factor3
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ACRONYMS SAVE A LOT OF TIME IN PN.
ACCORDING TO WWW.USMLE.ORG, WE CAN USE ABBREVIATIONS WHICH ARE COMMONLY USED IN THE US HOSPITALS OR UNDERSTANDABLE TO THE PHYSICIAN WHO WILL CHECK UR PN.
IT IS BEST TO REMAIN STICK IN ANY ONE FORMAT OF PN RATHER THAN CONFUSING IN EXAMS. LIKEWISE JUST LIKE YOUR Hx TAKING SHOULD BE HIGHLY FOCUSED, PE AND PN SHOULD ALSO BE VERY FOCUSED. FOR EXAMPLE IF PATIENT COMPLAIN OF BACK PAIN AND IF YOU DO FULL CHEST EXAMINATION THAT IS NOT FOCUSED (NO MORE THAT 30 SEC)
HERE ARE SOME WHICH I USED IN PN WHICH MIGHT BE HELPFUL:
GENERAL APPEARANCE (WRITE ALWAYS SOMETHIG)-WN/WD- (WELL NOURISHED WELL DEVELOPED) MALE, ILL/TOXIC APPEARING, IN NO ACUTE DISTRESS
HEENT- NCAT (NORMOCEPHALIC, NON-TRAUMATIC), NO BRUISES,
EYE- NO CONJUCTIVITAL PALLOR/ICTERUS, EOMI (EXTRAOCU MUS INTACT), PERRLA(PUPIL EQUAL,ROUND,Rx TO LIGHT AND ACCM), FUNDOSCOPY-N, OR SIMPLY EYE, MOUTH, NOSE, THROAT NORMAL TO EXAMINATION
OROPHARYNX-MOIST (ESP IN DEHYDRATED PT), DENTITION GOOD (IN ALCOHOLIC ETC), NO ERYTHEMA/EXUDATE, NO TONSILLAR SWELLING
NOSE-NO CONGESTION OR CONGESTION OF MUCOSAL ERYTHMA/EDEMA/RHINORRHEA/DISCHARGE
EAR-NON TENDER, NO GROSS ABNORMALITIES, TM L-INTACT OR PERFORATION/CERUMEN+, REDNESS/BULGING, WEBER/RHINNE TEST (ONLY IN HEARING DEFICIT OR ABNORMAL FINGER RUBBING/WHISPER TEST)
NECK-SUPPLE, NO CAROTID/THYROID BRUIT, NO JVD (JUGULAR VEIN DISTENSION), THYROID-N, NO LAD
LUNGS-NT, VTF (VOCAL TACTILE FREMITUS)- WNL, CTAB (CLEAR TO AUSCULTATION BILATERALLY), SOMETIME WITH NO RALES, CRACKLES,
WHEEZES OR RUBS IF IT IS A CHEST PAIN CASE. LUNG EXPANSION NORMAL, I DIDN'T DO EGOPHONY, WHISPER PECTORILOQUY, BRONCHOPHONIA-TIME WASTE
CVS- PMI NOT DISPLACED, RRR, S1,S2 WITH NO M/R/G (MURMUR/RUBS/GALLOPS)
ABD-FLAT, NO SCAR/PIGMENTATION, SOFT/NT/ND/ (NON TENDER/DISTENDED)/BS+ WITH NO GAURDING/REBOUND/MASSES/ORGANOMEGALY
CVAT+-, MURPHY'S/PSOAS/ROVSING/OBTURATOR ARE -
NEURO-GENERAL- RESTLESS, LETHARGY, DROWSINESS, APATHETIC, AGITATED, UNKEMPT APPEARING, NO EYE CONTACT, NON HOSTILE,
MMSE- AA&OX3- (AWAKE,ORIENTED TO PERSON,PLACE,TIME), MEMORIES-INTACT, PERFORMED 3 STEP COMMAND,JUDMENT-N, SPELL "WORLD"-BACKWARD CN-IITOXII-INTACT, DTR+2 AND MOTOR5/5-B/L, SYMMETRIC IN UE/LE
SENSORY (DULL/PINPRICK)-INTACT, IN/DE-CREASE VIBRATION AND POSITION SENSES,RAPID HAND MOVEMENT/FINGER TO NOSE-INTACT, ROMBERG-,GAIT-N, BABINSKI-,NO MENIGEAL SIGNS (OR NECK STIFFNESS/BRUDZINSKI/KERNIG)
PERIPHERAL PULSES (OR YOU CAN NAME SPECIFIC) STONGE OR +2 B/L,SYMMETRIC
EXT-NO CYANOSIS/EDEMA/CLUBBING/SWELLING/RASH SOMETIME NO RASHES OR ANY ABNORMALITIES, CALF MUSCLE SWELLING/TENDER+ OR HOMAN SIGN(IMP IN CHEST PAIN), SLR- - AT 90, ROM-WNL OR TENDERNESS ON ROM (U CAN BE SPECIFIC eg FLEXION) AS COMPARED TO OTHER LEG ARM
SPINE/JOINTS-NO OBVIOUS DEFORMITIES/BRUISES/ERYTHEMA/SWELLING/CREPITATION.TENDER OR NONTENDER PARASPINAL MUSCLES, Jt N TO ROM OR NON TENDER ROM OR TENDERNESS ROM AT FLEXION, INTERNAL ROTATION...,
SOME IMPORTANT TESTS APART FROM INSPECTION, PALPATION, PERCUSSION, AUSCULTATION, ROM- MCMURRAY'S, VALGUS/VARUS TEST, DRAWER SIGN (I PREFER)/LACHMAN SIGN, PATRICK TEST/SCHOBER TEST (FOR ANKY SPOND), TRENDELENBURG (HIP PAIN), GAIT EXAM- IN ALL LE PAIN CASES, CVA/NEURO/BACK PAIN CASE
APPENDICITIS-MCBURNEY PT TENDERNESS/ROVSING/PSOAS/OBTURATOR
CHOLECYSTITIS-MURPHY'S
NOTE: YOU PE SHOULD BE VERY SPECIFIC AND DESCRIBE IN PN ONLY WHICH U HAVE PERFORMED.
PN- DDx IN MY OPINION THE MOST IMPORTANT. WITHOUT KNOWING THEM U WON'T BE ABLE TO ASK Hx/PERFOME PE. THEN WORK UP- IT SHOULD BE ACCORDING TO YOUR DDx. THEN, HPI, ROS, PAMHUGSFOSS (SODA), LASTLY PE NOTES
LET ME KNOW IF I AM WRONG
FACTOR3
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