Thursday, April 7, 2016

Step 2 CS: Writing examination in patient note

Hello! In this post, I'll be noting some points how to write a patient note for step 2 CS. Especially, focusing on short forms that can be used in the exam.

I have noticed that writing the note in ALL CAPS is better and it does save a lot of time. Similarly, instead of using the "colon : " you could use the "dash - " and it'll make life simpler.

Writing physical examination findings in a concise manner, with short forms:

Head - NC/AT

Eyes - PERRLA, EOMI, normal fundus
(Write no lid lag, drooping of eye lids, nystagmus if suspecting cerebellar dysfunction or thyroid disease)

Nose - No congestion

Throat - No tonsillar Erythema, Exudates or Enlargement (Remember three E's)

Mouth - Mucus Membranes Moist (Three M's), no lesions

Neck - No cervical LAD, no thyromegaly
(If CVS case) No carotid bruits, No JVD

CNS - AAO x3, good concentration (Or failed 3 object recall)
Mnemonic: MRS
Motor: Strength 5/5 in all muscle groups
(If abnormal, 5/5 in all muscle groups except 3/5 in left arm)
Reflexes: 2+ intact, symmetric, Babinski -ve
(Assymetric, 2+ R and 1+ L knee)
Sensory: Intact
Tone: Normal (Increased or decreased)
Cerbellar: Romberg -ve, intact finger to nose

Lungs - CTAB
If detailed lung examination, then:
Non tender to palpation
Tactile fremitus WNL

Heart - RRR, S1 S2 heard
If detailed lung examination, then:
PMI not displaced
No murmurs, rubs or gallops
Non tender to palpation

Ext - No clubbing, cyanosis or edema

Abd - Soft, NT, ND
If detailed abdominal examination, then:
No organomegaly
No scars, sinuses

You can use the CS info manual to check which abbreviations and short forms they use.
For example, you can write NKA (No known allergies) instead of writing NKDA (No known drug allergies)
You can write Abd, Ext, Neuro and Meds for abdomen, extremities, neurologic and medications respectively

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