Doc750
transfer:step 3 prison
Topics: 52
Posts: 636
| | 10/30/07 - 12:55 PM
2 of 2 forum leaders found this post helpful
| #1 |
Here is a list of questions I had made up for the CS exam when I took it. Everyone knows the basic questions when you have a pt in pain (ie LIQORAAA). But then for those scenarios where you have a different complaint, there are other questions you must ask. Here is my list of questions based on common presenting symptoms. Hope this helps
feel free to add more, if you have them.
Cough
Onset, Blood in sputum
Preceding symptoms, Chest pain (LIQORAAA)
Changes in cough during the day, Night sweats
Cough at night, Exposure to TB
Fever/chills, Pet, animal exposure
Sputum production, Recent travel
Amount, Color, Odor Last PPD
Blood, Amount of blood
Yellow skin & Sclera
Onset, Blood transfusions
Color of stool, Fever, night sweats
Color of urine, Joint pain
Pruritis, Travel history
Abdominal pain, Immunization before travel
Colonoscopy, Similar episodes
Old Fart(forgetfulness)
Onset, Headaches
Progression, Head trauma
Things that are difficult to remember, Gait problems
Daily activities (bathing, feeding, toileting, dressing) Urinary incontinence
Shopping, Feeling (sad, depressed)
Lightheadedness or feeling faint, Cooking
Housework, Paying the bills
Passing out, Falls
Did you see a doctor for the fall, Any shaking/seizures
Speech difficulties, Support system,
Need to follow up with other family members
Diabetic
Onset, Last HbA1c
Treatment (type of insulin and dosage), Last eye exam/visual problems
Compliance with medication, Medication side effects,
Last blood sugar, reading, Polyuria, polydipsia
Blood sugar monitoring, Foot infection,
Libido
Dizziness
Meaning of “dizziness”, Tinnitus
Progression, Hearing loss
Constant/intermittent Fullness/pressure in ear,
Timing, Discharge from ear,
Positions that can illicit the dizziness
Fatigue (PTSD)
Onset, Feeling of blame or guilt,
Associated events, Sleeping problems (falling asleep, staying asleep, early waking)
Progression during the day, Snoring
Affecting job performance, Loss of concentration
Feeling of depression, Cold intolerance
Suicidal thoughts/plans/attempts Skin/hair changes
Fatigue (abuse)
Onset, Feel safe/afraid at home
Associated events, Are children being abused or threatened,
Progression through the day, Suicidal thoughts/plans/attempts,
Change in vision, Feeling of blame or guilt
Affecting job performance, Presence of guns at home
Feeling depression, Any family members who know about abuse,
Causes of bruises, Emergency plan
Abused physically/emotionally by anybody Sleeping problems,
Loss of concentration
- suggest safety is important, everything confid, child protective services, support groups, safety planning
Bloody urine
How do u know it’s blood Polyuria/polydipsia?
Onset, Nocturia
Progression, Weak stream,
Pain/burning on urination, Dribbling,
Fever, Onset of previous symptoms,
Abd pain, History of renal stones,
Hypertension Follow up:
Compliane with medication, Home monitoring of BP
Last BP, Medication side effects (sexual, sob, N/V/D/C)
Knee Pain:
Function, Photosensitivity,
Redness, Cold temp cause problems with fingers,
Swelling of joint Oral ulcers,
Other joint pain Rashes,
Stiffness in morning/duration
Tremor:
Context,
Alleviating/aggravating, Caffeine intake,
Previous similar episodes
Syncope:
Describe what happened, Lost control of bladder,
Loss of consciousness before, during, after fall, Weakness/numbness,
Palpitations before the fall, Speech difficulties,
Aura (sounds, lights, smells) Confusion after regaining consciousness
Spinning/lightheadedness, Head trauma
Shaking (seizure), Gait abnormalities
Duration of shaking, Similar previous episode,
Bit tongue
Weight Gain:
Lbs gained/time period Depression,
Cold intolerance, Sleeping problems (falling asleep, staying asleep, early awakening, snoring), Skin & hair changes,
Voice changes, Hirsutism
Loss of Menstraul periods:
Full gyn. History, Vaginal dryness
Weight changes, Hot flashes,
Cold intolerance, Urinary frequency,
Skin/hair changes, Nipple discharge,
Voice changes, Visual changes,
Fad diet or pills, Last pap smear,
Depression/anxiety/stress, History of abnormal pap smear,
Sleeping problems (falling asleep,
staying asleep, early wakening, snoring)
Pain during sex:
Describe pain, Sexual Desire,
Timing, Conflict with partner,
Location, Feeling safe at home,
Duration, History of physical, sexual, or emotional abuse,
Vaginal discharge, History of vaginal infection or STD,
Color, amount, smell, Last pap smear,
Itching, History of abnormal pap smear,
Douching, Depression/anxiety,
Painful periods, Hot flashes,
Postcoital/intermenstrual bleeding, Vaginal dryness during intercourse,
Sexual partner, Sleeping problems,
Contraception, Urinary frequency/pain with urination
Child w/diarrhea:
Progression Rash,
Frequency in bowel movements, Shaking (seizure)
Description of bowel movements, Recent travel,
Blood in stool, Day care center,
Relationship to oral intake, Ill contacts in day care center,
Previous regular bowel movements, Vaccinations,
Number of wet diapers, Last check up,
Treatment tried, Birth history,
Vigorous cry, Eating habits,
Recent URI, Developmental milestones,
Breathing fast
Hearing loss:
Description, Sensation of room spinning,
Onset, Feeling of imbalance,
Progression, Recent infection,
Location, Ringing in the ears,
Treatment tried, Trauma to the ears,
Ear pain, Exposure to loud noises,
Ear discharge, Insertion of foreign body
Bed wetting:
Frequency, Hematuria
Time of day, Snoring,
Onset, Nighttime awakening,
Interventions or drugs in past, Environmental changes related to wetting,
Volume of urine, Major stress,
Dysuria, Family history of enuresis,
Urinary urgency, Neurologic history,
Fever, Birth history,
Urine color, Weight, height and language development
Erectile Dysfuntion:
Onset, Previous treatment,
Desire for sex, DM/HTN/GAD,
Aggrevated by stress, Trauma,
Previous episode of sexual dysfunction, Meds,
Nocturnal erections, Alcohol intake, ***
Pain in legs/thighs, Occupation,
Number of sexual partners
Blurry Vision:
Onset, Pain in the eye,
Progression, Halos around the eye,
Eye discharge, H/N/V,
Food intake, Loss of weight,
Polydipsia/polyuria, Sudden transient complete loss of vision
Dysphagia:
Onset, Assoc with pain,
Exact location where food is getting stuck, Agg/allev factors,
Intermittent/progressive Choking sensation,
Solids or liquids or both, Regurgitation/Aspiration,
Which started first (solid or liquid)
HIV drug refill:
Drugs presently taking, Difficulty swallowing,
Compliance, Rash,
Side effects, Weakness/sensory in limbs,
Breathing problems, Genital problems (ulcers, discharge), F/H/N/V/D/C, Support system,
Eye problems, Depression,
Oral ulcers/white patches
Breathlessness/Anxiety:
Onset, duration, Restriction of activities,
Chest pain, Swelling or mass in neck,
Feelings, offright Bowel movements,
Fear of death, Support system,
Palpitations, dizziness, sweating
Depression:
Sleep, Psychomotor retardation,
Insomnia, Suicidal ideation,
Guilt Hobbies/interests,
Energy, Daily routine,
Concentration, Forgetfulness,
Appetite
Asthma:
First diagnosed with asthma? How often does it occur on weekly basis?
How have you been doing since then Trouble breathing with exersize?
Current medications? Episodes of excessive coughing?
Side effects/problems, Admitted to the hospital for acute/severe attack?
Trouble breathing during day/night? Precipitates the asthma?
Edited by Doc750 on 10/30/07 - 03:32 PM
___________________
Experience is a hard teacher because she gives the test first, and the lesson afterwards.
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| Doc750
transfer:step 3 prison
Topics: 52
Posts: 636
|
and this is the basic outline for my pt note sheet. Don't knwo if this is as useful, but I'll put it up anyway.
Name: ______________________ Age: _______________________
Chief complaint:___________________________
BP:_________________ Pulse: ______________ RR:_____________ Temp:_____________
HPI:
Location:
Intensity:
Quality:
Onset, Duration, Frequency:
Radiation:
Aggravating factors:
Alleviating factors:
Associated problems:
PMH:
Allergies:
Medications:
Hospitalizations:
Urinary complaints:
Gastrointestinal problems:
Sleep:
Family History:
OBGYN History:
Sexual History:
Social History:
Physical Exam
HEENT: NC/AT, AAOX3, PERRLA, Nose-clear, 0 turbines,
Neck: supple, 0 lymphadenopathy, 0 JVD, 0 Bruit, 0 deviation, 0 masses
CVS: S1/S2, RRR, 0 murmur, 0 rub, 0 gallup
Resp: clear bilaterally, 0 rhoncii, 0 rales
Abd: bowel sounds present X4, 0 scars, 0 distention, 0 hepatosplenomegaly
Extremities: 0 clubbing, 0 cyanosis, 0 edema, muscle strength 5/5
Skin: 0 rash, 0 edema, peripheral pulses 2+, & symmetrical
___________________
Experience is a hard teacher because she gives the test first, and the lesson afterwards.
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| muxia
Forum Newbie
Topics: 1
Posts: 30
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great job!!! thanks!!!
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| katchresidency
Forum Newbie
Topics: 4
Posts: 12
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thats really helpful!!! Doc750 would you please explain what does NC/AT, AAOX3 mean in HEENT exam.i know its a silly q but please pardon my ignorance !
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| Doc750
transfer:step 3 prison
Topics: 52
Posts: 636
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not a silly question at all. 
NC/AT = normocephalic, atraumatic
AAoX3 = Awake, alert, and oriented x 3
HEENT = Head, ears, eyes, nose, and throat
PERRLA = Pupils, equal, round & reactive to light and accomadation
___________________
Experience is a hard teacher because she gives the test first, and the lesson afterwards.
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| muxia
Forum Newbie
Topics: 1
Posts: 30
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stupid q, but for what stands F/H/N/V/D/C? fever??Hematemesis???nausea/vomiting/diarrhea/contipation-clear
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| Doc750
transfer:step 3 prison
Topics: 52
Posts: 636
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fever/headache/nausea/vomitting/diarrhea/constipation
sorry, these were my short hand notes. If there any others, post op and I'll let you know. 
___________________
Experience is a hard teacher because she gives the test first, and the lesson afterwards.
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| damselMD
Forum Senior
Topics: 8
Posts: 173
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these are great! great job Doc750. i am sure you aced the exam!
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| arlete
Intern in 2009!!!!!
Topics: 30
Posts: 2,223
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Cool...
Thanks.
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When men make the rules, God decides the exceptions.
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| Justice
Forum Fanatic
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muxia wrote:
stupid q, but for what stands F/H/N/V/D/C? fever??Hematemesis???nausea/vomiting/diarrhea/contipation-clear
I guess these are not standard abbreviations that allowed for PN...
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| ShweHope99.9998
Forum Fanatic
Topics: 12
Posts: 2,553
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Nice, thnx, N+V are using in med student here , not sure in pn , will check with experts when my CS come , not so yet .
If not sure write full up according to the CS teacher , like in CVS .. CP , SOB is common but some Doc will not know or accept , instead will like to get the real med tearms as dyspnoea which take times to write .
GL
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| Doc750
transfer:step 3 prison
Topics: 52
Posts: 636
|
No like I Said before those are my short hand notes, you can't use those abreviations on the actual exam.
but there is a list of them in the FA that you can use.
___________________
Experience is a hard teacher because she gives the test first, and the lesson afterwards.
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