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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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 16 ¼Ó]   INSOMNIA Doorway information about patient The patient is a 45-year old man who comes to the clinic with insomnia Vital signs . Temperature : 37¡¦C . Blood pressure : 120/70 mmHg . pulses : 80 /min . Respiratory arte : 14 /min 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: . Difficulty initiating or maintaining sleep . Impairment of daytime  function . Adequate opportunity for sleep(i.e., extended periods of time in bed without excessive noise or interruption) 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 . How long do you had insomnia ? . Do you have problems falling asleep? staying asleep? . How often do you have trouble sleeping ? . How long dose it take to fall asleep? . How much sleep of you get in a typical night ? . Do you feel tired in the morning when you wake up? . Do you feel tired during the day? . How dose your lack of sleep affect your daytime function (eg,work, driving )? . Have you taken any  medications to help you sleep? . Do you consume caffeine in the afternoon or evening ( in beverages [ eg, coffee, tea, colas] and foods [eg, chocolates])? . Do you watch television in bed? . DO you wake uno at night to urinate? . Have you been under more stress recently? . How is your mood ? . Has anyone noticed if you move your legs while sleeping? . Has anyone noticed tat you snore loudly or stop breathing for extended periods while sleeping? Past medical history . Have you been diagnosed with any otters medical conditions (eg,hypothyroidism, heart failure)? . Do you have any conditions that cause chronic pain? Medications / allergies . Inquires about stimulants , psychoactive medications , glucocorticoids, weight loss medications, and over the conner energy supplements? Social history . Do you smoke? When did you start& how much do you smoke? . Do you drink alcohol? How much & how often? Do you drink alcohol before you go to bed? . Have you used recreational drugs? Physical examination General . Note grooming , hygiene, alertness . Body habits HEENT . Facial & upper airway structure ( short mandible , wide craniofacial base , or hypertrophy of pharyngeal tissue increases risk of sleep apnea) Neck . Palpate thyroid lungs . Auscultate for breathing sounds & adventitious sounds heart . Auscultate ofr murmurs, gallops , rubs Extremities . Look for edema or tremor Psychiatric . psychomotor activity . Mood , affect . cognition 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: . Fasting glucose or hemoglobin A1c . TSH . Liver function panel (if heavy alcohol intake ) . Sleep study/ polysomnography (if features of obstructive sleep apnea) . Urine toxicology / drug screen 2018/05/24 09:53pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5621 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 17 ¼Ó]   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 . Temperature : 37¡¦C . Blood pressure : 120/70 mmHg . Heart rate : 80 /min . Respiratory rate : 12 / min 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 . Bronchitis . Lung cancer . Bronchiectasis Cardiac . Mitral stenosis / acute pulmonary edema Infectious . Tuberculosis . Lung abscess . Bacterial pneumonia . Aspergillosis Hematologic . Coagulopathy Vascular . Pulmonary embolism . Arteriovenous malformation Systemic disease . Granulomatosis with polyangiitis . Good pasture syndrome Other . Trauma . Cocaine use(inhalation) 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: . Pneumonia : Acute cough , fever and chills: red-streaked or rust -colored sputum . Lung abscesses : systemic symptoms with purulent sputum. . Pulmonary emboli : Subbed pleuritic chest pain and dyspnea ; risk factors for deep vein thrombosis . Tuberculosis : Chronic cough, low-grade fever , and weight loss (uncommon the Unite States but can be seen in immigrants and homeless individuals) 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 . When did you first start coughing up blood? . How often are you coughing up blood? . What does it look like? Bright-red blood? small streaks in the sputum ? Rust -  colored sputum? . How much sputum are you coughing up? How much blood? . Do you have breathing problems? . Have you had chest pain? . Have you had a fever or chills? . Have you had sweats at night that soak your clothes? . Have you lost weight? . Have you even exposed to anyone with tuberculosis ? . Have you traveled recently within or outside the United States? . Have you had nay other sick contacts? Past medical history . Have you been diagnosed with other medical conditions (eg, heart disease , asthma , emphysema)? Medications/ allergies . Do you take nay medications (especially aspirin , other antiplateles agents , anticoagulants)? Family history . Dose anyone in your family have significant lung disease? Social history . What kind of work do you do ? (industrial workers should be queried for asbestos exposure.) . Do you smoke? At what age did you start& how much do you smoke now? . Do you drink alcohol ? how much & How often? . Have you used recreational drugs? Physical examination HEENT . Examine nasal passage , teeth & oropharynx. Neck . Examine for cervical lymphadenopathy. Lungs . Observe for accessory muscle use & respiratory distress. . Palpate for symmetrical fremitus. . Percuss ofr dullness. . Auscultate for breath sounds. Heart . Auscultate for murmurs , gallops , & rubs. Extremities . Examine for clubbing  & cyanosis . Examine skin for rashes. 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) . Prothrombin time/ partial thromboplastin time ( bleeding disorder ) . High-sensitively D-dimer(pulmonary embolism) . Sputum Gram stain , culture , acid-fast smear . Arterial blood gas analysis 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. 2018/05/24 09:54pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6098 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 18 ¼Ó]   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 . Temperature : 37¡¦C . Blood pressure : 120/70 mmHg . Pulse : 80 /min . Respirations : 12 /min Approach to the patient Assessing patients with musculoskeletal symptoms requires understanding of the -underlying anatomy- and acute and chronic application of force interacts with patients factors(eg , age , bod y habits) to produce disease . Orthopedic disorders can be categorized by associating to injury-acute injury , chronic/ repetitive injury, or atraumatic disorders. 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 . pain maximum upon first stepping out of bed . Local point tenderness with dorsiflexion of the toes Ruptured plantar fascia . Sudden -onset pain . Loss of height of the arch . Visible swelling or ecchymosis Bone infection/ Metastasis . Constant throbbing pain . Nocturnal Worsening Calcanea stress fracture . Worse with activity . Palpation of the bone elects tenderness Tarsal tunnel syndrome . Pain , paresthesia & numbness on the sole of the foot . Percussion tenderness over the posterior tibial nerve in the tarsal tunnel 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 . Please tell me  about your pain. . Where do you feel it ? Dose the pain seem to radiate from here ?\ . When did you first noticed the pain ? Did it start suddenly , or did it come on slowly? . Have you had accidents / trauma involving your foot ? . On a scale 1 to 10 , with 10 being the worst ,how would you rate the severity of your pain? . What dose the pain feel like ( eg,sharp , dull, burning , aching)? . Dose anything make the pain better or worse? . Is the pain always there , or is it coming & going ? . Do you think it is getting worse over time? . How long dose an episode last & how often do episodes occur? . Do you stand for long periods during the day? . Do you walk a lot during the day? . Do you have other joint or back pain? . Do you have nay joint stiffness in the morning that improves as the days goes on? . Have you been diagnosed with bone , muscle , or joint disorders? . Do you have diabetes or problems with your circulation? Past medical history . Have you been diagnosed with other medical conditions(eg, diabetes , osteoarthritis)? . Have you had any surgeries? Physical examination Musculoskeletal . Inspect the foot for deformity. . Palpate foot for tenderness (especially insertion of plantar fascia). . Evaluate range of motion at ankle. . Palpate tendons during flexion to evaluate for tendinitis. . Examine spine of range of motion & tenderness in sacroiliac joints, . Examine knee & metatarsophalangeal joints. Cardiovascular . Assess regional pulses. . Inspect for varicosities & signs of venous stasis. Neurologic . Test light touch , vibration & joint position sense in the foot. Skin . Inspect for ulcerations , calluses & dermal atrophy. 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: . Inflammatory markers: Erythrocyte sedimentation rate , C-reactive protein (usually one or he other but not both) . Serologic studies : Antinuclear antibody, rheumatoid factor(do not order unless there are signs of specific  autoimmune disorder) . Joint aspiration : Gram stain , culture , cell count, polarized microscopy(for crystals) . MRI: Useful for soft -tissue and ligament injury , but not frequently ordered as a first -line test 2018/05/24 09:55pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6316 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 19 ¼Ó]   HEADACHE Doorway information about patient the patient is a 40-year-old woman who comes to the clinic due t headaches. Vital signs . Temperature : 37¡¦C . Blood pressure ; 120/70  mmHg . Pulse: 80/min . Respiratory rate; 19/min Approach to the patient Most primary headache syndrome(eg, migraine, tension-type headache) usually present at a young age, and often become less severe with age . Onset 9 or significant change) at age> 40 justified greater concern. clinical features suggesting a potentially serious causes of headache are summarized by the mnemonic ¡§SNOOP¡¨ . -Systemic- symptoms ( eg, weight loss, fever) or disease (eg, cancer , HIV/AIDS) . -Neurologic symptoms (eg, cal deficits , altered sensorium) . Sudden -onset- . -Older- age at first occurrence . Change from previous headache 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 Family history - often present Onset - variable location - Often unilateral Character - pulsatile & throbbing Duration - 4-72 hours Associated symptoms - Auras , photophobia, photophobia & nausea Cluster Male>Female No During sleep Behind eye Excruciating , sharp &steady 15-90 minutes sweating , facial flushing , nasal congestion m lacrimation &pupillary changes Tension Female> male No under stress Band-like pattern around the head(bilateral) Dull , tight &persistent 30 minutes to 7 days Muscle tenderness in the head , neck , or , shoulders 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: . Intracranial neoplasm: Morning or nocturnal headaches , worsened by bending over , neurologic deficits, or seizure . . Subarachnoid hemorrhage : Severe and sudden onset(¡§worst headache of mil life¡¨) , vomiting , loss of consciousness, neck stiffness . Angel closure glaucoma: Periorbital pain , vomiting , visual symptoms, abnormal ocular examination . Bacterial meningitis: Fever, confusion , nuchal rigidity . Giant cell arteritis : Age > 50 , temporal location , jaw claudication , shoulder or hip pain. . Hypertensive encephalopathy: Rapid rise in blood pressure (>180/120 mmHg) 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 . Describe what your headaches feel like. . How long have you had these headaches? . Do they start gradually or suddenly? . Are they constant or intermittent? . How severe are they (scale1-10)? . Where do you feel the headaches? . Dose it hurt anywhere else(eg, jaw, neck)? . What were you doing when the headaches started? . Dose anything relieve the pain ? Make it worse? . Is there nay relation to foods or your menstrual cycle? . Do you have nausea or vomiting ? . Have you had headaches like this before? . Do you have ay working signs (eg, blurry vision, light flashes)before the headache starts? . Do you have nay fever or chills? . Have you had any weakness , tingling , or numbers in your arms or legs? Past medical history . Do you have a history of cancer? . Have you been tested for HIV? Family history . Is there anyone in your family with severe headaches? Physical examination HEENT . Examine fundi(hypertensive changes , papilledema) . Palpate scalp( temporal artery tenderness) . Examine years & tympanic membrane . Examine nose & throat Neck . Auscultate ofr carotid bruits . Palpate for goiter or lymphadenopathy Musculoskeletal . Palpate  muscles in neck & shoulders for tenderness . Assess cervical range of motion Neurologic . Assess level of consciousness . Examine cranial nerves . Evaluate motor & sensory function in arms & legs . Romberg test . Check for cerebellar signs . Assess gait 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 Young patients with a classic headache history may to need any diagnostic tests . If no tests are needed to confirm the diagnosis , write , ¡§ No studies indicated ¡§ in the Diagnostic Studies section. 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). 2018/05/24 09:55pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7161 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 20 ¼Ó]   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 . Temperature : 36.1¡¦C(97.0F) . Blood pressure : 150/85 mmHg . pulse: 76/min . Respiratory rate: 16/min Approach to the patient Cognitive impairment in elderly patients Normal aging . Slight decrease in fluid intelligence (ability to process new information quickly) . - Normal functioning- in all activities of daily living. Mild neurocognitive disorder (mild cognitive impairment) . Mild declined >= 1 cognitive domains . Normal functioning in all activities of daily living with compensation Major neurocognitive disorder (dementia) . Significant decline in >=1 cognitive domains . -irreversible- global cognitive impairment . Marked functional impairment . Chronic & progressive , months to years Major depression . -Reversible- mild -moderate cognitive impairment . Features -depression-(mood , interest, energy) . Episodic , weeks to months 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 . -Early , insidious short -term memory loss- . Language deficits& spatial disorientation . Later personality changes Vascular dementia . -Stepwise- decline . Early executive dysfunction . -Cerebra infarction- &/or deep white matter changes on neuroimaging Frontaltemporal dementia . -Early personality changes- . Apathy , disinhibition & compulsive behavior . -Frontotemporal atrophy- on neuroimaging Normal pressure hydrocephalus . -Ataxia -early in disease . Urine -incontinence- . -Dilated ventricles- ion neuroimaging Prion disease . Behavior changes . -Rapid progression- . -Myoclonus- &/or seizure 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 . Please tele about your memory problems. . How long has this been going on ? Is it getting worse? . Do you have any problems sleeping? . Do you have nay trouble preparing meals for  yourself? Doing your shopping & housekeeping ? bathing /personal hygiene? Managing your finances? Driving? . Have you felt sad or lonely? . Do you have dizzy spell or falls? . Do you feel cold when everyone else feels comfortable? . Have you noticed any weight loss? . What do you think may be causing you problem, or what are you concerned for? Past medical history . Have you had a similar problem before? . Have you been diagnosed with any otters medical conditions (eg, diabetes, thyroid conditions)? Medications/ allergies . Do you take any medications (prescriptions, over-the-counter)? . How long have you been on these medications? Social history . Who do you live with / Do you  have someone to take care of you in an emergency? . What kind of work do(did) you do? . Do you smoke? . Do you drink alcohol? How much &how often? . Have you  used recreational drugs? Physical examination General . Attention & alertness . Grooming & hygiene . Nutrition & hydration Neck . Examine thyroid Cardiac . Auscultate the heart . Auscultate carotid ofr bruits Neurologic . Cranial nerve examination . ¡§Get up and go ¡§ test /gait . Power & reflexes . Cerebellar signs . Lower extremity sensory (position &vibration) - Mini-Mental state Exam - . What is the year ? Season ? month ? Date? Day ? (1 point each) . What country are we in ? State ? City ? Facility ? Floor (1 point each) . Name 3 common objects & ask patient to repeat (eg , bird , car , banana)(1 point each) . Count backward form 100 by 7¡¦s (alternate : spell ¡§world¡¨ backward)(1 point each, up to 5) . Name the 3 objects mentioned above (1 point each) . Point to 2 object in the room (eg, clock , pen ) & ask patient to identify them (1 point each) . Repeat the following : ¡§ No if ¡¦s and ,or but¡¦s¡¨(1 point) . 3-stage command : ¡§ take this paper in your right hand , food it in half & place it on the floor¡¨ (1 point each) . Write a command (¡§ close your eye¡¨) & ask patient to read & obey it(1 point) . Ask the patient to write a sentence(1 point) . Draw 2 interesting pentagons & ask patient to copy it(1 point) a score of <24/30 possible dementia Psychiatric . Mood /affect . Psychomotor activity . Speech/ language Closing the encounter Elderly patient have often seen how dementia has affect their friends or family members , and may be concerned about losing cognitive function and becoming a burden on their family. In light of this , physicians should be honest about whatever cognitive deficits they observe , but should also explain that there may be other possible explanations for the patient¡¦s symptoms. 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 . Blood urea nitrogen and creatinine . Liver function panel . Complete blood count . Urinalysis . Urine toxicology (drug ) screen 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. 2018/05/24 09:57pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7185 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 21 ¼Ó]   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 Etiology : Associated symptom 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 . Has your son ever been consistently dry at night or has he always wet the bed ? . How many times a night & how many mights a week dose he wet the bed? . How much fluid dose he drink during the day? what time of day dose he drink the most ? How much dose he drink before going to bed? . Tell me about his bathroom habits: How often dose he go , & with how much volume? . When he goes , dose he have drubbing , stopping the stream , or pain? When he is done, dose he feel like he still has to go? . Dose he lose control of his bladder during the day? . Dose he ever have to run to the bathroom? . Dose he have difficulty initiating the stream? . Dose he have problems associated with bowel movements? . How has this problems affect you & your family? . Are you aware of any stressful situations or incidents tat could be causing this problem? . What do you think may account for this problem , or what are you concerned about for your child? . Is there anything you¡¦ve tried so far to deal with this problem? Past medical history . Has he been diagnosed with any other medical conditions? . Has he had any urinary tract infections? . Has he had any surgeries or injury to his nervous system? . Were there any complications during pregnancy or delivery? Social history . Who dose he live with? . Would you describe your son as playful & social or shy & quiet? 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 . Review vital signs & growth / weight chart (if available). HEENT . Examine tonsils & adenoids for hypertrophy (suggesting obstructive sleep apnea) Gastrointestinal . Palpate abdomen of retained stool. Musculoskeletal . Inspection spine for deformities. Neurologic . Perform sensory , motor & reflex examination of the lower extremities. 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 : . Serum glucose and electrolytes . Serum creatinine . Urine culture . Complete blood count and hemoglobin electrophoresis (for sickle cell anemia) . Abdominal  x-ray(for retained stool) . Renal ultrasound . Voiding cystourethrogram . MRI of the spine 2018/05/24 09:58pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5900 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 22 ¼Ó]   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 . Temperature : 36.7¡¦C . Blood pressure : 122/80 mmHg . Heart rate : 90 / min . Respirations : 14 / min Approach to the patient Assessment of intimate partner violence Concerning signs . location of injuries (genital , breasts , abdomen , head , neck , teeth) . Inconsistent explanation of injuries. . Sexually transmitted disease , chronic pelvic pain. . Non adherence to visit & treatment / frequent emergency department visits . Overly attentive / intrusive partner who resists allowing patient to be seen alone . Discomfort / refusal to undress or consent to genital . rectal examination . Distress affect : Fearful , tearful , evasive Interview strategies . Ensure privacy(ask others to leave for interview) . Nonjudgemental , empathic , open-ended questioning . No pressure to discclose , report , press changes , or leave partner. . Ask if patient feels safe . Determine if patient has an emergency safety plan , provide referrals for shelters , domestic violence agency , mental health assistance as needed 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? . Are you currently in a relationship where you are physically hurt , threatened , or feel afraid? . Have you ever been attacked with weapon? . How long have you been in this relationship? . Has this happened before? . Are you afraid it will happen again? . Has anyone ever made you had sea when you didn¡¦t want to? . How are things between your partner and your children? . Dose the person you live with use alcohol or drugs? . Have you ever left home ? If nit , have you ever wished you could leave ? What prevented it? . Are you planning to leave/divorce your partner? . Has your partner ever threatened or tried to commit suicide ? . Do you think of suicide as a way out off the relationship ? Do you have a plan that involves killing yourself or your partner? . Are your friends or family aware of your situation? Social history . Who loves at home with you now? . Where do you go when you are not at home? . 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? 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: . Nucleic acid amplification testing for chlamydia and gonorrhea (swab site of exposure) . HIV screen . Hepatitis B screen . VDRL or rapid reagin screen for syphilis . Pregnancy test 2018/06/05 10:41pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6496 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 23 ¼Ó]   DIZZINESS Doorway information about patient the patient is a 65-year-old woman who comes to the clinic for episodes of dizziness Vital signs . Temperature: 36.7¡¦C . Blood pressure : 122/80 mmHg . Pulse : 90 /min . Respirations: 14/min 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 Primary causes Vertigo . -Benign paroxysmal positional vertigo- . Vestibular neuritis . Meziere disease . Migraine . Vertebrobasilar stroke Presyncope . -Cardiac arrhythmias- . Aortic stenosis . Orthostasis . Vasovagal event Disequilibrium . Peripheral neuropathy . Sensory disturbances . Neuromuscular disorders . Cervical spondylosis . Central nervous system disorders Nonspecific . Anxiety & other psychiatric disorders . Medications, substance abuse . Metabolic 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? . Describe what you mean by dizziness? . How often are you having episodes & how long do they last? . What brings on an episodes ? what makes it better or worse? . Do you have any warning signs that an episode its about to start? . Do changes in position (eg ,standing up) make you dizzy? . When you get dizzy, do you have a tendency to fall? . Do you feel like you are spinning , or the room is spinning around you ? . Have you ever lost consciousness? . Do you have loss of balance when walking? . Have you had any nausea or vomiting ? headache? . Have you had a feeling of your heart racing? . Have you noticed changes in your hearing , or a ringing or buzzing noise in your ears? . Do you  have  any double or blurry vision? . Have you noticed any weakness in your arms or legs, or numbness in your face , arms , or legs? . Do you  have nay problems with your bowel or bladder function? Past medical history . Have you had a similar problem before ? . Have you been diagnosed with any other medical conditions(eg, diabetes, hypertension)? Social history . Do you smoke? . Do you drink alcohol? how much & how often? . Have you used recreational drugs? Physical examination General . Alertness, orientation & level of distress . Body habitus & posture HEENT . Whisper , Rinne , Weber tests . Otoscopic examination Cardiovascular . Auscultation ofr murmurs , rubs , or gallops . Carotid upstroke & bruits . Peripheral pulses Neurologic . Cranial nerves . Muscle strength &tone . Peripheral reflexes . Light touch & joint position sense . Dix-Hallpike tests .  Gait & Romberg tests . Cerebellar signs 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. Additional studies might include: . Fasting glucose . Electrolytes ,blood urea nitrogen , creatinine . Compels blood count . Echocardiogram . CT scan or MRI of the brain 2018/06/05 10:42pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6648 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 24 ¼Ó]   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 . Temperature : 36.7¡¦C . Blood pressure: 135/70 mmHg . Pulse : 73/min . Respirations : 16/min Approach to the patient Oral anti diabetic agents Class Primary drugs side effects 1 Insulin secretagogues . Sulfonylureas (eg, glimepiride) . Meglitinides (eg, repaglinide) . Hypoglycemia . Weight gain 2 Biguanides . Metformin . Gastrointestinal upset . Lactic acidosis . Weight loss 3 Thiazolidinediones . Pioglitazone . Weight gain . Edema, heart failure¡¦ 4 DDP-4 inhibitors . Sitagliptin . Saxagliptin . Headache . Nasopharyngitis 5 GLP-1 receptor agonists . Eventide . Liraglutide . Nausea/vomiting . Abdominal pain . Weight loss 6 Alpha-glucosidase inhibitors . Acarbose . Miglitol . Diarrhea . Flatulence SGLT2 inhibitors . Canagliflozin . Dapagliflozin . Polyuria .Urinary tract infections . Hypotension 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-. . Determine whether the medication regimen is -effective-. 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? . What medications are you taking for diabetes? . Are you taking your medications regularly? . What medications did you take in the past? Why was your treatment regimen changed? . Do you check your blood sugar at home? what is the reading you have had recently ? the lowest? the average? . Have you had changes in vision ? When was the last time you had a dilated eye examination? . Do you feel abnormal sensations in your legs, such as tingling or numbness? . Have you had chest pain? . Do you have problems with urination? . Have you lost or gained weight lately? . Do you ever get dizzy or shaky, especially if you have not eaten recently?(Screen for hypoglycemia.) Past medical history . Have you ever been hospitalized for diabetic complications or for any other reason? . Do you have any other medical problems such as high blood pressure ? Are you on medications of those conditions? 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 ? Physical examination General . Assess alertness, orientation . Assess body habits & dress(hygiene, grooming) HEENT . Perform ophthalmoscopic examination . Perform oral inspection for dentition , dry mucosa , thrush Cardiovascular . Auscultate heart . Palpate peripheral pulses 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 Most patients require only standard drum and urine tests. Imaging(eg, x-ray, CT scan) and invasive studies (eg, colonoscopy_ are not typically necessary . However , be alert for additional conditions that may complicate management . for example , a TSH test is not routinely ordered in management of diabetes but might be considered if the patient has unexpectedly gained weight or the blood pressure is unexpectedly elevated. 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) . Electrolytes (especially of on blood pressure medication) . Blood urea nitrogen and creatinine . Liver function tests (if the patient is taking medication that can affect the liver) . Lipid panel . Urine microalbumin 2018/06/05 10:43pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5907 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 25 ¼Ó]   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 . Temperature : 36.7¡¦C . Blood pressure : 122/80 mmHg . Pulse : 90 / min . Respiratory rate : 14/min 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. ¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X -Manic or hypomanic episodes- Manic episodes Clinical features . >= 1weeks of elevated or irritable mood & increased energy/activity . >= 3 of the following symptoms (4 if mood is irritable only): 1 -Distractibility- 2 -Impulsivity-/indiscretion , risky behavior 3 -Grandiosity- 4 -Flight of ideas-/ racing thoughts 5 increased -activity-/psychomotor agitation 6 Decreased need for -sleep- 7 -Talkativeness-/pressured speech (-DIGFAST mnemonic) Severity . Impaired psychosocial function . May have psychotic features (hallucinations, delusions) . May require hospitalization ¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X¡X Different diagnosis Major depressive disorder . >=2 weeks . >= 5of 9 symptoms : Depressed mood & SIG E CAPS . Significant -functional impairment- Persistant depressive disorder (dysthymia) . Depressed mood >= 2 years . -At least 2 of the following - : Altered appetite ; sleep disruption; fatigue; low self-esteem; poor concentration or decision making; feelings of hopelessness. Adjustment disorder with depressed mood . Onset within 3 months of identifiable stressor . Marked distress & functional impairment Substance abuse . Alcohol . Illicit drugs Metabolic disorders . Hypothyroidism Neurologic disorders . Dementia . Multiple sclerosis SIG E CAPS -S-leep disturbance loss of -I-nterest excessive -G-uilt low -E-nergy impaired -C-oncentration -A-ppetite disturbance -P-sychomotor agitation/retardation -S-uicidal ideation 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?¡¨) . Loss of interest / anhedonia (¡¥What things do you usually enjoy doing ? Do you still enjoy them?¡¨) . Feelings of guilt, worthlessness , or hopelessness (¡§ Have you been having a lot of guilt feelings?) . Low energy (¡§Do you feel unusually tired?¡¨) . Impaired concentration (¡§Do you have trouble concentrating or remembering things?¡¨) . Appetite disturbance or weight changes(¡§How is your appetite? Has you r weight changed recently?¡¨)\ . Psychomotor retardation(note this drink the interview) . Suicidality(¡§have you ever felt life wasn¡¦t worth living? have you thought about hurting yourself?¡¨) History History of present illness . How long have you been feeling  this way? . Is there anything that has bought this on? . SIG E CAPS questions . Has there ever been a time when you felt so good & energetic that you got into trouble? Or felt energetic despite getting less sleep than usual? Did yu spend excessive amounts f money during these episodes , or do things that other thought were foolish? . Do you feel cold when otter¡¦s around you are comfortable? . Are you bowel movements regular? Past medical history . Have you had a similar problem before ? . Have you been diagnosed with any otters medical conditions (eg, diabetes, thyroid disorders)? Medications/allergies . Do you take any medications(prescription or over -the -counter)? Social history . Who do you live with? . What kind of worked you do? . 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 recreational drugs? Physical examination General . Alertness, orientation . Appearance & dress(hygiene,  grooming) . Level of distress Neck .Examine the thyroid Neurologic . Check reflexes , noting any delayed relaxation phase . Mental status Psychiatric . Mood & affect . Psychomotor activity . Psychotic features (¡§Have you heard or seen things that other¡¦s can¡¦t?¡¨) . Thought processes & speech 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 . Liver function tests . Urine toxicology / drug screen . Vitamin B12 level . HIV test . Viral hepatitis serologies . Therapeutic drug levels (eg, digoxin, carbamazepine) 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). 2018/06/05 10:43pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6927 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 26 ¼Ó]   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 . Temperature : 36.7¡¦C (98F) . Blood pressure : 122/80 mmHg . Pulse : 74 /min . Respirations : 14/min 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. . -Blue/green- : Food dyes , medications (eg, indomethacin, amitriptyline) , Pseudomonas urinary tract infection. . -Brown- : Medications (eg, ,metronidazole, senna), liver/kidney disease, myoglobin/rhabdomyolysis . -Orange- : Hepatobiliary disease, dehydration -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? . When did you first noticed the dark urine? . Is there blood in the urine? . Have you noticed a change in the quantity of urine? . Do you have pain with urination? . Have you had abdominal or back pain? . Have you  had fever or chills? . Do you have nausea , vomiting , or diarrhea? . Have you eaten anything(eg,berries , collared food , beets) that could cause this color? . Have you had recent injuries or heavy exercise? . Have you had rennet infections , such as a sore throat? . Have you had previous urinary or kidney problems? Psst medical history . Have you had a similar problem before? . Have you been diagnosed with any otters medical conditions(eg,diabetes, hypertension)? Medical /allergies . Do you take any medications? Social history . What kind of work do you do? . 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 recreational drugs? Physical examination General . Observe level of alertness & hydration HEENT . Examine the oropharynx. . Examine the sclera. Skin . Observer pallor or jaundice . Inspect for signs of liver disease (eg,spider angiomata, planar erythema) Abdomen . Auscultate bowel sounds. . Examine the liver & solemn for enlargement or tenderness . Examine for suprapublic & costovertebral angle tenderness. 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. Other studies may include: . Electrolytes , blood urea nitrogen, creatinine . Liver function tests (eg, direct and indirect bilirubin) . Urine culture . Complete blood count( and peripheral smear , reticulocyte count) . Muscle enzymes (eg, creatinine kinase, aspartate aminotransferase[AST]) . CT urogram (for identify kidney stones) . Liver /biliary CT scan , ultrasound . Cystoscopy {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) 2018/06/05 10:44pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5982 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 27 ¼Ó]   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 . Temperature : 36.7¡¦C(98.0F) . Blood pressure : 132/84 mmHg . Pulse : 80/min . Respiratory rate: 14/min 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 . Parkinson disease . Prior stroke . Advanced age . Sensory impairment Precipitating factors . Drugs (eg, narcotics , sedatives , antihistamines, muscle relaxers, polypharmacy) . Infections (eg, pneumonia, urinary tract infection , meningitis) . Electrolyte disturbances(eg, hyponatremia, hypercalcemia) . Metabolic derangements (eg, volume depletion, vitamin B12 deficiency, hyperglycemia) . Systemic illness (eg, congestive heart failure, hepatic failure , malignancy) . Central nervous system(eg, seizure, stroke, head injury, subdural hematoma) 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 History of present illness . Your spouse is concerned about you being confused . Do you feel unusual? . Are there nay specific times or situations that cause this confusion? . Have you noticed any problems with your memory? . Have you had any weakness, tingling , or numbness in your arm or legs? . Have you had any dizziness? . Have you ever had any jerky hand movements or seizures? . Do you have any history of head trauma? . Have you had any fever? . Do you have headaches? . Have you ever passed out? . Assess activities of daily living: - Are you able to do regular activities , such as dressing , eating , walking & bathing? - Are you able to go shopping ? manage your household finances? - Are you able to do your regular housework? Prepare your own food? - Are you able to drive ? have you had any accidents or traffic citations recently? Social history . Who do you live with? . What kind of work do (did) you do? . Do you smoke? . Do you drink alcohol? How much &how often? . Have you used recreational drugs? 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 - Memory , recent & remote (eg,recent events , recall of 3 objects) - Concentration (serial 7s , ¡§ world ¡¨ spelled backward) - Estimate of intelligence (fund of knowledge , current events) - Abstraction (interpretation of similarities, proverbs) - Insight (awareness of illness) . Examine cranial nerves . Test gait & reflexes . Evaluate muscle strength & sensory function 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 . Liver function tests . Complete blood count . TSH . Vitamin B12 . HIV serology . Urinalysis and culture . Urine drug screen . Lumbar puncture/cerebrospinal fluid analysis (especially for patient with fever or features suggesting meningitis) . MRI of the brain . CT scan of the brain . Electroencephalogram (especially of patients with prior seizures or head trauma ) 2018/06/05 10:45pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6627 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 28 ¼Ó]   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) . Blood pressure : 118/78 mmHg . Pulse: 86/min . Respirations: 14/min 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 . Irritable bowel syndrome: loose stools , altered bowel habits , sensation of incomplete . Inflammatory bowel disease: 1, Crohn disease : watery diarrhea , fever m weight loss , abdominal pain 2, Ulcerative colitis : cramps , tenesmus (sensation of needing to strain to pass stool), visible blood . Malabsorption : Increased stool volume , weight loss, steatorrhea , flatulence , possible association with foods(dairy products , gluten) . Paradoxic diarrhea: impacted stool with diarrhea due to passage of watery stool around the impaction(especially in frail or elderly patient) 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¡¨ . When did the diarrhea start? . How many times a day are you going? . Do you have large or small volume? . What is the pattern ? Are symptoms continuous m or do you have normal bowel movements in between? . Do you see blood or pus? . Do you pass mucus in the stool? . Is the diarrhea greasy or oily? . Do you have abdominal pain or cramps? . Have you had fever , chills or weight loss? . Is the diarrhea associated with any particular foods? . Have you started any new medications, include over-the-counter medications? . Are you taking weight loss pills (eg, orlistat) or artificial sweeteners(eg sorbitol)? . Have you been traveling or camping recently? . Dose anyone around you have similar symptoms? Past medical history . Have you had abdominal surgeries? Social history . Are you sexually attire ? Have you been active with men , women , or both? . Do you use illicit drugs? Physical examination General . Assess fluid & nutritional status (eg, tachycardia, orthostatic hypotension, decreased subcutaneous fat) HEENT/Neck . Examine oropharynx for ulcers , thrush. . Inspect eyes for conjunctivitis, episcleritis. . Palpate neck ofr enlarged lymph nodes , thyromegaly. Abdomen . Inspect for scars & distension. . Auscultate for bowel sounds . Percuss for bowel gas pattern. . Palpate for tenderness , especially along the course of colon. 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) . TSH . Inflammatory markers (eg, erythrocytes , sedimentation rate, C-reactive protein) . Quantitative stool fat . Stool Guardia antigen . Anti-tissue transglutaminase antibody assay(suspicion for celiac disease , comorbid type 1 diabetes) . HIV serology . Colonoscopy 2018/06/05 10:46pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5244 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 29 ¼Ó]   CHRONIC COUGH Doorway information about patient Vital signs . Temperature : 36.7¡¦C (98.0F) . Blood pressure: 122/80 mmHg . Pulse : 90/min . Respirations : 14/min 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) . Chronic sinusitis Lower airway & parenchymal disorders . Asthma . Post-respiratory tract infection . Chronic bronchitis . Bronchiectasis . Lung cancer . Non asthmatic eosinophilic bronchitis Other causes . Gastroesophageal reflux . ACE inhibitors -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? . Is it a day cough or dose it bring up sputum ? What color is the sputum? Has there been blood in the sputum? . Is there anything that makes your cough worse ? better? . Have you noticed drainage in the back of your throat? . Do you get short of breath? . Have you noticed wheezing? . Do you have frequent heartburn or acid reflux? . Do you have chest pain? . Have you had a fever? chills? Night seats ? Weight loss? . Features of heart failure - prior heart problems ? - Swelling in your feet ? - How many pillow do you sleep on ? Do you get out of breath if you lie flat? Past medical history . Have you had heart or uno problems in the past? . Do you have trouble with allergies or eczema9recently or as a child)? . If history of hypertension m review medications for ACE inhibitors. 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) . Do or did you smoke? . Have you traveled outside the US recently? Physical examination HEENT/neck . Oropharynx: Erythema, drainage, lesion. . Nasal mucosa : Edema, polyps . Sinus tenderness . Cervical lymph node enlargement Cardiac . Auscultate for murmurs, rubs, or gallops. Lungs . Inspection : Chest wall abnormalities ,accessory muscle use. . Auscultation : Decreased or abnormal breath sounds, Wheezing . Signs of consolidation: Dullness ,ego phony, increased fremitus Abdomen . Upper abdominal tenderness Extremities . Peripheral edema . Clubbing 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) . Pulmonary function tests : Asthma, wheezing , suspected chronic bronchitis . Arterial blood gas analysis : Tachycardia , tachypnea , or abnormal pulse oximetry . ECG, echocardiogram; Heart failure or valvular heart disease . Chest CT: Risk of malignancy , interstitial lung disease . Esophagram : Dysphagia , obstructive symptoms 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 2018/06/05 10:46pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 5417 ¦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®É36¤À20¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 30 ¼Ó]   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 . Temperature : 36.7¡¦C (98F) . Blood pressure : 122/80 mmHg . Pulse : 90/min . Respiratory : 14/min 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 2 Radiation to arm , shoulder , or jaw 3 Precipitated by exertion 4 Relieved by rest or nitroglycerin Pulmonary / pleuritic (pleurisy , pneumonia pericarditis , PE) 1 Sharp . stabbing pain 2 Worse with inspiration 3 Pericarditis : Worse when lying flat 4 PE, pneumothorax : Respiratory distress ,hypoxia Aortic (dissection , intramural hematoma) 1 Sudden , severe ¡§tearing¡¨ pain 2 Radiates to back 3 Elderly men 4 Hypertension &risk factors for atherosclerosis Gastrointestinal / esophageal 1  Nonexertional , relieved by antacids 2 Upper abdominal & substernal 3 Associated with regurgitation, nausea, dysphagia 4 Nocturnal pain Chest wall / musculoskeletal 1 Persistant &/or prolonged pain 2 Worse with movement or change in position 3 Often follows repetitive activity 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? . Do you still have pain or has it resolved ? . For active chest pain 1 What were you doing when the pain begin? 2 Can you think of anything that may have caused the pain? . For resolved or intermittent chest pain? 1 How long ago did the chest pain episodes begin? 2 How often do the episodes occur? 3 How long do the episodes last? 4 What brings on the pain (eg, walking , exercising)? 5 How far can you walk before you develop chest pain or shortness of breath? . Point to where the pain is . Do you feel it anywhere else? . On a scale of 1 to 10 , how severe is it? . Describe the point (eg, sharp , burning , crushing , heavy). . Dose anything make the pain better/worse? . Do you have other symptoms associated with the pain (eg ,shortness of breath , palpations , nausea , sweating , lightheadedness )? . Have you had a fever? . Have you had a cough? . Do you have swelling in the leg? . Do you have leg pain while walking? . Risk factors for pulmonary embolism; Unilateral leg pain/ swelling , immobilization , recent surgery, clotting disorders 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? . Do you drink alcohol? How much & how often? . Do you use recreational drugs(especially cocaine or amphetamine)? Review of system . Pulmonary : cough , dyspnea , wheezing , hemoptysis . Cardiovascular ; palpations , tachycardia, pedal edema, orthopnea . Gastrointestinal : Heartburn , hematemesis, nausea/vomiting, acid reflux Physical examination General . Patient position & body habitus Cardiac . Carotid pulse , carotid bruits; jugular venous pressure . Location & character of point of maximum impulse . Heart sounds : S1,S2 , murmurs , rubs, gallops . Abdominal aorta(bruits , enlargement) Lungs . Work of breath/ accessory muscle use . Lung sounds . Signs of consolidation (Eg, dullness, egophony) Gastrointestinal . Epigastric tenderness . Liver/gall bladder tenderness (Murphy sign) Extremities . Peripheral pulses . Lower extremity edema . Shoulder examination 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 . Chest-x-ray . Pulse oximetry (if not provided) or arterial blood gas analysis . High-sensitivity D-dimer . CT pulmonary angiogram or ventilation/ perfusion scan . Echocardiogram . CT scan of the chest . Barium esophagram or upper GI endoscopy . Liver / gall bladder ultrasound 2018/06/05 10:47pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6692 ¦ì¤¸²Õ]¡@

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