- Joined
- Oct 4, 2012
- Messages
- 358
- Reaction score
- 18
I finished 10/12 cases with 1-2 minutes to spare, 1 case I literally finished (said goodbye to the pt) and the buzzer went off and the final case, I got through counseling, summary of what I did, condition, thoughts and answered the patients tough question before the time ran out --> so not QUITE finished.
The Good:
Washed hands q case, before physical exam summarized HPI back to patient and answered questions at that time. Anytime the patient had pain, or expressed that a family member died etc. I told the patients how sorry I was, that it must be hard for them. I told every patient at least a few times that I would do everything I could do to help them. When patients coughed, I asked if I could give them some water. Did basic overview of each patient (looked at hands, eyes, general appearance), HEENT on most patients in the form of looking for LAD, looked in throat, shined light in eyes. Neuro cases was able to do briefer form of MMSE - namely - AOx3, remote memory (remembering presidents in the past) and 3 word recall. I would do an associated neuro exam that had CNs, patellar reflexes, strength (upper and lower extremities) and for a older patient with memory problems, I had them walk with me guiding them every step of the way.
When I walked out of the room, I had answered questions until the patient said they had no more questions, I would always tell the patient I would call them with their test results as soon as they came in and we could meet in my office in 1-2 weeks to go over the next steps, I then also said that they should not hesitate to call me if there was a problem in the meantime.
Notes - Finished all notes on time - Did following format for all notes.
CC:
HPI: LOPQRST and associated symptoms
PSH, Past hospitalizations, Allergies, Meds
Social history: Appetite, weight changes, diet, occupation, sexual activity, smoke, drink, drugs (counseling occurred right after patient said something - I would tell the patient that it can be harmful for health and that we have many good counselors at the clinic that can give them more resources and then asked if they would want to get some help...if they said, yes, I told them I would set it up and if they said "no" I would tell them my door is always open if they change their minds.
FHx
ROS: ROS usually only had 2-4 things extra...the big stuff like chest pain, SOB, abd. pain, LE swelling.
Exam:
General:
HEENT:
CV:
PULM:
ABD.
Neuro:
Psych:
(CV and Pulm for all patients), abd. complaints and urinary...had ABd. exam. Neuro had neuro and psych. Added AOx3 and normal mood and affect on most patients for me completeness.
I cannot really talk about the diagnoses as this would probably violate test rules and I don't want to do that.
Overall, I felt pretty decent about my diagnoses. Although for one patient I put "malingering" as the third diagnoses only because she asked for pain meds...but nothing else really pointed to malingering. I just put that she had asked for pain meds in my reasoning.
I NEVER put negative things in my reasoning. 2/3 of the cases only had 1-2 things from the history that supported a diagnosis, with NO physical exam findings. Only one case had some physical exam findings that were pertinent to the case.
Areas of uncertainty:
1) One patient's feet were not long enough to reach the foot support when I pulled it out, so in a panic, I pulled the draw above it out...which was a literal drawer and just left it open (pretty laughable in hindsight) and the patient said that he did not want to have an open drawer below him. I apologized and closed it, stating I was trying to find a way to balance his legs so they didn't have to dangle there.
2) 3 of my patients had REAL exam findings. One of them told me about it a chest wall problem that had had a surgical repair (I am vague so I don't violate the test). I MAY have written "no surgeries" by mistake but I don't remember the note enough to know for sure if I made that mistake or not. Regardless, I noted this chest wall deformity in my note.
TWO other patients had actual findings. One person's thyroid was mildly enlarged to me and this was a case where the thyroid was in question too, so I DID put that enlargement as part of my reasoning. Another patient had a mild heart murmur that was NOT pertinent to the case, but I know how to pick up murmurs pretty well and simply put it in my note. I am still worried that their own people didn't note these things or something and will think I made something up which VERY WELL my represent paranoia on my part.
3) This MAY or may NOT be a bad thing. One of the patients told me "you are not causing pain but you are pressing too hard on abdomen." In the moment, I profusely apologized and corrected myself. I then continued the exam and fixed my technique. I was paralyzed by this, in a lot of fear...wondering if I failed this case....but I know I didn't push any harder than I normally do...I normally only do light palpation on SP's as they usually illicit their responses just by that....so maybe this was staged...no idea.
4) One patient that was in a lot of pain, I told him that I would give him something for pain at the end of the case (I know we are not meant to do this) and I even saw the standard pt raise his eyebrow as if he would have an opportunity to come after me (so I perceived), but I then quickly said, my main goal is to make sure that your pain level is decreased...the standard patient then kind of ignored it all, so this may mean I saved myself from some time wasting questions etc.
Tests: I am sure I didn't write all pertinent tests and what not and certainly don't remember all that I put...but I usually put something like:
CBC, metabolic panel, UA
If thyroid or weight problems or depression: TSH with or without 24 hour urine cortisol etc.
Back problems would go to CT lumbar spine...then MRI down further on the list...this type of thing.
If abdominal pain with fever: would do fecal occult blood, stool leukocytes, stool lactoferrin, culture (THING I FORGOT TO PUT RECTAL ON A FEW CASES).
This is just an example, and again, isn't everything.
The Good:
Washed hands q case, before physical exam summarized HPI back to patient and answered questions at that time. Anytime the patient had pain, or expressed that a family member died etc. I told the patients how sorry I was, that it must be hard for them. I told every patient at least a few times that I would do everything I could do to help them. When patients coughed, I asked if I could give them some water. Did basic overview of each patient (looked at hands, eyes, general appearance), HEENT on most patients in the form of looking for LAD, looked in throat, shined light in eyes. Neuro cases was able to do briefer form of MMSE - namely - AOx3, remote memory (remembering presidents in the past) and 3 word recall. I would do an associated neuro exam that had CNs, patellar reflexes, strength (upper and lower extremities) and for a older patient with memory problems, I had them walk with me guiding them every step of the way.
When I walked out of the room, I had answered questions until the patient said they had no more questions, I would always tell the patient I would call them with their test results as soon as they came in and we could meet in my office in 1-2 weeks to go over the next steps, I then also said that they should not hesitate to call me if there was a problem in the meantime.
Notes - Finished all notes on time - Did following format for all notes.
CC:
HPI: LOPQRST and associated symptoms
PSH, Past hospitalizations, Allergies, Meds
Social history: Appetite, weight changes, diet, occupation, sexual activity, smoke, drink, drugs (counseling occurred right after patient said something - I would tell the patient that it can be harmful for health and that we have many good counselors at the clinic that can give them more resources and then asked if they would want to get some help...if they said, yes, I told them I would set it up and if they said "no" I would tell them my door is always open if they change their minds.
FHx
ROS: ROS usually only had 2-4 things extra...the big stuff like chest pain, SOB, abd. pain, LE swelling.
Exam:
General:
HEENT:
CV:
PULM:
ABD.
Neuro:
Psych:
(CV and Pulm for all patients), abd. complaints and urinary...had ABd. exam. Neuro had neuro and psych. Added AOx3 and normal mood and affect on most patients for me completeness.
I cannot really talk about the diagnoses as this would probably violate test rules and I don't want to do that.
Overall, I felt pretty decent about my diagnoses. Although for one patient I put "malingering" as the third diagnoses only because she asked for pain meds...but nothing else really pointed to malingering. I just put that she had asked for pain meds in my reasoning.
I NEVER put negative things in my reasoning. 2/3 of the cases only had 1-2 things from the history that supported a diagnosis, with NO physical exam findings. Only one case had some physical exam findings that were pertinent to the case.
Areas of uncertainty:
1) One patient's feet were not long enough to reach the foot support when I pulled it out, so in a panic, I pulled the draw above it out...which was a literal drawer and just left it open (pretty laughable in hindsight) and the patient said that he did not want to have an open drawer below him. I apologized and closed it, stating I was trying to find a way to balance his legs so they didn't have to dangle there.
2) 3 of my patients had REAL exam findings. One of them told me about it a chest wall problem that had had a surgical repair (I am vague so I don't violate the test). I MAY have written "no surgeries" by mistake but I don't remember the note enough to know for sure if I made that mistake or not. Regardless, I noted this chest wall deformity in my note.
TWO other patients had actual findings. One person's thyroid was mildly enlarged to me and this was a case where the thyroid was in question too, so I DID put that enlargement as part of my reasoning. Another patient had a mild heart murmur that was NOT pertinent to the case, but I know how to pick up murmurs pretty well and simply put it in my note. I am still worried that their own people didn't note these things or something and will think I made something up which VERY WELL my represent paranoia on my part.
3) This MAY or may NOT be a bad thing. One of the patients told me "you are not causing pain but you are pressing too hard on abdomen." In the moment, I profusely apologized and corrected myself. I then continued the exam and fixed my technique. I was paralyzed by this, in a lot of fear...wondering if I failed this case....but I know I didn't push any harder than I normally do...I normally only do light palpation on SP's as they usually illicit their responses just by that....so maybe this was staged...no idea.
4) One patient that was in a lot of pain, I told him that I would give him something for pain at the end of the case (I know we are not meant to do this) and I even saw the standard pt raise his eyebrow as if he would have an opportunity to come after me (so I perceived), but I then quickly said, my main goal is to make sure that your pain level is decreased...the standard patient then kind of ignored it all, so this may mean I saved myself from some time wasting questions etc.
Tests: I am sure I didn't write all pertinent tests and what not and certainly don't remember all that I put...but I usually put something like:
CBC, metabolic panel, UA
If thyroid or weight problems or depression: TSH with or without 24 hour urine cortisol etc.
Back problems would go to CT lumbar spine...then MRI down further on the list...this type of thing.
If abdominal pain with fever: would do fecal occult blood, stool leukocytes, stool lactoferrin, culture (THING I FORGOT TO PUT RECTAL ON A FEW CASES).
This is just an example, and again, isn't everything.
