Bioetica

I. Step 2 CS Outline
A. Patient Encounter
1. Outdoor Organizing Blue sheet(45 sec – 1min)
2. Entrance
* Good morning Mr. Jones. I am Dr. Robles, nice to meetyou. I’ll be your physician today and I would like to ask some questions and perform a physical exam, it’s that ok for you? Is everything in the room alright for you? Let me drapeyour legs to make you feel a little more. comfortable.
3. History of Present Illness (3min)
* LIQORAAA
* Location of the symptoms
* Intensity on the scale from 1-10* Quality of the symptom (sharp, stabbing, dull, burning, pulling, pulsating, cramping or pressure-like)
* Onset of the symptom (e.g., started after a sudden stop whiledriving Activity at the moment), course duration, anterior event, frequency, timing and precipitating factors)
* Radiation
* Associated symptoms (eg., fever, SOB, HA)* Alleviating factors that make the symptom better (e.g., resting)
* Aggravating factors that make the symptom worse (e.g., going up the stairs)
4. PAMHUGSFOSSS (4Min)
* Past history
* Allergies
* Medicines
* Hospitalizations
* Urinary changes
* Gastrointestinal illness Same for all
* SleepPatients
* Family
* Ob/Gyn
* Sex
* Social
* Surgeries
5. General Exam (30 sec)
* Look up for me* Look down for me
* Open your mouth “say ah” Please
* Can you swallow for me
* Neck exam for nodes
* Exam Hands
* Skin
* Exam legs
6. PhysicalExam (3 min 30sec)
* Tell him/her what are you trying to do
* Use Please and Thank you
* Maintain Eye contacts
7. Closure (3 min)
B. Patient Note (10 min)