08-13-2011, 06:57 PM
TYPING PATIENT NOTE
SET YOUR ALARM ON 8 MINUTES THEN SNOOZE FOR TWO MINUTES. STOP WRITING AT TEN.
FOR PRACTICE JUST READ FIRST AID PATIENT NOTE AND THEN START CLOCK, DO TEN NOTES DAILY, IN THIS WAY YOU CAN COMPLETE YOUR CASES IN FOUR DAYS,
1.first of all type diagnosis and work up portion in (1:30-2:00) minutes
2. NOW come In HPI portion, FIRST TYPE TITLES(HPI,RAM,PSFO) IN 30 SECONDS THEN COME AT TOP AND TRY TO WRITE IN 4 MINUTES
HPI; 40 YO F, C/O ABD PAIN X 1 MONTH IN , GRADUAL, WORSENING, CONSTANT RADIATES TO R SHOULDER, NAUSEA AND VOMITED 2 X, SOUR YELLOW NO BLOOD, ANOREXIA & DENIES WEIGHT LOSS, SOB, LMP 2 WEEK AGO, CYCLE 4 WEEK FOR 5 DAYS
ROS: NL
ALL:NKA
MED: TYLENOL
PMH: HTN, STROKE
SH: SMOKE 1PPD X 20 YEARS,
FH: FATHER DIED OF PANCREAS CA
OCCU: TEACHER
3. PHYSICAL EXAM(3:30)
PATIENT IS NOT IN ACUTE DISTRESS
ABD SOFT, TENDER IN RUQ, MURPHE'S +VE, BS +,NO REBOUND,-VE PSOAS, NO ORGANOMEGALY
CHEST: CBSB
CVS: RRR, S1S2 NL,NO M,R,G
FOR NEURO EXAM (C-MD-GBS)
1.CRANIAL 2-12 INTACT, MOTOR 5/5, DTR INTACT, GAIT NL,BEBINISKY -VE, SENSATION INTACT
ONLY FOR FORGETFULNESS, TIA, CONFUSED PATIENT
FOR MME ALERT & ORIENTED X 3, SPELL BACKWARD, RECALL 2/3
JUST DO FOCUS EXAM ONLY
ANY JOINT DONT FORGET 6 THINGS= TELL SP NOW I AM DOING THIS
1.INSPECTION
2.PALPATION (ANY TENDERNESS)
3.RANGE OF MOTION (ALL DIRECTIONS)
4.STRENGTH (FOR EXAMPLE IF YOU CHECK STRENGHT OF ARM, DON'T LET ME PUSH YOU 'UP,DOWN, IN & OUT)
5.DTR ANY TWO AT LEAST NOT ALL
6.SENSATION
ALSO DO AND MENTION 1 OR 2 EXAM OF SAME JOINT
LIKE
NECK=SEE UP, SEE DOWN, SEE AT YOUR RIGHT, SEE AT YOUR LEFT, TILT TO RIGHT, TILT TO LEFT, ALSO ASK FOR NUMBNESS AND TINGLING IN FINGERS
SHOULDER AFTER ALL SIX= SPCIFIC EXAM SHOULDER APPPRIHENSION, ARM DROP, NEER TEST ANY 1 OR 2
WRIST TINNEL'S AND PHALEN'S SIGN
BACK PAIN AND HIP JOINTS MUST DO LEG RAISE TEST, AND ALSO ASK FOR WALK
KNEE ANT AND POST DRAWER SIGN THATS ENOUGH
HEEL MUST SEE VIDEOS ON YOU TUBE ITS EASY,
3 POINTS PRESSURE AT CALCANIUM, THEN 1 POINT PRESSURE, THEN CURVE OF HEEL, THEN ACHILLES TENDON
FOR CS NEED NOT TO BE VERY ACCURATE BUT MUST NOT MISS IMPORTANT ONES THAT'S IT
IN THE END PLEASE DON'T FORGET 6 THINGS,
(INSPECT, PALPATE. ROM, STRENGTH, DTR,SENSATION
FOR ANY JOINT 3 DIAGNOSIS EASY TO REMEMBER
1.SPRAIN OR STRAIN
2. DISLOCATION
3.FRACTURE
ADD TWO FOR THAT SPECIFIC JOINT, OR AGE LIKE
OSTEOPOROSIS,
RA,
OA,
SERO -VE,(ANKYLOSING SPODOLISIS, REITER IBD, PSORIATIC ARTHRITIS)
DISC HERNIATION,
OR DISC PROLEPS
MATS TUMOR
IF YOU ARE WEEK IN MUSCULOSKELETAL THEN JUST GIVE ONE DAY FOR ALL JOINTS, ALONG WITH VIDEO CLIPS FROM YOU TUBE, YOU WILL BE MASTER ''INSHALLAH''
DEAR FRIENDS SEE IF THIS GIVE YOU ANY BENEFIT, IF YOU FEEL IT DIFFICULT THEN KEEP ON YOUR WAY STUDY,
PRAY FOR ME, MY EXAM IS NEAR, FAR AWAY FROM HOME AND PARENTS AND FRIENDS
one is Romberg's test
ask patient can you stand up please for me, and put both of your feet together and close eyes, I assure you I won't let you fall.
when patient do it, MUST SAY THANK YOU.
also check gait
ask can you walk for me please few steps so I can see is there any problem when you walk......... THANK YOU (''
only 2 question
I will recommend you to give smile ('',) to SP for at least 4 time throughout encounter,
people says you should be keep smiling when you are taking Hx and physical? no one can do it, its exam you have lot of anxiety, and also some time patient need empathy! but you can minimize anxiety, see how
QUEST 1:how to smile? practice it in front of mirror FOR 10 -15 TIMES DAILY
Show your teeth, and simultaneously close your both eyes for fraction of second ('',), it will make you happy inside and your SP will laugh for sure...
QUEST 2: WHEN TO GIVE SMILE? ('',)
ANS: FOUR TIMES THROUGHOUT ENCOUNTER
1: WHEN YOU INTRODUCE YOUR SELF TO SP 1st ('',)
2: WASH YOUR HAND'' EXCUSE ME WHILE I WASH MY HANDS'' 2nd ('',)
3:WHEN SP ASK YOU ANY QUESTION, AND AFTER YOU REPLIED LIKE '' DID THAT ANSWER YOUR QUESTION 3rd ('',)
4: WHEN COMPLETE EXAM AND ASKING FOR ''SEE YOU AGAIN'' 4th ('',)
I HOPE IT WILL HELP YOU AND KILL ALL ANXIETY, WISH YOU BEST OF LUCK
SET YOUR ALARM ON 8 MINUTES THEN SNOOZE FOR TWO MINUTES. STOP WRITING AT TEN.
FOR PRACTICE JUST READ FIRST AID PATIENT NOTE AND THEN START CLOCK, DO TEN NOTES DAILY, IN THIS WAY YOU CAN COMPLETE YOUR CASES IN FOUR DAYS,
1.first of all type diagnosis and work up portion in (1:30-2:00) minutes
2. NOW come In HPI portion, FIRST TYPE TITLES(HPI,RAM,PSFO) IN 30 SECONDS THEN COME AT TOP AND TRY TO WRITE IN 4 MINUTES
HPI; 40 YO F, C/O ABD PAIN X 1 MONTH IN , GRADUAL, WORSENING, CONSTANT RADIATES TO R SHOULDER, NAUSEA AND VOMITED 2 X, SOUR YELLOW NO BLOOD, ANOREXIA & DENIES WEIGHT LOSS, SOB, LMP 2 WEEK AGO, CYCLE 4 WEEK FOR 5 DAYS
ROS: NL
ALL:NKA
MED: TYLENOL
PMH: HTN, STROKE
SH: SMOKE 1PPD X 20 YEARS,
FH: FATHER DIED OF PANCREAS CA
OCCU: TEACHER
3. PHYSICAL EXAM(3:30)
PATIENT IS NOT IN ACUTE DISTRESS
ABD SOFT, TENDER IN RUQ, MURPHE'S +VE, BS +,NO REBOUND,-VE PSOAS, NO ORGANOMEGALY
CHEST: CBSB
CVS: RRR, S1S2 NL,NO M,R,G
FOR NEURO EXAM (C-MD-GBS)
1.CRANIAL 2-12 INTACT, MOTOR 5/5, DTR INTACT, GAIT NL,BEBINISKY -VE, SENSATION INTACT
ONLY FOR FORGETFULNESS, TIA, CONFUSED PATIENT
FOR MME ALERT & ORIENTED X 3, SPELL BACKWARD, RECALL 2/3
JUST DO FOCUS EXAM ONLY
ANY JOINT DONT FORGET 6 THINGS= TELL SP NOW I AM DOING THIS
1.INSPECTION
2.PALPATION (ANY TENDERNESS)
3.RANGE OF MOTION (ALL DIRECTIONS)
4.STRENGTH (FOR EXAMPLE IF YOU CHECK STRENGHT OF ARM, DON'T LET ME PUSH YOU 'UP,DOWN, IN & OUT)
5.DTR ANY TWO AT LEAST NOT ALL
6.SENSATION
ALSO DO AND MENTION 1 OR 2 EXAM OF SAME JOINT
LIKE
NECK=SEE UP, SEE DOWN, SEE AT YOUR RIGHT, SEE AT YOUR LEFT, TILT TO RIGHT, TILT TO LEFT, ALSO ASK FOR NUMBNESS AND TINGLING IN FINGERS
SHOULDER AFTER ALL SIX= SPCIFIC EXAM SHOULDER APPPRIHENSION, ARM DROP, NEER TEST ANY 1 OR 2
WRIST TINNEL'S AND PHALEN'S SIGN
BACK PAIN AND HIP JOINTS MUST DO LEG RAISE TEST, AND ALSO ASK FOR WALK
KNEE ANT AND POST DRAWER SIGN THATS ENOUGH
HEEL MUST SEE VIDEOS ON YOU TUBE ITS EASY,
3 POINTS PRESSURE AT CALCANIUM, THEN 1 POINT PRESSURE, THEN CURVE OF HEEL, THEN ACHILLES TENDON
FOR CS NEED NOT TO BE VERY ACCURATE BUT MUST NOT MISS IMPORTANT ONES THAT'S IT
IN THE END PLEASE DON'T FORGET 6 THINGS,
(INSPECT, PALPATE. ROM, STRENGTH, DTR,SENSATION
FOR ANY JOINT 3 DIAGNOSIS EASY TO REMEMBER
1.SPRAIN OR STRAIN
2. DISLOCATION
3.FRACTURE
ADD TWO FOR THAT SPECIFIC JOINT, OR AGE LIKE
OSTEOPOROSIS,
RA,
OA,
SERO -VE,(ANKYLOSING SPODOLISIS, REITER IBD, PSORIATIC ARTHRITIS)
DISC HERNIATION,
OR DISC PROLEPS
MATS TUMOR
IF YOU ARE WEEK IN MUSCULOSKELETAL THEN JUST GIVE ONE DAY FOR ALL JOINTS, ALONG WITH VIDEO CLIPS FROM YOU TUBE, YOU WILL BE MASTER ''INSHALLAH''
DEAR FRIENDS SEE IF THIS GIVE YOU ANY BENEFIT, IF YOU FEEL IT DIFFICULT THEN KEEP ON YOUR WAY STUDY,
PRAY FOR ME, MY EXAM IS NEAR, FAR AWAY FROM HOME AND PARENTS AND FRIENDS
one is Romberg's test
ask patient can you stand up please for me, and put both of your feet together and close eyes, I assure you I won't let you fall.
when patient do it, MUST SAY THANK YOU.
also check gait
ask can you walk for me please few steps so I can see is there any problem when you walk......... THANK YOU (''
only 2 question
I will recommend you to give smile ('',) to SP for at least 4 time throughout encounter,
people says you should be keep smiling when you are taking Hx and physical? no one can do it, its exam you have lot of anxiety, and also some time patient need empathy! but you can minimize anxiety, see how
QUEST 1:how to smile? practice it in front of mirror FOR 10 -15 TIMES DAILY
Show your teeth, and simultaneously close your both eyes for fraction of second ('',), it will make you happy inside and your SP will laugh for sure...
QUEST 2: WHEN TO GIVE SMILE? ('',)
ANS: FOUR TIMES THROUGHOUT ENCOUNTER
1: WHEN YOU INTRODUCE YOUR SELF TO SP 1st ('',)
2: WASH YOUR HAND'' EXCUSE ME WHILE I WASH MY HANDS'' 2nd ('',)
3:WHEN SP ASK YOU ANY QUESTION, AND AFTER YOU REPLIED LIKE '' DID THAT ANSWER YOUR QUESTION 3rd ('',)
4: WHEN COMPLETE EXAM AND ASKING FOR ''SEE YOU AGAIN'' 4th ('',)
I HOPE IT WILL HELP YOU AND KILL ALL ANXIETY, WISH YOU BEST OF LUCK