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!