I was wondering...is it required to do heart and lung exam in every patient-encounter?
How about history and physical..just only specific to the case or need to include general exam
OMM...is it also required to check if there is any dysfunction in every patients? what if it is required but no enough time to do treatment..is it ok just to put on SOAP note..in assessment and plan?
SOAP note..how much do require to document..I mean just to the point or should be more?
Thanks for the tip.
You know, I really didn't do much different in the PE than I do in real life and I passed. I did a qucik heart and lung on almost all of the patients, but not more than 4 points on the back for the lungs (never listened to the lungs in front) and three to four spots for the herat. I did make sure that I hot bare skin, though. Do ypu have to do that? No, probably not, but I always do it in real life so it's kind of a habit. I even listen to the heart and lungs when someone comes in for a foot problem... probably because I feel that the more people I listen to the better I am at hearing something. You might be surprised at the number of murmurs and things you'll hear just by doing that and it certainly doesn't hurt anuone or take up much time. BUT, when it was possibly a heart or lung problem.... I did a whole lot more.
I tend to spend more time on histories than on the physical exam by far. And, few of my focused exams were truly complete. I did the "main" stuff that would tend to rule in or rule out things in my differential. Instead of doing a complete head and neck exam I looked in the ears, did a Dix-Hallpike, and a very brief eye exam for suspected vertigo. I sometimes think it's more in looking like you know what you are doing than in what you really do.
I've mentioned this before, but I would have failed the OSCE at my school doing it this way. They were really more concerned with following the stuff you memorized in the book than really examing the patient and getting a working diagnosis. I actually got some horrible comments from the person grading OMM for the practice OSCE we had to do at the end of third year. But, I was determined to follow the instructions from NBOME and forget about what I was told by my instructors. After all, none of them has EVER taken COMLEX PE... and I'm not really sure that any of them has ever even read the material COLEX provides or even looked at the video. Case in point... I was reamed for not performing OMM for a headache thaat I thought was stress-related in our OSCE, even though I mentioned that I "would have done it" in my SOAP note. NBOME says that you can mention it, but you don't necessarily have to perform it. Like was mentioned earlier, It's pretty clear when you REALLY need to do it. I even deferred doing it on someone who asked me to during the real exam because I told her I wanted to see her x-rays first. From the way she reacted I thought she might have a fracture. I wasn't about to do it then.
I'll admit thata I was a bit scared after it was over because I took the NBOME at there word and performed OMM "where indicated" rather than on every single patient like some of my colleagues did. One guy I talked to said her performed OMM on a woman that most certainly suffered from depression. He did a pedal pump on her to get her lymph flowing just becaus ehe was afraid of not doing enough OMM. I think that is one of the generaal misconceptions-- it's even a misconception but the faculty at my school. They really don't expect you to do OMM on a patient with a URI. Yes, technically, you learned some things that you COULD do on her to help, but you really only need to do it when it really is indicated.
I did do a quck spinal check on most patients and wrote down "No somatic disfunction found" on a whole lot of patients. But, there were a couple that I didn't even check. It was just that obvious to me that looking at the spine on this patients wouldn't do a damned bit of good, and would probably be a waste of my time. Do I know whether or not I might have had a failing gade on those patients? No. All I know is that I passed both domains and was either the first or second person finished with every clinical encounter.
I always finished early, so I had time to write a lot of stuff down but I mostly wrote down just what I did. Sometimes, I did things and forgot to write it all down. What you have to keep in mind is that you should write down enough stuff to justify the things you put down in your DDX. If you rule out something, you can still put it in the DDX and write "doubtful" after it. You don't really have to pout a whole lot of stuff down, IMHO, as long as your thought processes are kind of clear. Remember that something like 93% of people pass this thing on the first try. It's not all that hard. I even did some things wrong and still passed.
