PBL 5 session 2

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PBL 5 session 2 by Mind Map: PBL 5 session 2

1. Step 8

1.1. Diagnostic decision

1.2. Mechanism

1.3. Presentation

1.4. Supporting data

1.5. 10 minutes

2. Step 7

2.1. Inquiry plan and info gathering

2.1.1. History of presenting complaint

2.1.1.1. fatigue for 3 mo

2.1.1.2. nocturia for 12 mo

2.1.1.3. mild ankle swelling at the end of day

2.1.1.4. burning sensation

2.1.1.4.1. foot

2.1.2. Previous medical / surgical history

2.1.2.1. T2DM 5 years ago

2.1.2.2. laser surgery 2 yr ago

2.1.2.3. HTN last 8 years

2.1.2.4. dyslibidemia 4 years ago

2.1.3. Drug history / allergy

2.1.3.1. metformin

2.1.3.2. metoprolol

2.1.3.3. aspirin daily

2.1.3.4. paracetamol

2.1.3.5. atrovostatin

2.1.4. Family history

2.1.4.1. mother died at 63 yo after kidney failure and 2 years dialysis

2.1.4.2. father died at 74 yo after MI

2.1.5. Personal hx

2.1.5.1. taxi driver

2.1.5.2. has 8 sons

2.1.5.3. lives with his wife, who has breast cancer

2.1.5.4. smokes 10 cigarittes per day

2.1.5.5. alcohol infrequently

2.1.5.6. 4 diet cola per day

2.1.6. Social / occupational history

2.1.7. Systemic review

2.1.8. Physical examination

2.1.8.1. vitals

2.1.8.1.1. PB

2.1.8.1.2. HR 84

2.1.8.1.3. RR 18

2.1.8.1.4. afebrile

2.1.8.2. JVP 3 cm, not elevated

2.1.8.3. apex beat palbale 1 cm lateral to mid-clavicular

2.1.8.4. heart sounds dual, no murmers

2.1.8.5. abdomin

2.1.8.5.1. non tender

2.1.8.5.2. kidney not palbalbe

2.1.8.5.3. liver palbale 3 cm below costal margin with span 12 cm

2.1.8.6. bilatreal pitting edema up to 3 cm above lateral maleolus

2.1.8.7. reduced pitting sensation

2.1.8.8. funduscopy

2.1.8.8.1. thickned and tortuous arteriols with AV-nipping, scarring

2.1.8.8.2. weight

2.1.8.8.3. height

2.1.9. tests results

2.2. 50 minutes

3. Step 6

3.1. Review session 1

3.2. Report new knowledge

3.3. 30 minutes

3.3.1. The scribe does not have to write in this step!