Thursday, January 12, 2017

Review of Systems (Physical exam findings) & Patient Note - USMLE Step 2 CS

Here is a detail about All Review of Systems to ask your patients when taking a complete History



Physical Exam findings with abbreviation

PATIENT NOTE :
HPI : Cheif complaints

ROS : headache , fever , nausea / vomitting , travel , diarrhea , constipation , urination ,weight , appetite , diet , excercise , chest pain SOB,racing of heart ,rash , edema , pain in joints , infection , dizziness if yes vision problem , sleep problem

ALLERGIES : none
MEDICATIONS :
PMH :

(h) ospitalized ?
(i) ll contacts
(t) rauma ?

PSH :
FH :
SH :

PHYSICAL EXAM:

HEENT: NC/AT
NECK: WNL
RS: Breath sounds are normal
BACK:
CVS: S1/S2 normal
ABDOMEN:
EXTERMITIES:
NEURO:
MINI MENTAL EXAM

Diagnosis 3 with History and physical findings

Work plan : ...?

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