comlex PE quesiton

[cheruka]

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Hi all,
Regarding the assessment and plan section for the note, how much detail do we have to give the patient before leaving the room? I usually can think better upon leaving the room when I am by myself. When I did my school SPALs, I used to make it more general when I talked to the patient but add more detail in the assessment and plan. Noone ever said it was wrong.

 

[thepoopologist]

As long as you counsel them before you leave the room, you should be fine. The detail doesn't matter as much as the interaction.

 

[bleeker10]

I would say something to the effect of "I think you have X. I would like to do some labs to check your (blood, kidneys, liver, lipids, etc). I would also like to get an (X-ray, CT, MRI, US, etc if indicated). I am going to give you a prescription for (antibiotics, anti-hypertensive, NSAID, etc). If this first work, come back in X (days, weeks, months) and we will do (more tests, physician consult, dietician consults, PT). Do you have any questions? I am going to go over the plan with my attending and will be back shortly"

You don't have to be specific on the names of drugs or tests but you should be able to come up with a basic plan to present to the patient.