic stenosis , HCM , anomalous coronary arteries 2: Syncope with exertion or  during exercise 1: Ventricular arrhythmias 2: Prior history of CAD m MI , cardiomyopathy , or decrease EF 1: Sick sinus syndrome , Bradyarrhythmias , atrioventricular block 2: Sinus pauses , ^ PR or ^ QRS duration 1: Torsades de points (acquired long QT syndrome) 2: Hypokalemia , hypomagnesemia, medications causing ^QT interval 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. . What were you doing when this happened? . Has this happened before? . Did someone see you pass out? . How long were you out? . Did you have any jerky movements of your hands or legs ? . Did you bite your tongue? . Did you lose control of your bladder or bowels? . Were you feeling fine before the event? . Did you have nausea or vomiting? . Have you had chest pin , palpitations, or breathing problems ? . Have you had  weakness m  numbness m or tingling in your face , legs , or arms? . Have you had change vision? . Have you had recent trauma? 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? . Has anyone died suddenly? Social history . Do you smoke? At what age did you start & how much do you smoke ? . Do you drink alcohol ? How much & how often? . Have you used illicit drugs ? 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. . Perform a cranial nerve examination. . Check motor strength &sensation in the face and all the extremities. . Evaluate balance , gait & cerebellar function. . Assess deep tendon reflexes Closing the encounter 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 . Serum electrolytes and magnesium . Urine toxicology (eg,amphetamine abuse) . Complete blood count . Echocardiogram (if murmur or other sign of structural heart disease) 2018/05/11 07:01pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7115 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 8 ¼Ó]   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 . Blood pressure : 122/80 mmHg . Pulse : 70/min . Respirations : 14/min Approach to patient 1 Precontemplation : Not really to change : patient does not acknowledge negative consequences . Encourage patient to evaluate consequence of current behavior . Explain & personalize the risk . Recommending actions is premature 2 Contemplation : Think of change : patient acknowledge consequences but is ambivalent . Encourage evaluation of pros & cons of behavior change . Promote new, positive behaviors 3 Preparation : Ready to change : patient decides to change . Encourage small initial steps . Reinforce positive - outcome expectations 4 Action : Making change : patient makes specific , overt changes . Help identify appropriate change strategies & enlist social support . Promote self-efficacy for sealing with obstacles 5 Maintenance : Changes integrated : into patient;s life ; focus on relapse prevention . Follow-up support; reinforce intrinsic rewards . Develop relapse prevention strategies 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 . Advise and encourage patient who smoke to quit . Assess willingness to quit (stage of change) . Assist with smoking cessation , including counseling and possible drug therapy . Arrange follow-up (unperson or by phone ) to reinforce the behavior chanegs 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 ? . How many cigarettes do you smoke in an average day? In the past , did you smoke more or less than you do now? . What were the circumstance that cause you begin smoking ? . Do you enjoy smoking ? . Are there any situations (eg, morning coffee times at work ) that tend to reinforce your smoking ? . Have you tried to quit before ? How did it go ? . Are you concern about your health? . Is stress or depression a reason for your smoking ? . Have you ever had any smoking -related complications such as heart or lung problems ? Past medical history . Do you have nay otters medical problems (eg, cancer, cardiovascular disease )? . Have you had depression or other emotional problems ? Social history . What kind of work do you do ? . Who lives was home with you ? . Are there any other thinks in your life that are adding to your stress? . Do you drink alcohol ? How much & how often? . have you used recreational drugs ? 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 . Substance sue disorder . Other behaviors in patients who are not ready to change 2 Principles . Acknowledge resistant to change . Address discrepancies between behavior & long-tern goals . Enhance motivation to change . Nonjudgemental 3 Technique (OARS) . ask ¡§O¡¨pen-ended questions (encourage further discussion) . give ¡§A¡¨ffirmations . ¡§R¡¨eflect & ¡§S¡¨ummarize main points 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. 2018/05/11 08:19pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5509 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 9 ¼Ó]   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 . Temperature : 37¡¦C . Blood pressure : 130/80 mmHg . Pulses : 80 / min . Respirations : 12/min Approach to the patient Shoulder pain can be categorized based on the following factors: . Acute (<2weeks) or chronic . Traumatic or atraumatic . Intrinsic or extrinsic , include radicular and referred pain . Location (eg, anterior, superior , diffuse) 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 . Pain with abduction , external rotation . Subacromial tendernes . Normal range of motion with positive -impingement tests-(eg, Neer, Hawkins) 2 Rotator cuff tear . Similar to rotator cuff tendinopathy . Weakness with external rotation . Age>40 3 Adhesive capsulitis (frozen shoulder) . Decreased passive &active range of motion . More stiffness than pain 4 Biceps tendionpathy/rupture . Anterior shoulder pain . Pain with lifting , carrying , or overhead reaching . Weakness less common 5 Glenohumeral osteoarthritis .Uncommon & usually cause by trauma . Gradual onset of anterior or deep shoulder pain . Decreased active & passive abduction & external rotation 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. . When did this pain begin? . Did you fall or experience any trauma? . Where do you feel it the worst ? Dose the pain move anywhere? . How severe is the pain ? . What makes it better or worse? . Is it constant or intermittent? . Do you have numbness or tingling in your arms or hands? . Have you noticed redness or swelling in the shoulder? . Do you have pain in any other part of your body? . Do you have nay otters symptoms?(eg, cough, shortness of breath)? . Have you taken medications of the pain? If so , did they help? . How is this affecting your daily activities? Past medical history . Have you ever had a similar problem? . When was it diagnosed & treated ? . have you been diagnosed with other medical conditions (eg,diabetes , heart disease) Social history . What kind of work do you do? . Do you smoke? At what age did you stare & how much do you smoke ? . Do you drink alcohol ? how much & how often? . Have you ever used recreational drugs? 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. . Palpation for warmth or tenderness. . Chance range of motion (passive & active), including flexion , extension , abduction & adduction . Perform specific maneuvers as appropriate. . Examine both shoulder for comparison . Examine the cervical spine , sternoclavicular joint & elbow Skin . Examine ofr rash (eg, Herpes zoster). Neurologic . Check reflexes. . Check motor fiction & gross sensory examination in hand & arm. 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 . 2018/05/12 03:36pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 4964 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 10 ¼Ó]   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 . Temperature:37¡¦C . Blood pressure : 117/80 mmHg . Pulses : 64/min . Respirations : 12/min 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 : . Fasting glucose . Lipid panel . Urine toxicology(drug test) . Tuberculin skin test 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). 2018/05/24 09:38pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 3148 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 11 ¼Ó]   PALPITATIONS Doorway information about patients The patient is a 28-year-old man who comes to the clinic sue too palpitations. Vital signs .Temperature: 37¡¦C . Blood pressure : 130/80 mmHg . Pulses : 80 /min . Respirations : 12 /min 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. . Do you have additional symptoms(eg,chest pain , dizziness) with the palpations? . Have you passed out ? . When did these episodes begin? . How often are they happening? . How long do they last ? . What are you doing when you have this episode? . Does anything seem to trigger them? . Do you drink coffee(caffeine) ? if so , how much? . Have you had breathing problems or swelling in your legs? 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? . Did anyone in your family die unexpectedly at a young age ? Social history . Do you smoke ? At what age did you start & How much do you smoke ? . Do you drink alcohol , include beer ? How much & How often ? . Have you used recreational drugs? PHYSICAL EXAMINATION Neck . Examine thyroid for enlargement or nodules. Lungs . Auscultate for breath sounds & adventitious sounds. Heart . Inspect neck viens & precordium. . Palpate carotid & peripheral pulses . . Palpation precordium for displaced point of maximal impulse. . Auscultate for murmurs , gallops&rubs (repeat with Valsalva) Neurologic . Evaluate deep tendon reflexes. . Examine for hand tremor. Extremities . Examine for many peripheral edema . Skin . Examine skin for warmth , flushing & diaphoresis 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 : . Complete blood count . Electrolytes . Glucose . TSH Chest - x -ray ,may helpful to assess the cardiac silhouette , advanced imaging studies (eg , CT scan , MRI ) are usually not needed. 2018/05/24 09:42pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6076 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 12 ¼Ó]   OBESITY Doorway information about patient The patient is a 40-year-old woman who comes to the clinic due to weight gain Vital signs . Temperature ; 36.7¡¦C . Blood pressure : 150/90 mmHg . Pulse :68/min . Respiration: 16/min Approach to the patient initial assessment of obesity History&symptoms of obesity & obesity-related complications . Back pain . Osteoarthritis . Atherosclerotic cardiovascular disease . Sleep apnea Biometric measurements . Blood pressure & pulse . Weight . BMI . Waist circumference Laboratory studies . Glucose (or hemoglobin A1c) . TSH . Lipids . Hepatic enzymes 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): . Normal : 18.5-24.9 kg/m2 . Overweight : 25-29.9 kg/m2 . Obesity : >=30kg/m2 . Severe obesity : >=40 kg/m2 (or >= 35 kg/m2 with weight -related complications ) 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 . kHow long have you been gaining weight? . How many pounds have you gained ? . Can you think of any reasons for this weight gain ? . How is your appetite? . How may meals you eaten a day ? . Describe a typical meal. . Do you eat snakes between meals? . How often do you eat out ? . Have you tired diets or weight loss programs in the past ? . Do you sore excessively or have problems with breathing at night? . Do you feel thirstier than usual or urinate more than usual ? . Do you feel cold when these around you are comfortable ? . Do you are joint pain ? . For woman : when was your last period ? Have your periods been irregular? Past medical history . Do you have other medical conditions(eg, diabetes , hypertension )? . Have you had your cholesterol checked recently ? Medications / allergies . Do you take any medications? . Have you taken steroid medication (eg prednisone ) recently? Family history . Is there any obesity in your family? . Do any of your close family members have heart disease , diabetes , or a thyroid disorder ? Social history . Do you smoke ? When did you start& how much do you smoke ? . Do you drink alcohol ? how much & how often? . Have you used illicit drugs? 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 . Assess body habitus. . Assess gait & ambulation. HEENT . Examine for lid lag & exophthalmos. Neck . Examine for thyromegaly Lungs . Auscultate for breath sounds & adventitious sounds. Heart . Auscultate ofr murmurs , gallops & rubs. 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 for -complications- and -revesible causes - should include a - TSH -, - fasting glucose (or hemoglobin A1c) -, -liver function markers- (to rule out hepatic steatosis). and - lipid panel -. Testing for hypercortisolism (eg , 24 hour urine cortisol ) is not done unless there are additional findings of Cushing syndrome. Imaging is not usually necessary , although a plain dlim-x-ray of weight-bearing joints can be considered for patient with symptoms of osteoarthritis. 2018/05/24 09:45pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5625 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 13 ¼Ó]   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 . Temperature : 36.9¡¦C . Blood pressure : 115/80 mmHg . Pulse : 68 / min . Respiration : 12 / min 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) . Localizing sign and symptoms (eg,, cough , skin rash) . Smoking history or alcohol or drug abuse . Disease -specific risk factors (eg, obesity ,unprotected sexual intercourse) . Immunosuppressive conditions ( eg, recent cancer treatment) 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 . Infection (eg , tuberculosis , HIV , osteomyelitis , endocarditis) . Malignancy (eg, lymphoma) . Systemic inflammatory / autoimmune disorders . Thyroid disordes . Gastroesophageal reflux . Hypoglycemia . Medications (eg, antidepressants) . Alcohol or opioid withdrawal 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 . What happens when you have hight sweats? . How long have they been happening ? . Have you had fevers or chills ? . Have you lost weight unintentionally ? . How is your appetite ? . Do you have weakness or fatigue ? . Have you noticed lumps in your neck , armpits  or groin? . Do you have pain anywhere? . Do you have cough or breathing problems ? . Have you noticed a racing or pounding heart? . Do you feel warm when those around you feel comfortable? . Have you traveled anywhere recently? Past medical history . have you had a similar problems before ? . What prior medical conditions & surgeries have you had ? Family history . Is there anyone in your family with thyroid problems? cancer ? Social history . What kind of work do you do ? . Do you smoke ? Wen did you start & how much do you smoke . . Do you drink alcohol ? how much & how often ? . have you used illicit drugs ? . Are you sexually active ? Do you have sex with men , women , or both ? 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 . Examine for lip lag / exophthalmos. . Examine oropharynx for thrush. Neck . Examine for thyromegaly & thyroid nodules . lymphatic . palpate all major lymphatic chains lungs . Auscultate for breath sound & adventitious sounds, Heart . Auscultate ofr murmurs, gallops & rubs . Abdomen . Palpate ofr hepatosplenomegaly . Percuss the spleen. Neurologic . Evaluate deep tendon reflexes. . Examine for hand tremor. Skin . Examine for rashes 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: . Complete blood count . Erythrocyte sedimentation rate or C-reactive protein . Glucose and electrolytes . TSH . HIV test . Chest X-ray . Purified protein derivative skin test or interferon please assay for tuberculosis 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. 2018/05/24 09:48pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5373 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 14 ¼Ó]   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 . Temperature : 37¡¦C . Blood pressure : 126/80 mmHg , Heart rate : 72/ min . Respirations : 12/ min Approach to the patient Evaluation of hand symptoms should address 2 interrelated aspects: . The symptoms itself (eg, pain , stiffness ) . The effect on fiction , including , occupational function Begin by inquiring about the pain¡¦s location (eg, joints , fingertips ) . quality ( eg, aching , burning ), severity , onset. duration , course over time , triggering/modifying factors , context (eg, occupation , prior musculoskeletal disorder ) , and associated symptom( eg , swelling ). 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. . Rheumatoid arthritis predominantly affects the wrist and metacarpiphalangeal joints . . Carpal tunnel syndrome affects the palm and planar aspect of the first 3 or 4 digits. . Ulnar neuropathy affects the medial wrist , hand and fifth digit, . De Quervain tenosynovitis causes pain at the base of the thumb. 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 . Please tell me about your pain . When did you first noticed the pain ? . Can you point to where the pain is ? . How dose the pain feel(eg, sharp , achy , burning )? . How bad dose the pain get ? is there anything that makes it worse? . Is the pain always present , or dose it come & go ? . Is it getting better or worse overtime? . Have you noticed swelling or stiffness in the joints ? How long does the stiffness last? . is there numbness or weakness in your hand ? . How are you doing with daily activities at home or at work ? Have you had to change your activities? Past medical history . Have you had  bone , muscle , or joint disorders in the past? . Have you had significant trauma? Medications/allergies . Are you taking any medications , especially pain medications ? Social history . What kind of work do(did) you do? . Is anyone available at home to help you with normal activities , such as driving or housework? 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 . Note body habits ,gaits & posture. Neck . Note range of motion , deformities , or tenderness. Cardiovascular . Examine pulses; radial , ulnar , digital (if possible) Musculoskeletal . Examine elbow , first & digits : range of motion , swelling , deformities , tenderness. . Palpate anatomic snuffbox (especially if trauma is present ). . Note atrophy of hand muscles (eg , thenar eminence , interosseus muscles) Neurologic . Check upper extremity reflexes. . Assess light touch sensation. . Assess motor strength (eg, grip strength) 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. 2018/05/24 09:52pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5768 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É11¤À43¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 15 ¼Ó]   MENOPAUSE Doorway information about patient The patient is a 52-year-old woman who comes to the clinic due to hot flashes. Vital signs . Temperature ; 37¡¦C . Blood pressure : 130/80mmHg . Heart rate: 80/min . Respiration : 12/min Approach to the patent Menopause Clinical features . Vasomotor symptoms . Oligomenorrhea/ amenorrhea . Sleep disturbances . Decrease libido . Depression . Cognitive decline . Vaginal atrophy Diagnosis . Clinical manifestations . ^ FSH Treatment . Topical vaginal estrogen . Systemic hormone -replacement therapy 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 . When was your last menstrual period? . How old were you when your first began having periods? Hone did your periods start become irregular? . Are you symptoms impacting your sleep & quality of life? . Do you feel any burning or pain when urinating ? . Have you had any pain with sexual intercourse? . How has your mood been recently? . Do you have nay headaches ? . Have you had any weight changes? Past medical history . Have you had any pregnancies? Were there any significant complications? . Have you had any problems involving your uterus or ovaries? . Have you had a hysterectomy or any other surgeries ? . Do you have a history of cancer , especially cancer of the uterus , ovaries , or breast? . Have you had nay abnormal blood clots in your veins? Medications/ allergies . Do you take nay medications? . Have you taken nay over-the - counter or herbal products for menopause? Social history . Do you smoke? When did you start,& how much do you smoke? . Do you drink alcohol ? How much & how often? . Have you used recreational drugs? 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 . Examine body habitus . Assess skin texture & jar distribution Neck . Examine for thyromegaly Abdomen . palpate ofr masses & tenderness Psychological . Assess mood & affect 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. 2018/05/24 09:53pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5279 ¦ì¤¸²Õ]¡@

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