SP Exam Prep

Things to remember Name, age CC: HPI: Get all the problems before starting OPQRST for each problem For the ddx: go by anatomy, worst case scenario, VITAMIN C(below) for ideas ROS: see below Past medical history: remember to get allergies, home meds Social history: habits, lives with... Family history: CAD, HTN, DM, cancer + relevants Physical exam: Wash hands to collect your thoughts Give vital signs & general appearance in physical exam section

VITAMIN C: Vascular Infectious Trauma Autoimmune Metabolic / medications Idiopathic Neoplastic Congenital ROS:
Const: sick contacts, fever, chills, wt loss, malaise, weakness, dizziness, appetite HEENT: blurry vision, photophobia, vision, hearing, sore throat, tinnitus, drainage Resp: SOB, cough, sputum, pleuritic chest pain, hemoptysis Cardio: orthop, PND, DOE, LE edema, pain chest/ L arm/shoulder/neck/jaw/back, syncope, palp, claudication GI: N, V, regurg, heartburn, odynophagia, dysphagia for solids/liquids, abd pain, diarrhea, constipation, bloat, hemetem, melena, hematochezia, mucus GU: urgency/ frequency/ incontinence, dysuria, hematuria, hesitancy, post- void dribbling, impotence, testicular masses,vaginal dc, dyspareunia, bleeding Endo: thirst, polyuria, heat/ cold intole, tremor, menstrual irreg, hair/ skin/ nails, libido, body hair Skin: rashes, itch Breast: masses, pain, discharge, lactation Hematologic: bruising, h/o excessive bleeding, LAD Msk: arthralgias, deformity, swelling, myalgias, muscle weakness Neurologic: HA, focal wknss, sz, tremor, falls, memory loss, paresthesias, sensory loss, vertigo Psych: Sleep, interest, guilt, energy, concentration., appetite, psychomotor, suicide

Sample sheet setup Name: Age: CC: HPI: Get all problems before starting OPQRST for each; has this happened before? DDx: VINDICATE Anatomy 1. 2. 3. 4. 5.

ROS: PMHx:

Allergies: Meds:

To order: 1. 2. 3. 4. 5. Plan: ASK/TELL/ ASK

FHx: CAD, HTN, DM, cancer & relevants to problem SHx: habits, lives with, work

PE: include VS, Gen Appearance. Listen to heart & lungs. Do more>less

From Step 2 CS: what the forms look like (a reminder): HISTORY: Include significant positives and negatives from history of present illness, past medical history, review of system(s), social history, and family history.

PHYSICAL EXAMINATION: Indicate only pertinent positive and negative findings related to the patient's chief complaint.

DIFFERENTIAL DIAGNOSES: In order of likelihood (with 1 being the most likely), list up to 5 potential or possible diagnoses for this patient's presentation (in many cases, fewer than 5 diagnoses are likely): 1. 2. 3. 4. 5.

DIAGNOSTIC WORKUP: List immediate plans (up to 5) for further diagnostic workup: 1. 2. 3. 4. 5.