1. Step 8
1.1. Diagnostic decision
1.1.1. squamus cell carcinoma of the lung with liver and bone metastasis (TIIb Nx MI)
1.2. Mechanism
1.2.1. cigerette smoking and genetic predospisition led to chronic irritation, metaplasia, dysplasia and eventually lung cancer
1.3. Presentation
1.3.1. cough, SOB, bone pain
1.4. Supporting data
1.4.1. history, physical examination, imaging and biopsy
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. 4 weeks ago for the cough, SOB and the pain
2.1.1.2. for 10 years, daily cough and SOB with exertion
2.1.1.3. 2 years ago, flu like symptoms with an x-ray done
2.1.1.3.1. he refused further investigations
2.1.2. Previous medical / surgical history
2.1.2.1. appendectomy at age of 18
2.1.2.2. psoriasis that was treated
2.1.2.3. inguinal hernia repair at age of 32
2.1.3. Drug history / allergy
2.1.4. Family history
2.1.5. Social / occupational history
2.1.5.1. 25 cigerettes per day for 35 years
2.1.5.2. fillipino immigrant at age of 25
2.1.5.3. ocassional drinking
2.1.5.4. 3 sons and 2 daughters, and a healthy wife
2.1.5.5. father and all siblings died if lung cancer
2.1.6. Systemic review
2.1.7. Physical examination
2.1.7.1. vital signs
2.1.7.1.1. BP 110\65
2.1.7.1.2. 90
2.1.7.1.3. 50-150 (h-w)
2.1.7.1.4. 37.4
2.1.7.1.5. RR 30
2.1.7.2. cachectic
2.1.7.3. skin and nail changes consistent with psoriasis
2.1.7.4. respiratory
2.1.7.4.1. hyperexpanded chest
2.1.7.4.2. bony tenderness while palpating the left hemipelvis and ribs
2.1.7.4.3. scattered crepitations
2.1.7.5. abdominal
2.1.7.5.1. liver is irregular and palpated 15 cm under the costal margin, liver span 18 cm
2.1.8. 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!