发信人: dingdingsun (xsun), 信区: MedicalCareer
标 题: my CS protocols, hope can help whoever going to take the test, I don’t need any more.
发信站: BBS 未名空间站 (Mon Mar 24 10:49:05 2014, 美东)
this one of my CS protocols, hope can help whoever going to take the test, I
don’t need any more.
not perfect, but good to figure out diagnosis, should not miss the diagnosis
do not need to ask all questions , must adjust base the case,
if better ideas, pleas modify to make easier for people who may need
Mental check list:
Patricia Garrison, a 36-year-old female, comes to the office complaining of
not having menstrual periods recently.
Vital Signs BP:120/85 mmHg Temp:98.0°F (36.7°C) RR:13/minute HR:65/minute,
1. Take a focused history.
2. Perform a focused physical exam (do not perform rectal, genitourinary, or
female breast exam).
3. Explain your clinical impression and workup plan to the patient.
4. Write the patient note after leaving the room.
CHALLENGING QUESTIONS TO ASK
“Am I going through menopause?”
I understand you concern, I hope not.
“I doubt it. It would be extremely unusual at your age. I need to learn
more by asking you about other symptoms and examining you, and then we can
discuss possible reasons you are not having periods.”
Examinee knocked on the door before entering.
Examinee introduced self by name.
Examinee identified his/her role or position.
Examine correctly used patient’s name.
Examinee made eye contact with the SP.
Examinee showed compassion for your illness.
Onset OB/GYN/pregnancy/menopause/ hyperprolectinemia/ hypothyroidism/
anxiety, depression/anorexia nervosa/ strenuous exercise/ PAM HUGA FOSS
(Knock 3 times)
Hi, Mrs. Garraddion. I am Dr. xxx, nice to meet you. (with a smile and firm
handshake). I am a physician here and I will be taking care of you today. (
(Look around the room) Is everything alright for you in this room?
Ok, Let me first cover you up. (apply the drape over the legs) Do you feel
May I sit down and take the note?
Mrs. Garraasion, tell me what brings you in today?
I haven’t had a period in three months.
Can you tell me more about your menstrual periods?
Obstetric and GYN history(PCOS):
When was your last menstrual period?
Are your cycles regular? I used to have regular periods every month lasting
for 4–5 days, but over the last year I started having them less frequently
every 5–6 weeks lasting for seven days
How often do you have your period?
How long does your menstrual period last?
How many pads do you use per day? It was 2–3 Pads/tampons changed a day,
but the blood flow is becoming less, and I use only one a day now.
Do you have any vaginal spotting now?
When was your very first menstrual period?
Age at menarche Age 14.
Have you ever pregnant?
Pregnancies: I have one child; he is 10 years old.
How many times had you been pregnant? Have you ever had miscarriages /
abortions(Asherman syndrome)? No.(don’t ask miscarriages directly, will
cause cry. )
Did you have any problems during your pregnancy or delivery? No, it was a
normal delivery, and my child is healthy.
When was your last Pap smear? Last Pap smear Ten months ago. It was normal.
Did you have abnormal Pap smear? History of abnormal Pap smears No.
Pregnancy symptoms question:
Do you have a fever?
Do you have any rash?
Are you feeling short of breath?
Do you feel morning sickness?
Are you nauseated?
Did you vomit?
Do you have any belly pain?
Do you notice any vaginal bleeding or discharge?
Do you notice any swelling in your feet?
Do you notice any increase urinary frequency?
Are you feeling any hot flashes? No.
Are you feeling any vaginal dryness/itching? No.
Do you have any sleeping problems (falling asleep, No. staying asleep, early
Do you have any headache? No.
Have you noticed any visual changes? No.
Have you noticed any nipple discharge? Yes, just last week I noticed some
milky discharge from my left breast.
Have you ever had any problems adjusting temperatures? Cold intolerance No.
Have you noticed any skin/hair changes? Actually, I noticed some facial hair
recently that I am plucking.
Have you noticed any voice change? No.
Have you noticed any change in bowel habits? No.
Are you feeling fatigued? No.
Do you have any depression?
Are you feeling anxious?
Are you feeling stress about anything?/ No.
How is your appetite? I have a good appetite.
Have you noticed any weight changes? I have gained 15 pounds over the past
Are you on diet?
Fad diet or diet pills No, I’ve been a vegetarian for 10 years. Food fad is
a term originally used to describe simple, catchy diets that often focused
on a single element such as cabbage, grapefruit or cottage cheese. In 1974,
the term was defined as three categories of food fads. 1. A particular food
or food group is exaggerated and purported to cure specific diseases. 2.
Foods are eliminated from an individual’s diet because they are viewed as
harmful. 3. An emphasis is placed on eating certain foods to express a
Are you taking strenuous exercise?
Exercise I run two miles three times a week.
Is there anything special you want tell me?
Past medical history (Transition): Now, I need to ask some questions about
your past medical history.
Have you had similar problems before?
Have you had any other medical illnesses in the past?
Allergies: Are you allergic to any medications? no
Medications: Are you currently taking any prescribed medications? Can you
show me the prescription?
Are you taking any over-the-counter medications?
Have you ever been hospitalized before?
Had you ever had any surgeries?
Family history (Transition): Now let me ask some questions about your family
Does anyone in your family have any medical illnesses?
My father and mother are healthy.
Do you know the ago of menopause of your other family members?
My mother began menopause at age 55.
Sexual history (Transition): let me ask some personal questions. I want to
assure you what you tell me will be kept confidential, OK?
Are you currently sexually active?
Sexual activity Once a week on average with my husband.
Do you use any form of contraception? Contraceptives The same pills for
Have you ever been test for STD?
Social life: (Transition) Now, let me ask you some question about your
social life and personal habits.
Smoking: Do you smoke? How many packs a day? How long have you been smoking?
Paraphrase and counsel briefly (1 pack per day for 30 years. Since smoking
can put you at high risk of developing lung cancer and Heart attack, I
highly suggest you to cut down your smoking and eventually quit it. If you
are interested, we have many ways to help you, Okay? )
Alcohol: Do you drink any alcohol? What do you drink? How much do you drink
Ask cage question. Counsel then and there briefly as above
Drugs: Do you use any recreational drugs? Which one? How often? Counsel then
and there so that you won’t forget it.
Occupation: What type of work do you do?
Examinee washed his/her hands.
Examinee asked permission to start the exam.
Examinee used respectful draping.
Examinee did not repeat painful maneuvers.
Exam Component Maneuver
Neck exam Examined thyroid gland
CV exam Auscultation
Pulmonary exam Auscultation
Abdominal exam Auscultation, palpation, percussion
Neurologic exam Visual fields, extraocular movements, checked DTRs
Examinee discussed initial diagnostic impressions.
Examinee discussed initial management plans:
Follow-up tests: Examinee mentioned the need for a pelvic and breast exam.
Examinee asked if the patient has any other questions or concerns.
Ms. Garrison, there are a few reasons you may not be having regular periods.
The first thing we need to do is determine whether you are pregnant. We can
do that with a simple urine test.
The other thing we need to do is conduct a breast and pelvic exam,
especially since you have had some nipple discharge, and look for any signs
of menopause. Menopause is highly unlikely in your age group, but on rare
occasions it may occur.
A blood test to measure your hormone levels will also help us determine if
you are menopausal or have a hormonal imbalance.
This will give us a good start in figuring out why you haven’t had your
period, and we will go from there if we don’t find anything. Do you have
any questions for me?
I will follow you up
case 25 amenorrhea case
30 yo F c/o amenorrhea for 3 mo,
with left nipple milky discharge and facial hair growth, oligomenorrhea and
hypomenorrhea, 20 lb weigh gain for last year.
denies headache, visual change,
no cold intolerance, constipation, voice change,
no morning sickness, belly pain , frequency of urine,
no vaginal dryness, itching or hot flashes,
no diet change or vigorous exercise,
ROS : negative except as above. ALL:NKA, MED:none, PSH: none, SH: no smoking
, no ETOH, no rec drugs, SXH: sexual active with husband only,on OTP, denies
STD.OB/GYN: LMP 3 mo ago, 28d/4-5d, G1P1, LPS 9 mo ago, was normal, FH:
mother menopause at 55
Pt in no acute distress, facial hair, no conjunctivae pale, PERRLA, EOMI
without diplopia or lidlag, visual field intact, no thyromegaly, chest : CTA
BL , heart: RRR, no M,R,G. abdomen: NT/ND/+BS. No mass. DTRs: 2+ symmetric
hyperprolatinemia, 30 yo F c/o amenorrhea for 3 months, facial hair growth,
oligomenorrhea and hypomenorrhea, 20 lb weigh gain for last year
PCOS: 30 yo F c/o amenorrhea for 3 months, with left nipple milky discharge
and facial hair growth, oligomenorrhea and hypomenorrhea, 20 lb weigh gain
for last year
Pregnancy, 30 yo F c/o amenorrhea for 3 months, sexual active
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