Bear with me here – OCSEs

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ArteryStudyPainting

Artery: The study of painting
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Alright, probably a horrible and simple question, but I want other opinions:

We just took an OSCE, and I was given some interesting advice/directions.

The pt had c/c of RUQ pain. Fair. Hx was no problem. Then, I got to the PE. Per our guidelines, I performed soft palpation, deep palpation, painful quadrant rebound tenderness, then for this at least, Murphy's sign.

But, on soft palpation, barely touching the pt in RUQ, he flinched w/ pain. Then, I barely hooked my hand into his gallbladder region and had him inspire, he flinched. So, I figured that's the end of it. Basically, I didn't do anymore b/c I had my results, and I didn't want the pt to be in pain. In my past life, I learned that pain = stop: you've got what you need!

Faculty told me, "ah, sometimes you need to do, what you need to do. It may hurt, but you have to do it to get all your data."

Ik it's an OSCE, but if I did more, I'd be docked for hurting the pt. Or, I don't do enough, and get docked for not getting my data!

What is a person supposed to do? XD

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Normally you want to be as gentle as possible but in terms of the PE you need to be sure you are getting as accurate as an assessment as possible. You can tell the patient this might hurt but ... then explain the reasoning for completing the exam. A patient always has the right to deny medical treatment or forgo certain parts of testing but as your job is to as accurately find out what is wrong you have to try and have the patient work through some of the pain.
 
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Deep palpation with your knuckles and tell them that is the baseline for real pain.

Then, proceed with your abd exam.
 
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OP, what I did that seemed to work well and check the boxes was to verbalize something like “at this point I would usually try and press a little harder in order to better examine your _____, but you seem to be in a lot of pain. Would you mind if perform the exam anyhow so i can do the best exam possible?” Basically just say what you want to do and ask if it’s ok. SPs can’t decline a required maneuver so you’ll be able to check the box and it usually gets you the empathy box too.

This is similar to what you’re told to do for CS with more invasive exams - you verbalize what exam you want to do and the SPs decline but then hand you results if applicable.
 
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Just to clarify, are you talking specifically about RUQ exam or abdominal exam because you 100% still need to examine the rest of the abdomen.
 
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In real life, you wouldn’t necessarily stop your physical exam due to pain... Certainly you’d acknowledge their pain, but explain you need to complete your exam and ask permission to proceed.

Some patients are just sensitive to touch everywhere, so sometimes you need to delineate what is going on.

And OSCE is all about hitting everything on the checklist, they want to see you can do a complete exam.


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Did that quadrant last, so all of the exam was done.
 
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Alright, probably a horrible and simple question, but I want other opinions:

We just took an OSCE, and I was given some interesting advice/directions.

The pt had c/c of RUQ pain. Fair. Hx was no problem. Then, I got to the PE. Per our guidelines, I performed soft palpation, deep palpation, painful quadrant rebound tenderness, then for this at least, Murphy's sign.

But, on soft palpation, barely touching the pt in RUQ, he flinched w/ pain. Then, I barely hooked my hand into his gallbladder region and had him inspire, he flinched. So, I figured that's the end of it. Basically, I didn't do anymore b/c I had my results, and I didn't want the pt to be in pain. In my past life, I learned that pain = stop: you've got what you need!

Faculty told me, "ah, sometimes you need to do, what you need to do. It may hurt, but you have to do it to get all your data."

Ik it's an OSCE, but if I did more, I'd be docked for hurting the pt. Or, I don't do enough, and get docked for not getting my data!

What is a person supposed to do? XD
Sounds like the SP is taking the whole response to pain to an exaggerated level. IMO you got the data you needed: the patient is in pain on (mild palpation). That is what you would document on ur exam. You performed the Murphy exam as well as you could, so you could either document "positive Murphy sign" or "Murphy sign exam incomplete due to patient pain". As long as you document it accurately.

In school, was taught to do abs exam starting at mild palpation then to medium then to deep. In reality I do medium right away and I will keep palpating until the patient moves away or appears to grimace to the point of moving away. You'll learn to decipher who is "overreacting" vs who is in real pain based on subtle signs like guarding or the "accidentally bump the bed" trick which can allow you to look for peritoneal signs fairly well as patients aren't prepared at all vs. someone who becomes hyperaware of their pain when you explain to them the exam.
 
I know OSCEs are silly in that regard. They are helpful, but come on XD:

1574271234374.png
 
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SP comments: “He was much too quiet. He needs to speak up.”

me: *changes nothing and proceeds to next patient*

SP comments: “He was too loud. Basically shouting.”

me: *changes nothing and proceeds to next patient*

SP comments: “He listened to my heart for too long. Needs to work on time management.”

me: *changes nothing and proceeds to next patient*

SP comments: “Didn’t listen to my heart very long. Its not believable that he actually tried to hear anything.”


me: *changes nothing and proceeds to next patient*

SP comments: “Great smile.”


me: *changes nothing and proceeds to next patient*


SP comments: “Fake smile.”


me: *changes nothing and proceeds to next patient*


SP comments: “Very empathetic.”


me: *changes nothing and proceeds to next patient*

SP comments: “lacks empathy”


me: *changes nothing and proceeds to next patient*

SP comments: “polite”


me: *changes nothing and proceeds to next patient*

SP comments: “rude”

me: *changes nothing and proceeds to next patient*

SP comments: “funny and friendly”

me: *changes nothing and proceeds to next patient*

SP comments: “unprofessional”

me: *changes nothing and proceeds to next patient*

SP comments: “confident”

me: *changes nothing and proceeds to next patient*

SP comments: “awkward”

Oh yeah. Lots of utility here...
 
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SP comments: “He was much too quiet. He needs to speak up.”

me: *changes nothing and proceeds to next patient*

SP comments: “He was too loud. Basically shouting.”

me: *changes nothing and proceeds to next patient*

SP comments: “He listened to my heart for too long. Needs to work on time management.”

me: *changes nothing and proceeds to next patient*

SP comments: “Didn’t listen to my heart very long. Its not believable that he actually tried to hear anything.”


me: *changes nothing and proceeds to next patient*

SP comments: “Great smile.”


me: *changes nothing and proceeds to next patient*


SP comments: “Fake smile.”


me: *changes nothing and proceeds to next patient*


SP comments: “Very empathetic.”


me: *changes nothing and proceeds to next patient*

SP comments: “lacks empathy”


me: *changes nothing and proceeds to next patient*

SP comments: “polite”


me: *changes nothing and proceeds to next patient*

SP comments: “rude”

me: *changes nothing and proceeds to next patient*

SP comments: “funny and friendly”

me: *changes nothing and proceeds to next patient*

SP comments: “unprofessional”

me: *changes nothing and proceeds to next patient*

SP comments: “confident”

me: *changes nothing and proceeds to next patient*

SP comments: “awkward”

Oh yeah. Lots of utility here...
The time and effort that went into this.














I like it.
 
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SP comments: “He was much too quiet. He needs to speak up.”

me: *changes nothing and proceeds to next patient*

SP comments: “He was too loud. Basically shouting.”

me: *changes nothing and proceeds to next patient*

SP comments: “He listened to my heart for too long. Needs to work on time management.”

me: *changes nothing and proceeds to next patient*

SP comments: “Didn’t listen to my heart very long. Its not believable that he actually tried to hear anything.”


me: *changes nothing and proceeds to next patient*

SP comments: “Great smile.”


me: *changes nothing and proceeds to next patient*


SP comments: “Fake smile.”


me: *changes nothing and proceeds to next patient*


SP comments: “Very empathetic.”


me: *changes nothing and proceeds to next patient*

SP comments: “lacks empathy”


me: *changes nothing and proceeds to next patient*

SP comments: “polite”


me: *changes nothing and proceeds to next patient*

SP comments: “rude”

me: *changes nothing and proceeds to next patient*

SP comments: “funny and friendly”

me: *changes nothing and proceeds to next patient*

SP comments: “unprofessional”

me: *changes nothing and proceeds to next patient*

SP comments: “confident”

me: *changes nothing and proceeds to next patient*

SP comments: “awkward”

Oh yeah. Lots of utility here...
This is so accurate it hurts.
 
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