Draping and closure for CS

[medstudent234]

I was wondering how you recommend draping for the female cardiac exam. Since the SP has the gown tied in the back and is wearing a bra, do you just pull down the gown in front on the left side (after asking permission) to auscultate the tricuspid and mitral valves, or do you pull it up and also pull the gown on their lap up and auscultate in the space between the two gowns?

My other question is with the closure. I'd love to get an example of closure that someone who passed CIS did since that was probably one of my weak points. Let's say you think the patient has appendicitis or cholecystitis. Could you give me an example of what you would say in the closure? Do you think it would be okay to say something like:

"I'm concerned about a few different things. You may have appendicitis. That's a type of inflammation of your appendix which is part of your large intestine in your belly. I would like to do a CT scan (similar to an x-ray) and also look at your blood counts to see if there is any inflammation going on. Another possibility is that you have gallstones. Those can give you stomach pain especially after you eat fatty foods. For that I'd like to do an ultrasound, similar to what pregnant women get but this would be of your gallbladder. Does that all make sense? Do you have any concerns or questions? (obviously wait for pause) It was so nice to meet you, I'll order those tests right now so we can figure out what is going on. I'm sorry you are in so much discomfort now, hopefully we can get to the bottom of this and you'll be feeling better really soon." Then shake hands.

I was watching a video of myself yesterday since we have to do an exam similar to CS with our med school to graduate, which I passed. The attending and I both realized that I did too much explanation of the pathophysiology of the ddx (even though I did not use jargon) and that may have overwhelmed the patient. I Just wondering if the above was sufficient. I was also wondering whether if we tell the patient a certain differential and tests and then end up changing that on our note once we've had a few more minutes to think about it, does that cost us points?

Thanks so much!

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[Missorleans]

As far as draping during the cardiac exam, I'd ask the patient to lower their gown just far enough, indicate on yourself how far down you need the front of the gown.

I don't think you lose points for putting something on your differential list or putting a test in the note that you didn't discuss with the patient. I did that several times.

 

[Plasmatron88]

I was wondering how you recommend draping for the female cardiac exam. Since the SP has the gown tied in the back and is wearing a bra, do you just pull down the gown in front on the left side (after asking permission) to auscultate the tricuspid and mitral valves, or do you pull it up and also pull the gown on their lap up and auscultate in the space between the two gowns?

My other question is with the closure. I'd love to get an example of closure that someone who passed CIS did since that was probably one of my weak points. Let's say you think the patient has appendicitis or cholecystitis. Could you give me an example of what you would say in the closure? Do you think it would be okay to say something like:

"I'm concerned about a few different things. You may have appendicitis. That's a type of inflammation of your appendix which is part of your large intestine in your belly. I would like to do a CT scan (similar to an x-ray) and also look at your blood counts to see if there is any inflammation going on. Another possibility is that you have gallstones. Those can give you stomach pain especially after you eat fatty foods. For that I'd like to do an ultrasound, similar to what pregnant women get but this would be of your gallbladder. Does that all make sense? Do you have any concerns or questions? (obviously wait for pause) It was so nice to meet you, I'll order those tests right now so we can figure out what is going on. I'm sorry you are in so much discomfort now, hopefully we can get to the bottom of this and you'll be feeling better really soon." Then shake hands.

I was watching a video of myself yesterday since we have to do an exam similar to CS with our med school to graduate, which I passed. The attending and I both realized that I did too much explanation of the pathophysiology of the ddx (even though I did not use jargon) and that may have overwhelmed the patient. I Just wondering if the above was sufficient. I was also wondering whether if we tell the patient a certain differential and tests and then end up changing that on our note once we've had a few more minutes to think about it, does that cost us points?

Thanks so much!

Sounds like an excellent closure to me, if delivered exactly as you've written, if you cam come up with closures of the same quality during the actual exam you can expect high performance in CIS.
For the gown just ask permission and explain to them how much portion you will lower in order to hear the heart and lungs, BUT when moving towards the back (after you are done auscultating the front completely) you can ask them to lift up the front portion exposing the back only (this will earn you points for No unnecessary exposure), also try to complete all the auscultation at the front and back in one go, as in dont keep switching front and back (e.g heart at the front , lungs at the back then again lungs at the front and sides)
instead do (Heart + lungs at front Then lungs at the back), this will be a smoother transition.

 

[medstudent234]

Thanks so much! I was also wondering if it's necessary to have the patient lie down during the cardiac exam? We were taught to do that even on a brief exam, but I'm not sure if others did. Thanks!

 

[Plasmatron88]

Thanks so much! I was also wondering if it's necessary to have the patient lie down during the cardiac exam? We were taught to do that even on a brief exam, but I'm not sure if others did. Thanks!

No you dont need to do that for auscultation, PMI palpation or pulses, but yes if checking JVP then make them lie down (with gown closed) at 45 degree angle and check accordingly.

 

[Nabin]

Check this out:

 

[Plasmatron88]

Nice video but this all needs to be done much faster due to time limits

 

[Nabin]

Nice video but this all needs to be done much faster due to time limits

I did my med school where no patient wore a gown. haha. So, I had to get a visual confirmation of how it needs to be done. I thought this one's a pretty legit way to do it with more pace of course.

 

[scoKraz4]

She should have told her to cross her arms for percussion/auscultation of lung fields. Them scaps are in the way

 

[Psai]

She should have told her to cross her arms for percussion/auscultation of lung fields. Them scaps are in the way

do they really care about that

 

[Plasmatron88]

do they really care about that

No they don't, because there aren't any real findings we would find.