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- Feb 12, 2007
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Ran out of time on virtually every patient so had to cut short the physical exam in most cases to do counseling.
#1- pt with low back pain from an acute injury. I just palpated her back where it hurt, had her stand up and bend over(how do you check rom anyways for lbp?) and then checked for sensation in lower extremeties. That was pretty much it. Then just put herniated disc, vertebral fracture, and osteoporosis as my differential. Left the other two blank. Only tests I ordered were x-ray lumbar back, ct lumbar, and dexa scan.
#2- pt with hurt knee while on vacation with no inciting event. Again another wtf case. I palpated the knee, compared it to the other one, tried to twist it back and forth a bit, etc....asked about sexual history or history of autoimmune diseases. Just put septic arthritis as my #1, I think gout as my #2, maybe rheumatoid arthritis or OA as well. ordered cbc, esr, x-ray knee and I think that was it.
#3- classic chest pain case, but the little **** was also telling me his chest pain had improved with antacids in the past(but was not associated with foods) but that 3 days ago he had a more severe pressure like chest pain. I did a cvs exam and pulm exam(dont know if I did it right or not, didnt do apical impulse or anything) and just listed MI, unstable angina, and GERD on the differential. Maybe one more I think. Ordered cardiac enzymes, ecg, cath, echo, maybe something else.
#4- guy says he was feeling "tired" for the last 2 months. Looks depressed as hell when I enter the room. I ask him about blood in stool, when his last colonoscopy was(1 year ago and it was normal), if he's coughing up blood, short of breath, etc. All no. Then I screen him for SIGECAPS and *everything* is positive. Even passive SI. So I decide it's clearly not a medical case, examine his cvs and pulm briefly, and just write down MDD and adjustment disorder as my differential(since he wasn't complaining of anything but fatigue with NO other constitutional symptoms). I did get a cbc to check for anemia(probably should have put that on the differential too) and thyroid tests, but I think thats it. What the hell are you supposed to order for an mdd patient with no psychosis or ams besides cbc and thyroid?
#5- classic PID vs appendicitis case. I asked all the right questions(OLDCARTS, sexual activity, vaginal discharge, etc). Sounded more like PID because of the vaginal discharge but she was giving me this right sided nonsense too. So I put PID at the top, then appendicitis, then gastroenteritis(?) even though there is no way that patient would have had a stomach bug....but what the hell I cant have just 2 differentials for everything. So I ordered ultrasounds, ct, pelvic exam with culture, HIV, etc...I think thats one of the few times I ordered at least 5 things.
#6- nonsense fatigue case. older black guy with fatigue and also sob. No history of heart or lung disease. Once he complained about being able to only walk a block anymore I went down the chf vs copd road. Did cvs and pulm exam, but fairly crappy ones. I think I put down chf, copd, atypical pneumonia and maybe iron deficiency anemia on the diff. Ordered echo, spirometry, cxr, cbc. Forgot to order abg's. ****.
#7- nonsense "my heart is racing" case. No other symptoms except tachycardia and anxiety. So Im going down the graves angle, but she's answering no to all the other graves stuff. Her symptoms get worse when exercising, Then in her fh questions she says her brother died after exercising at age 21. So I give her a quick cvs exam and checked pulses and whatnot. In my differential I put down orthostatic hypotension, cardiomyopathy(but picked the wrong one...****), dehydration induced syncope(even though she isnt losing consciousness or feeling dizzy...dont know why I was so intent on giving her syncope). Wanted to put down some type of arrythmia but wasn't sure which one to put. Ordered ekg, orthostatics, echo(why I dont know), and cbc. Pretty sure I had no idea what was going on this case.
#8- classic acute bronchitis superimposed on chronic bronchitis in a long term smoker. A pretty easy case. I put acute bronchitis, chronic bronchitis/copd, lung cancer, and pneumonia as my 4 differentials(couldnt think of a 5th). Ordered cxr, chest ct, cbc, spirometry. forget abg's again. Whatever. did some kick ass counseling too.
#9- then a case where the mom is there but her 4 day old son isn't. She's there because he's turned yellow over the last 24 hours and she thinks he has jaundice(she used that word, not me). So I ask all the pregnancy questions, feeding history, birth history, and family history questions related to hyperbilirubinemias. But what the hell do I put on the differential........I dont know much about neonatal jaundice. So I just put neonatal jaundice, uncomplicated and hereditary hyperbilirubinemia(??). Kid has uncomplicated neonatal jaundice.....why am I going to get docked so many points for not putting 5 freaking differentials? Then I order some liver stuff, cbc(why I dunno?), and maybe one other thing. And I give her some good counseling on phototherapy.
#10- nonsense syncope case about a young athlete who was really trying to be a sullen prink who had suddenly passed out at soccer practice. Said he had used x for the first time the night before, so one of the things on my diff was actually "drug induced syncope".....does x make people pass out the next day? Let's hope so........for me at least. Ordered ekg, orthostatics, toxicology and one other thing I guess. Did a quick cvs exam and a partial neuro exam(cranial nerves I think and cerebellar stuff). also assessed for basic orientation.
Cant remember the other two....but I somehow doubt I rocked on those. Oh one was a classic dementia case in a longterm diabetic with pvd. Put the usual ****(multiinfarct dementia, AD, etc on the differential). Did something of a neuropsych exam mainly assessing for orientation and memory and cognitive functioning. Cant remember what I ordered for labs, but probably missed a lot of big labs to rule out organic causes of dementia(should have gotten an rpr/vrdl, and maybe I did).
So I did at least a partial physical exam on everyone, finished my note on everyone but on many patients only had 3 or so differentials and tests to order. I gave everyone except one patient counseling and/or my impression of what they had. Used gloves on every patient. Asked a lot of the basic history questions on everyone(probably my best part of the day was getting the histories). On the downside my exams werent particularly extensive(never did a romberg, never did a psoas sign on the pid vs appy patient even though I put it in the note) and Im pretty sure I had no clue what was going on with at least two-three cases(the syncope case and the "heart is racing" bs case).
So I dunno....I mean I dont think what I did was so horrible that it's in the bottom 4% of american students....but Im a little worried.
#1- pt with low back pain from an acute injury. I just palpated her back where it hurt, had her stand up and bend over(how do you check rom anyways for lbp?) and then checked for sensation in lower extremeties. That was pretty much it. Then just put herniated disc, vertebral fracture, and osteoporosis as my differential. Left the other two blank. Only tests I ordered were x-ray lumbar back, ct lumbar, and dexa scan.
#2- pt with hurt knee while on vacation with no inciting event. Again another wtf case. I palpated the knee, compared it to the other one, tried to twist it back and forth a bit, etc....asked about sexual history or history of autoimmune diseases. Just put septic arthritis as my #1, I think gout as my #2, maybe rheumatoid arthritis or OA as well. ordered cbc, esr, x-ray knee and I think that was it.
#3- classic chest pain case, but the little **** was also telling me his chest pain had improved with antacids in the past(but was not associated with foods) but that 3 days ago he had a more severe pressure like chest pain. I did a cvs exam and pulm exam(dont know if I did it right or not, didnt do apical impulse or anything) and just listed MI, unstable angina, and GERD on the differential. Maybe one more I think. Ordered cardiac enzymes, ecg, cath, echo, maybe something else.
#4- guy says he was feeling "tired" for the last 2 months. Looks depressed as hell when I enter the room. I ask him about blood in stool, when his last colonoscopy was(1 year ago and it was normal), if he's coughing up blood, short of breath, etc. All no. Then I screen him for SIGECAPS and *everything* is positive. Even passive SI. So I decide it's clearly not a medical case, examine his cvs and pulm briefly, and just write down MDD and adjustment disorder as my differential(since he wasn't complaining of anything but fatigue with NO other constitutional symptoms). I did get a cbc to check for anemia(probably should have put that on the differential too) and thyroid tests, but I think thats it. What the hell are you supposed to order for an mdd patient with no psychosis or ams besides cbc and thyroid?
#5- classic PID vs appendicitis case. I asked all the right questions(OLDCARTS, sexual activity, vaginal discharge, etc). Sounded more like PID because of the vaginal discharge but she was giving me this right sided nonsense too. So I put PID at the top, then appendicitis, then gastroenteritis(?) even though there is no way that patient would have had a stomach bug....but what the hell I cant have just 2 differentials for everything. So I ordered ultrasounds, ct, pelvic exam with culture, HIV, etc...I think thats one of the few times I ordered at least 5 things.
#6- nonsense fatigue case. older black guy with fatigue and also sob. No history of heart or lung disease. Once he complained about being able to only walk a block anymore I went down the chf vs copd road. Did cvs and pulm exam, but fairly crappy ones. I think I put down chf, copd, atypical pneumonia and maybe iron deficiency anemia on the diff. Ordered echo, spirometry, cxr, cbc. Forgot to order abg's. ****.
#7- nonsense "my heart is racing" case. No other symptoms except tachycardia and anxiety. So Im going down the graves angle, but she's answering no to all the other graves stuff. Her symptoms get worse when exercising, Then in her fh questions she says her brother died after exercising at age 21. So I give her a quick cvs exam and checked pulses and whatnot. In my differential I put down orthostatic hypotension, cardiomyopathy(but picked the wrong one...****), dehydration induced syncope(even though she isnt losing consciousness or feeling dizzy...dont know why I was so intent on giving her syncope). Wanted to put down some type of arrythmia but wasn't sure which one to put. Ordered ekg, orthostatics, echo(why I dont know), and cbc. Pretty sure I had no idea what was going on this case.
#8- classic acute bronchitis superimposed on chronic bronchitis in a long term smoker. A pretty easy case. I put acute bronchitis, chronic bronchitis/copd, lung cancer, and pneumonia as my 4 differentials(couldnt think of a 5th). Ordered cxr, chest ct, cbc, spirometry. forget abg's again. Whatever. did some kick ass counseling too.
#9- then a case where the mom is there but her 4 day old son isn't. She's there because he's turned yellow over the last 24 hours and she thinks he has jaundice(she used that word, not me). So I ask all the pregnancy questions, feeding history, birth history, and family history questions related to hyperbilirubinemias. But what the hell do I put on the differential........I dont know much about neonatal jaundice. So I just put neonatal jaundice, uncomplicated and hereditary hyperbilirubinemia(??). Kid has uncomplicated neonatal jaundice.....why am I going to get docked so many points for not putting 5 freaking differentials? Then I order some liver stuff, cbc(why I dunno?), and maybe one other thing. And I give her some good counseling on phototherapy.
#10- nonsense syncope case about a young athlete who was really trying to be a sullen prink who had suddenly passed out at soccer practice. Said he had used x for the first time the night before, so one of the things on my diff was actually "drug induced syncope".....does x make people pass out the next day? Let's hope so........for me at least. Ordered ekg, orthostatics, toxicology and one other thing I guess. Did a quick cvs exam and a partial neuro exam(cranial nerves I think and cerebellar stuff). also assessed for basic orientation.
Cant remember the other two....but I somehow doubt I rocked on those. Oh one was a classic dementia case in a longterm diabetic with pvd. Put the usual ****(multiinfarct dementia, AD, etc on the differential). Did something of a neuropsych exam mainly assessing for orientation and memory and cognitive functioning. Cant remember what I ordered for labs, but probably missed a lot of big labs to rule out organic causes of dementia(should have gotten an rpr/vrdl, and maybe I did).
So I did at least a partial physical exam on everyone, finished my note on everyone but on many patients only had 3 or so differentials and tests to order. I gave everyone except one patient counseling and/or my impression of what they had. Used gloves on every patient. Asked a lot of the basic history questions on everyone(probably my best part of the day was getting the histories). On the downside my exams werent particularly extensive(never did a romberg, never did a psoas sign on the pid vs appy patient even though I put it in the note) and Im pretty sure I had no clue what was going on with at least two-three cases(the syncope case and the "heart is racing" bs case).
So I dunno....I mean I dont think what I did was so horrible that it's in the bottom 4% of american students....but Im a little worried.
