Posted by Jimmy doo from IP 126.96.36.199 on January 28, 2017 at 04:40:50:
I finished 10/12 cases with 1-2 minutes to spare, 1 case I literally
finished (said goodbye to the pt) and the buzzer went off and the final
case, I got through counseling, summary of what I did, condition, thoughts
and answered the patients tough question before the time ran out --> so not
Washed hands q case, before physical exam summarized HPI back to patient and
answered questions at that time. Anytime the patient had pain, or expressed
that a family member died etc. I told the patients how sorry I was, that it
must be hard for them. I told every patient at least a few times that I
would do everything I could do to help them. When patients coughed, I asked
if I could give them some water. Did basic overview of each patient (looked
at hands, eyes, general appearance), HEENT on most patients in the form of
looking for LAD, looked in throat, shined light in eyes. Neuro cases was
able to do briefer form of MMSE - namely - AOx3, remote memory (remembering
presidents in the past) and 3 word recall. I would do an associated neuro
exam that had CNs, patellar reflexes, strength (upper and lower extremities)
and for a older patient with memory problems, I had them walk with me
guiding them every step of the way.
When I walked out of the room, I had answered questions until the patient
said they had no more questions, I would always tell the patient I would
call them with their test results as soon as they came in and we could meet
in my office in 1-2 weeks to go over the next steps, I then also said that
they should not hesitate to call me if there was a problem in the meantime.
Notes - Finished all notes on time - Did following format for all notes.
HPI: LOPQRST and associated symptoms
PSH, Past hospitalizations, Allergies, Meds
Social history: Appetite, weight changes, diet, occupation, sexual activity,
smoke, drink, drugs (counseling occurred right after patient said something
- I would tell the patient that it can be harmful for health and that we
have many good counselors at the clinic that can give them more resources
and then asked if they would want to get some help...if they said, yes, I
told them I would set it up and if they said "no" I would tell them my door
is always open if they change their minds.
ROS: ROS usually only had 2-4 things extra...the big stuff like chest pain,
SOB, abd. pain, LE swelling.
(CV and Pulm for all patients), abd. complaints and urinary...had ABd. exam.
Neuro had neuro and psych. Added AOx3 and normal mood and affect on most
patients for me completeness.
I cannot really talk about the diagnoses as this would probably violate test
rules and I don't want to do that.
Overall, I felt pretty decent about my diagnoses. Although for one patient I
put "malingering" as the third diagnoses only because she asked for pain
meds...but nothing else really pointed to malingering. I just put that she
had asked for pain meds in my reasoning.
I NEVER put negative things in my reasoning. 2/3 of the cases only had 1-2
things from the history that supported a diagnosis, with NO physical exam
findings. Only one case had some physical exam findings that were pertinent
to the case.
Areas of uncertainty:
1) One patient's feet were not long enough to reach the foot support when I
pulled it out, so in a panic, I pulled the draw above it out...which was a
literal drawer and just left it open (pretty laughable in hindsight) and the
patient said that he did not want to have an open drawer below him. I
apologized and closed it, stating I was trying to find a way to balance his
legs so they didn't have to dangle there.
2) 3 of my patients had REAL exam findings. One of them told me about it a
chest wall problem that had had a surgical repair (I am vague so I don't
violate the test). I MAY have written "no surgeries" by mistake but I don't
remember the note enough to know for sure if I made that mistake or not.
Regardless, I noted this chest wall deformity in my note.
TWO other patients had actual findings. One person's thyroid was mildly
enlarged to me and this was a case where the thyroid was in question too, so
I DID put that enlargement as part of my reasoning. Another patient had a
mild heart murmur that was NOT pertinent to the case, but I know how to pick
up murmurs pretty well and simply put it in my note. I am still worried that
their own people didn't note these things or something and will think I made
something up which VERY WELL my represent paranoia on my part.
3) This MAY or may NOT be a bad thing. One of the patients told me "you are
not causing pain but you are pressing too hard on abdomen." In the moment, I
profusely apologized and corrected myself. I then continued the exam and
fixed my technique. I was paralyzed by this, in a lot of fear...wondering if
I failed this case....but I know I didn't push any harder than I normally
do...I normally only do light palpation on SP's as they usually illicit
their responses just by that....so maybe this was staged...no idea.
4) One patient that was in a lot of pain, I told him that I would give him
something for pain at the end of the case (I know we are not meant to do
this) and I even saw the standard pt raise his eyebrow as if he would have
an opportunity to come after me (so I perceived), but I then quickly said,
my main goal is to make sure that your pain level is decreased...the
standard patient then kind of ignored it all, so this may mean I saved
myself from some time wasting questions etc.
5) Did not write vitals in PN's, I think when there was an abnormal, I wrote
something like vitals: febrile (not sure if I wrote the value).
6) For a pulm complaint, I think I did a cursory, if not absent pulmonary
exam beyond auscultation and inspection, did not percuss.
Tests: I am sure I didn't write all pertinent tests and what not and
certainly don't remember all that I put...but I usually put something like:
CBC, metabolic panel, UA
If thyroid or weight problems or depression: TSH with or without 24 hour
urine cortisol etc.
Back problems would go to CT lumbar spine...then MRI down further on the
list...this type of thing.
If abdominal pain with fever: would do fecal occult blood, stool leukocytes,
stool lactoferrin, culture (***THINK I FORGOT TO PUT RECTAL ON A FEW CASES).
***Did NOT put "genital exam" for a patient with scrotal complaints.
This is just an example, and again, isn't everything.
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