Someone Explain Focus History

[Kaustikos]

---

Members don't see this ad.

I just got grilled on my recent focused history examination on 4 patients. We had 12 minutes with each patient to assess and diagnose their issue. I've never been taught/explained the focus history aspect and honestly only screwed up one focus history but I apparently did a **** job...

Patient 1 - I screwed it up because I asked about his complaint, listened to his lung (and then forgot to percuss). I know that was ****ty. I got the diagnosis based on his history and present complaints - smoking and sob/coughing. Listened and heard expiratory wheezes... COPD - order pulmonary function test and chest x-ray. I know I could've done the history better...but I was nervous about the 12 minutes.

Patient 2 - I just got livid with the preceptor who graded me. I saw what he "didn't count" which I did...
Symptoms - tired, depressed, weight gain, enlarged thyroid, no pain/fever/change in diet. I narrowed it to hypothyroidism. I forgot to ask about menstrual cycles/hair/conspitation. Yes, I know these are symptoms of this disease. But I had 12 minutes and narrowed it down to hypothyroidism.

Another patient (and I hate this actor) - Photosensitivity, nuchal rigidity, positive brudzinski/kurnig sign (which she didn't even know were tests and didn't know how to respond initially so I had to ask her again) and then I asked if she had any other symptoms and she said she noticed a weird rash - Oh, tell me more about it! She explained it and told me where it was.... and apparently this is where she should've given me a "card" that showed what type of rash it was. No card...I was baffled. But I didn't care because I knew it was meningitis....

I'm not sure what the hell I was supposed to do. I do great on full history/examinations. But I just got destroyed on these focused histories. I guess I didn't know I was supposed to be this good at diagnosing in 12 minutes... before 3rd/4th year.

 

[jerseytrash]

I just got grilled on my recent focused history examination on 4 patients. We had 12 minutes with each patient to assess and diagnose their issue. I've never been taught/explained the focus history aspect and honestly only screwed up one focus history but I apparently did a **** job...

Patient 1 - I screwed it up because I asked about his complaint, listened to his lung (and then forgot to percuss). I know that was ****ty. I got the diagnosis based on his history and present complaints - smoking and sob/coughing. Listened and heard expiratory wheezes... COPD - order pulmonary function test and chest x-ray. I know I could've done the history better...but I was nervous about the 12 minutes.

Patient 2 - I just got livid with the preceptor who graded me. I saw what he "didn't count" which I did...
Symptoms - tired, depressed, weight gain, enlarged thyroid, no pain/fever/change in diet. I narrowed it to hypothyroidism. I forgot to ask about menstrual cycles/hair/conspitation. Yes, I know these are symptoms of this disease. But I had 12 minutes and narrowed it down to hypothyroidism.

Another patient (and I hate this actor) - Photosensitivity, nuchal rigidity, positive brudzinski/kurnig sign (which she didn't even know were tests and didn't know how to respond initially so I had to ask her again) and then I asked if she had any other symptoms and she said she noticed a weird rash - Oh, tell me more about it! She explained it and told me where it was.... and apparently this is where she should've given me a "card" that showed what type of rash it was. No card...I was baffled. But I didn't care because I knew it was meningitis....

I'm not sure what the hell I was supposed to do. I do great on full history/examinations. But I just got destroyed on these focused histories. I guess I didn't know I was supposed to be this good at diagnosing in 12 minutes... before 3rd/4th year.

A focused history involves doing all parts of the history in an abbreviated manner, especially for an OSCE. For the patient you suspect meningitis in, you don't really care about his psychiatric disease, for example.

This takes a lot of practice and it's something that involves years and years of learning. Don't get down about it.

 

[Wordead]

Sounds to me like you're just skipping things because you're worried about time. I bet you know what you're supposed to ask, you're just rushing yourself.

Smoker - pack years, mucus, asthma...did you do heart?

According to what we were taught, you should be asking ALL women about menstrual periods, hypothyroidism or not.

Otherwise, if a standardized patient sucks, they suck. I remember I had one that didn't understand that they were supposed to give each card with results as I did the exam - then he just handed them all to me at the end. I was just panicking the whole time like WTF is going on?

All in all, I think you're fine. Just need to relax and think through all the relevant systems and ask about them.

 

[Kaustikos]

I guess I'm frustrated about it. I know how to ask questions... I've never had that problem. I do ROS just fine when I'm interviewing a patient. If the whole idea is to ask that in 12 minutes, fine. I guess my confusion was in the fact that I had 12 minutes. I nailed the diagnosis and in my brain just thought "You have it, you've got the symptoms"...

and then I get my review. No explanation about how I do these things except now. I should've asked beforehand, which is my fault. I suppose it isn't all about the diagnosis

 

[Wordead]

I guess I'm frustrated about it. I know how to ask questions... I've never had that problem. I do ROS just fine when I'm interviewing a patient. If the whole idea is to ask that in 12 minutes, fine. I guess my confusion was in the fact that I had 12 minutes. I nailed the diagnosis and in my brain just thought "You have it, you've got the symptoms"...

and then I get my review. No explanation about how I do these things except now. I should've asked beforehand, which is my fault. I suppose it isn't all about the diagnosis

OSCE's are in no way about the diagnosis - it's whether or not you know the steps of going through the motions. I aced it and couldn't even get a reflex half the time. And visualizing the optic cup - crap, probably 10% success rate.

So if you have your diagnosis, you need to ask about all the related symptoms of that condition. And don't discount the social history - I remember a lot of people in my class missing those.

 

[tco]

OSCE's are in no way about the diagnosis - it's whether or not you know the steps of going through the motions. I aced it and couldn't even get a reflex half the time. And visualizing the optic cup - crap, probably 10% success rate.

So if you have your diagnosis, you need to ask about all the related symptoms of that condition. And don't discount the social history - I remember a lot of people in my class missing those.

I've debated just grabbing the otoscope, glancing at the ears. Grabbing the ophthalmoscope, glancing in the eyes. "No erythema in the external ear canal. Normal tympanic membrane. No erythema. Good cone of light reflex." "Optic disc sharp. Cup to disc ratio 0.3. No AV nicking, hemorrhage, or exudates." BOOM! 30 seconds. I've never played the game, but the way this system works, I'm about to start.

OP, it sounds like you're fine...You just got flustered due to the time constraints.

 

[evilbooyaa]

Focused history means you ask about pertinent positives/negatives. If someone comes in talking bout meningitis, is there a benefit of doing a ROS on abdominal pain?

Generally, they tell us to always auscultate heart, lungs, and check the abdomen regardless of chief complaint.

Ask all the questions you normally would. Just try to do it faster. Social history - ask about tobacco/smoking/drugs, occupation/stress if possibly important.

Case 1 - Smoker? How many pack years? ALWAYS listen to the heart (along with the lungs). Don't forget about family history, including cancers. CC = SOB? Ask about occupation (to r/o job related things)

Case 2 - Weight gain, depression, fatigue, irregular menstruation are the main ones I remember for hypothyroid. I don't know if this is part of it, but talk about what tests you'd order (obviously, check TSH for hypothyroidism; if elevated, start pt on titrating dose of synthroid)

Case 3 - Meningitis + weird rash? Possibly disseminated neisseria? This will guide your empiric ABx therapy after you do a LP.

As for standard patients sucking, yeah. It happens. Gotta deal with it and move on. I will say that this whole thing about handing cards with results and stuff is new to me. I've always just talked about what tests we ordered in our 15 minute enounters.

Don't let it get under your skin. If there was some reading you were supposed to do prior to this activity, then you know what you need to do now. If there wasn't, tell the preceptor either in person or in the feedback for that activity that you had no idea what the expectations were for that exercise.

 

[Rothbard]

First Aid for Step 2 CS will give you a good idea of what they're looking for.

 

[evilbooyaa]

I've debated just grabbing the otoscope, glancing at the ears. Grabbing the ophthalmoscope, glancing in the eyes. "No erythema in the external ear canal. Normal tympanic membrane. No erythema. Good cone of light reflex." "Optic disc sharp. Cup to disc ratio 0.3. No AV nicking, hemorrhage, or exudates." BOOM! 30 seconds. I've never played the game, but the way this system works, I'm about to start.

OP, it sounds like you're fine...You just got flustered due to the time constraints.

Unless the patient comes in with eye/ear complaints, or has symptoms that require checking the eyes (such as uncontrolled diabetes or hypertension), I wouldn't bother doing these (especially if they expect you to do a full patient encounter in 12 minutes as a MS2).

I don't even know what 1/3 of those statements are. Ears = normal tympanic membrane
Eyes = optic disk present, no retinal hemorrhages. I haven't required anything beyond that. YMMV.

 

[NeuroLAX]

Unless the patient comes in with eye/ear complaints, or has symptoms that require checking the eyes (such as uncontrolled diabetes or hypertension), I wouldn't bother doing these (especially if they expect you to do a full patient encounter in 12 minutes as a MS2).

I don't even know what 1/3 of those statements are. Ears = normal tympanic membrane
Eyes = optic disk present, no retinal hemorrhages. I haven't required anything beyond that. YMMV.

😱 Pick up a Bates' or a Mosby's! That's pretty basic stuff. At my school you'd be chewed out for saying "normal".

 

[Rendar5]

Just a little confused ont he part about teachign the preceptor about Kernig and Brudzinski? Honestly, wouldn't waste your time on it (explaining it to them or trying to get them to enact it), just mark it down as being negative on your exam. I've actually never seen those signs in my meningitis patients, they're only a few steps from rigor mortis anyway 🙂

 

[Kaustikos]

Just a little confused ont he part about teachign the preceptor about Kernig and Brudzinski? Honestly, wouldn't waste your time on it (explaining it to them or trying to get them to enact it), just mark it down as being negative on your exam. I've actually never seen those signs in my meningitis patients, they're only a few steps from rigor mortis anyway 🙂

Well, I was about to dismiss it, but I felt like she didn't know how to respond. And I am glad I did because another classmate of mine did have her after me and got her to "elicit a response".

And normally I wouldn't of minded, but it seems like I'm supposed to be finding all the symptoms associated with the diseases. Which, I know, but oh well...

 

[Armadillos]

Well, I was about to dismiss it, but I felt like she didn't know how to respond. And I am glad I did because another classmate of mine did have her after me and got her to "elicit a response".

And normally I wouldn't of minded, but it seems like I'm supposed to be finding all the symptoms associated with the diseases. Which, I know, but oh well...

http://www.ncbi.nlm.nih.gov/pubmed/12060874

 

[Charles_Carmichael]

Unless the patient comes in with eye/ear complaints, or has symptoms that require checking the eyes (such as uncontrolled diabetes or hypertension), I wouldn't bother doing these (especially if they expect you to do a full patient encounter in 12 minutes as a MS2).

I don't even know what 1/3 of those statements are. Ears = normal tympanic membrane
Eyes = optic disk present, no retinal hemorrhages. I haven't required anything beyond that. YMMV.

😱 Pick up a Bates' or a Mosby's! That's pretty basic stuff. At my school you'd be chewed out for saying "normal".

Agreed (not the getting chewed out part though).

The residents/attendings I've worked with prefer that I mention everything I asked in the ROS because they want to know what specific questions I asked and what I didn't/forgot. Saying something is "normal" is a no-no, for the most part. In the context of a 12-minute focused H&P, I guess it's reasonable not to go too in-depth with the ROS if you've already got a pretty good idea of what's going on with the patient.

 

[evilbooyaa]

😱 Pick up a Bates' or a Mosby's! That's pretty basic stuff. At my school you'd be chewed out for saying "normal".

Might've been exaggerating a little bit. But seriously, cone of light reflex? Cup to disc ratio? I don't think I even learned those at my school, and I couldn't imagine that they were relevant unless I was an ENT or an ophtho. Other signs/symptoms of otitis media are likely much more sensitive/specific than cone of light reflex. Cup to disc ratio for diagnosing glaucoma?

I'm not saying they have no purpose. But expecting a MS2 to do a patient encounter in 12 minutes (after being told to do a focused exam) and including this level of depth in their oto/ophtho exams? Seems a little overboard. I haven't officially started studying for Step 2 CS, but I can't imagine that terminology like above is warranted, even in cases that require an oto/ophtho exam.

Check out Evidence-Based Physical Diagnosis sometime. Sensitivity for Kernig's and Brudzinski's is < 20% in acute bacterial meningitis patients. Stuff like cone of light reflex and cup to disc ratio isn't even mentioned in the book, otherwise I'd have numbers.

 

[Charles_Carmichael]

Might've been exaggerating a little bit. But seriously, cone of light reflex? Cup to disc ratio? I don't think I even learned those at my school, and I couldn't imagine that they were relevant unless I was an ENT or an ophtho. Other signs/symptoms of otitis media are likely much more sensitive/specific than cone of light reflex. Cup to disc ratio for diagnosing glaucoma?

I'm not saying they have no purpose. But expecting a MS2 to do a patient encounter in 12 minutes (after being told to do a focused exam) and including this level of depth in their oto/ophtho exams? Seems a little overboard. I haven't officially started studying for Step 2 CS, but I can't imagine that terminology like above is warranted, even in cases that require an oto/ophtho exam.

Check out Evidence-Based Physical Diagnosis sometime. Sensitivity for Kernig's and Brudzinski's is < 20% in acute bacterial meningitis patients. Stuff like cone of light reflex and cup to disc ratio isn't even mentioned in the book, otherwise I'd have numbers.

That's a good point. I was referring to saying more than just "normal" in previous post, not the specifics of what the other guy/gal mentioned.

I love the Evidence-Based Physical Diagnosis book! I didn't use it as much as I probably should have this year. Hopefully, I'll have some time to comb through it more thoroughly next year.

 

[tco]

Check out Evidence-Based Physical Diagnosis sometime. Sensitivity for Kernig's and Brudzinski's is < 20% in acute bacterial meningitis patients. Stuff like cone of light reflex and cup to disc ratio isn't even mentioned in the book, otherwise I'd have numbers.

You said before, "Optic disc present," which is a much more silly thing to say. Of course it's present. If you can see it, you should at least make an estimate of the disc to cup ratio. If you can't see it, you shouldn't be documenting that it's present. What if it isn't?

Comparing what I said to Kernig and Brudzinski is like saying, "Hoffman negative," in every patient. It is a specific sign that you don't need to look for usually (okay, always, because they're worthless). However, every patient has an optic disc (despite what your previous post might indicate), so saying "Optic disc to cup ratio ___" instead of "Normal optic disc" really doesn't take that much more time and it is much more informative. I do this on all of my real patients when I look into their eyes. Can't tell you what I'll do on the SPs until I get there...

 

[evilbooyaa]

You said before, "Optic disc present," which is a much more silly thing to say. Of course it's present. If you can see it, you should at least make an estimate of the disc to cup ratio. If you can't see it, you shouldn't be documenting that it's present. What if it isn't?

Comparing what I said to Kernig and Brudzinski is like saying, "Hoffman negative," in every patient. It is a specific sign that you don't need to look for usually (okay, always, because they're worthless). However, every patient has an optic disc (despite what your previous post might indicate), so saying "Optic disc to cup ratio ___" instead of "Normal optic disc" really doesn't take that much more time and it is much more informative. I do this on all of my real patients when I look into their eyes. Can't tell you what I'll do on the SPs until I get there...

Hmm, I guess I see your point. I honestly can't remember the last time I used an ophthalmoscope for doing anything except red reflex in peds. Definitely not during anything else in MS3. Even in MS2... we used the ophtho scope but I can't remember what I said. Idk, just my experience. Hasn't negatively affected my life.

 

[Wordead]

You said before, "Optic disc present," which is a much more silly thing to say. Of course it's present. If you can see it, you should at least make an estimate of the disc to cup ratio. If you can't see it, you shouldn't be documenting that it's present. What if it isn't?

Comparing what I said to Kernig and Brudzinski is like saying, "Hoffman negative," in every patient. It is a specific sign that you don't need to look for usually (okay, always, because they're worthless). However, every patient has an optic disc (despite what your previous post might indicate), so saying "Optic disc to cup ratio ___" instead of "Normal optic disc" really doesn't take that much more time and it is much more informative. I do this on all of my real patients when I look into their eyes. Can't tell you what I'll do on the SPs until I get there...

I've literally never heard of optic disc to cup ratio used in any setting so far, nor were we ever taught it. YMMV. Could be poor physical diagnosis skills taught to us though, who knows.

 

[ijn]

The only time I used an ophthalmoscope during 3rd year was for my family med OSCE where the patient had diabetes and I correctly guessed one of the lame check boxes is a nearly worthless, non-dilated eye exam.

You don't get credit for doing what family med residents actually do: refer to optho/local mall Eye Masters.

 

[siliso]

How are these standardized patient encounters working? You are asking the patient, "do you have a kernig sign?" Or are you actually carrying out the maneuver and seeing if they say "ow"? The latter is how all our OSCE type things have worked.

Your problem may be "premature closure". Fixing on your diagnosis early, and ignoring the differential/related questions and exams. That will lose you points even if you prematurely closed on the right diagnosis.

Or your problem may be freaking out and getting pissy with administrators or SPs or whoever over things being right and correct and fair all the time, which they are not so get used to grinning and bearing it. It's good practice for third year and life in general. They give this test at the end of second year so they can prove you learned something when you take it again at the end of third year.

 

[p30doc]

These encounters can be BS and are all about checking the nebulous grading boxes.

This is the recipe and easily accomplished in 12 mins imo.

cc:
hpi:
pmh:
psh:
sh: tobacco, etoh, drugs. Only ask other social bs if it is related to the complaint.
meds:
allergies:

always listen to heart/lungs, then do only exams on systems related to their complaint. don't waste precious time on exams/maneuvers that can not be accomplished quickly. Ie don't dick around with the ophthalmoscope unless the cc is something with the vision which it is pretty much never is.

Very quickly give them your impression and part of your plan.

Ask any q's or comments.

This recipe generally works for seeing real pts too!

 

[NeuroLAX]

Agreed (not the getting chewed out part though).

The residents/attendings I've worked with prefer that I mention everything I asked in the ROS because they want to know what specific questions I asked and what I didn't/forgot. Saying something is "normal" is a no-no, for the most part. In the context of a 12-minute focused H&P, I guess it's reasonable not to go too in-depth with the ROS if you've already got a pretty good idea of what's going on with the patient.

Might've been exaggerating a little bit. But seriously, cone of light reflex? Cup to disc ratio? I don't think I even learned those at my school, and I couldn't imagine that they were relevant unless I was an ENT or an ophtho. Other signs/symptoms of otitis media are likely much more sensitive/specific than cone of light reflex. Cup to disc ratio for diagnosing glaucoma?

I'm not saying they have no purpose. But expecting a MS2 to do a patient encounter in 12 minutes (after being told to do a focused exam) and including this level of depth in their oto/ophtho exams? Seems a little overboard. I haven't officially started studying for Step 2 CS, but I can't imagine that terminology like above is warranted, even in cases that require an oto/ophtho exam.

Check out Evidence-Based Physical Diagnosis sometime. Sensitivity for Kernig's and Brudzinski's is < 20% in acute bacterial meningitis patients. Stuff like cone of light reflex and cup to disc ratio isn't even mentioned in the book, otherwise I'd have numbers.

I'll definitely take a look at it. Thanks. I was also exaggerating slightly when I said we are "chewed out" for saying something is normal. We lose points and get a lot of red ink on our SOAP notes for physical diagnosis lab if we say things are normal without any detail as to what is or is not present.

 

[tco]

People always throw me off when they put "PSH and PMH" in different categories because I include surgical in PMH. I literally just spent a couple of seconds trying to figure out what you meant.

 

[Kaustikos]

How are these standardized patient encounters working? You are asking the patient, "do you have a kernig sign?" Or are you actually carrying out the maneuver and seeing if they say "ow"? The latter is how all our OSCE type things have worked.

Your problem may be "premature closure". Fixing on your diagnosis early, and ignoring the differential/related questions and exams. That will lose you points even if you prematurely closed on the right diagnosis.

Or your problem may be freaking out and getting pissy with administrators or SPs or whoever over things being right and correct and fair all the time, which they are not so get used to grinning and bearing it. It's good practice for third year and life in general. They give this test at the end of second year so they can prove you learned something when you take it again at the end of third year.

I didn't ask her if she literally had a positive kernig sign. I did the exam and did the kernig/brudzkinski sign. She already demonstrated the nuchal rigidity before and so I just asked more questions and then did those two exams. She just didn't respond appropriately... I told her to move her leg/whatever and she did and I asked her if it hurt... And she then said "Oh, yeah, it hurts!" 😕 Whereas before, she would moan/grimace when she moved her neck while sitting.

I agree, I may have rushed it because I came to the diagnosis too early for the other ones. That's my issue... but only because I wasn't comfortable with doing 12 minute focused histories.

These encounters can be BS and are all about checking the nebulous grading boxes.

This is the recipe and easily accomplished in 12 mins imo.

cc:
hpi:
pmh:
psh:
sh: tobacco, etoh, drugs. Only ask other social bs if it is related to the complaint.
meds:
allergies:

always listen to heart/lungs, then do only exams on systems related to their complaint. don't waste precious time on exams/maneuvers that can not be accomplished quickly. Ie don't dick around with the ophthalmoscope unless the cc is something with the vision which it is pretty much never is.

Very quickly give them your impression and part of your plan.

Ask any q's or comments.

This recipe generally works for seeing real pts too!

Yup. Thanks.

It wasn't negligence in doing what you said, it was just them never explaining WHAT I should do. What you just put up there makes a lot of sense and I could easily do that. Thanks

 

[jerseytrash]

Wait, people haven't heard of cup-to-disc ratios? That's a pretty big part of the ophtho exam - we were taught it in our physical exam classes - though granted I was briefly interested in ophtho so that may be why I know about it.

I guess it's not as widespread in use as I thought

 

[Kaustikos]

Wait, people haven't heard of cup-to-disc ratios? That's a pretty big part of the ophtho exam - we were taught it in our physical exam classes - though granted I was briefly interested in ophtho so that may be why I know about it.

I guess it's not as widespread in use as I thought

Nah,
I knew what you meant. It's one of the things that was part of our physical diagnosis exam. Relating to glaucoma...or that's the only time I've heard of it being used. I just wouldn't be able to tell you for sure because I'm not a pro with opthalmoscopes.

 

[Wordead]

Wait, people haven't heard of cup-to-disc ratios? That's a pretty big part of the ophtho exam - we were taught it in our physical exam classes - though granted I was briefly interested in ophtho so that may be why I know about it.

I guess it's not as widespread in use as I thought

I'd heard of it from reading Bates, but it was never mentioned in our PE class and I've yet to hear it in clinic.

 

[jerseytrash]

I'd heard of it from reading Bates, but it was never mentioned in our PE class and I've yet to hear it in clinic.

I saw it used in ophtho clinic when evaluating glaucoma patients and its used in the community at eye screenings; but yes it doesn't have day to day utility

 

[jerseytrash]

Nah,
I knew what you meant. It's one of the things that was part of our physical diagnosis exam. Relating to glaucoma...or that's the only time I've heard of it being used. I just wouldn't be able to tell you for sure because I'm not a pro with opthalmoscopes.

Eh, it's alright, it's very hard to become a pro with ophthalmoscopes for sure. Either way the best standard of measurement for glaucoma is tonometry anyway.

 

[Rendar5]

I didn't ask her if she literally had a positive kernig sign. I did the exam and did the kernig/brudzkinski sign. She already demonstrated the nuchal rigidity before and so I just asked more questions and then did those two exams. She just didn't respond appropriately... I told her to move her leg/whatever and she did and I asked her if it hurt... And she then said "Oh, yeah, it hurts!" 😕 Whereas before, she would moan/grimace when she moved her neck while sitting.

She did respond appropriately, you just wanted her to have more physical exam signs than she did =p

 

[Armadillos]

She did respond appropriately, you just wanted her to have more physical exam signs than she did =p

on this note, anyone else find it kind of weird how overkill a lot of the physical exam stuff they teach you in preclinicals is?

Was examining a patient with my preceptor and the patient was like " What the hell are you doing son, I can always tell who has no idea what they are doing because they do all these moves I've never seen from a real doctor"

My preceptor couldnt stop laughing for like 10 minutes

 

[Wordead]

on this note, anyone else find it kind of weird how overkill a lot of the physical exam stuff they teach you in preclinicals is?

Was examining a patient with my preceptor and the patient was like " What the hell are you doing son, I can always tell who has no idea what they are doing because they do all these moves I've never seen from a real doctor"

My preceptor couldnt stop laughing for like 10 minutes

I always wonder what is overkill and useless and what is just thrown out by lazy physicians, who pass it to residents/medical students.

I saw on one rotation that this resident only listened to heart sounds in 1 area and lung sounds on ONE side of the chest in 2 spots. I know nobody listens to all 16 spots or whatever the hell you're supposed for lungs, but come on there's no way you can only listen to the anterior side, even if you have superhuman hearing. Unfortunately I never know for sure what's actually useful half the time.

 

[Raryn]

I'm graduating in 10 days and have absolutely no clue how to measure a cup-to-disk ratio and have never documented one (and almost certainly never will). I'm lucky if I can even see the optic disc on a good day.

No one other than an ophthalmologist should be measuring that.

 

[VenusinFurs]

To the OP: No matter what the stated intent, IMO the only thing these types of OSCEs are testing you on is whether you will pass CS, and CS is much less fussy than the OSCEs your school administers. If you read a Step 2 CS book that will get you thinking in terms of commonly tested diagnoses/ categories of chief complaint and the type of history, physical, lab tests you should order. Real medicine works nothing like this. You will do fine, don't worry.

 

[tco]

I'm graduating in 10 days and have absolutely no clue how to measure a cup-to-disk ratio and have never documented one (and almost certainly never will). I'm lucky if I can even see the optic disc on a good day.

No one other than an ophthalmologist should be measuring that.

So you're the gold standard to determine what all is useless and useful in the physical exam, almighty fourth year? Good to know. I'll toss you a PM when I have a question about ANYTHING.

I always wonder what is overkill and useless and what is just thrown out by lazy physicians, who pass it to residents/medical students.

I saw on one rotation that this resident only listened to heart sounds in 1 area and lung sounds on ONE side of the chest in 2 spots. I know nobody listens to all 16 spots or whatever the hell you're supposed for lungs, but come on there's no way you can only listen to the anterior side, even if you have superhuman hearing. Unfortunately I never know for sure what's actually useful half the time.

Exactly. Ultimately, if someone has SOB and a fever, they end up with a CXR anyway...Are we really just kidding ourselves with listening to lung sounds? How do we judge improvement in pneumonia? Clinically with how the patient feels, pulse ox, and CXR. Murmurs are a different story, I feel.

I think it should be on a case-by-case basis. Since I'm still a n00b, I listen to most patients lung sounds in four areas anteriorly, six posterior, and the right middle lobe. I listen to all four heart areas on most patients. However, I feel that most of this is just "doing it because that's how it's supposed to be done."

 

[Raryn]

So you're the gold standard to determine what all is useless and useful in the physical exam, almighty fourth year? Good to know. I'll toss you a PM when I have a question about ANYTHING.

Maybe you're efficacious at being able to monitor glaucoma with a non-dilated eye exam, but no one else I know (in any non-ophthalmalogic specialty) would feel comfortable doing that.

I'm going into medicine and every medicine intern, resident, and attending I've ever discussed this with has enough difficulty with recognizing possible papiledema (I've never had a patient with it myself), much less starting to measure any cupping.

 

[jerseytrash]

Maybe you're efficacious at being able to monitor glaucoma with a non-dilated eye exam, but no one else I know (in any non-ophthalmalogic specialty) would feel comfortable doing that.

I'm going into medicine and every medicine intern, resident, and attending I've ever discussed this with has enough difficulty with recognizing possible papiledema (I've never had a patient with it myself), much less starting to measure any cupping.

I think at the very least you should be able to recognize papilledema. I've never seen it myself either, but I have a resident who have noticed it and subsequently ended up diagnosing said patient with idiopathic intracranial hypertension (along with the rest of the clinical picture of course).

Doing a lot of ophtho exams helped me get good at it, but yes, it's a tougher part of the exam to do, and your patient has to be willing to put up with some discomfort.

Also, IMO just because some attendings dont do part of the physical exam doesn't mean they shouldn't. They're uncomfortable with it, but that doesn't mean its efficacy doesn't exist.

 

[45408]

😱 Pick up a Bates' or a Mosby's! That's pretty basic stuff. At my school you'd be chewed out for saying "normal".

Yeah, I don't remember any of those things, nor have I examined a patient's eyes (beyond looking for obvious injury, pupil reactivity, or jaundice) in at least 3 years.

People always throw me off when they put "PSH and PMH" in different categories because I include surgical in PMH. I literally just spent a couple of seconds trying to figure out what you meant.

When their PSH is much more complicated than their PMH, I separate it out. Otherwise I try to tie it in, like "CAD s/p CABG, OA s/p bilat TKA, etc."

I always wonder what is overkill and useless and what is just thrown out by lazy physicians, who pass it to residents/medical students.

I saw on one rotation that this resident only listened to heart sounds in 1 area and lung sounds on ONE side of the chest in 2 spots. I know nobody listens to all 16 spots or whatever the hell you're supposed for lungs, but come on there's no way you can only listen to the anterior side, even if you have superhuman hearing. Unfortunately I never know for sure what's actually useful half the time.

What are you trying to find? What impact will that finding have on your decision? How much time do you have? The two most important things I want to know when I listen to their heart is the rate and rhythm, which pretty much requires listening in one place. In an adult with normal exercise tolerance, I'm not going to listen for physiologic S2 splitting to see if they have an ASD or for a hint of mitral regurg. If I have an elderly pt with a significant murmur, I'm going to get an echo to actually characterize their degree of AS, the gradient, etc.

In some specialties, the physical exam often gives you your answer quite readily. When I was on ENT, they usually figured out most of what they needed with an otoscope and flexible endoscope. When I'm seeing someone with an anorectal complaint, the physical exam usually gives you the answer. For most breast cancers these days, which aren't palpable until they're quite advanced, the physical exam isn't nearly as useful as the ultrasound or mammogram.

 

[Dwindlin]

I'm graduating in 10 days and have absolutely no clue how to measure a cup-to-disk ratio and have never documented one (and almost certainly never will). I'm lucky if I can even see the optic disc on a good day.

No one other than an ophthalmologist should be measuring that.

Truth. Unless you can dilate the eyes the opthalmoscope is almost worthless on most patients.

 

[Dwindlin]

I always wonder what is overkill and useless and what is just thrown out by lazy physicians, who pass it to residents/medical students.

I saw on one rotation that this resident only listened to heart sounds in 1 area and lung sounds on ONE side of the chest in 2 spots. I know nobody listens to all 16 spots or whatever the hell you're supposed for lungs, but come on there's no way you can only listen to the anterior side, even if you have superhuman hearing. Unfortunately I never know for sure what's actually useful half the time.

I only listen anteriorly occasionally. Especially for hospitalized patients on pre-rounds in the mornings. I generally go front of chest near apex, then fairly low on anterior-axillary line-ish.

For hearts I generally only listen over aortic and mitral area. As Prowler posted, if there is something strange going on your going to need the echo anyways.

 

[evilbooyaa]

I always wonder what is overkill and useless and what is just thrown out by lazy physicians, who pass it to residents/medical students.

I saw on one rotation that this resident only listened to heart sounds in 1 area and lung sounds on ONE side of the chest in 2 spots. I know nobody listens to all 16 spots or whatever the hell you're supposed for lungs, but come on there's no way you can only listen to the anterior side, even if you have superhuman hearing. Unfortunately I never know for sure what's actually useful half the time.

When you're doing surgery pre-rounds at 5 in the morning, it's hard enough to wake up patients to answer your questions. Never mind getting them to sit up (after just having their colon removed) or roll over so you can listen to the 6 posterior lung sounds. On post op day 1, everyone should just write,"Decreased breath sounds at bases", because they all have atelectasis. However, they don't. Unless the pt is having an issue, everyone just puts CTAB (or CTABL).

That's the thing with SOB - You can generally see it progressing. The things that you can hear on a lung exam (like atelectasis/PNA/asthma) generally aren't going to go from asymptomatic to rapidly killing the patient (well maybe asthma, but unless it's a kid, they should have it documented in their admitting H&P). The things that you can hear and might kill the patient (like a tension PTX) will cause the patient symptoms. Then there are things that you can't hear, the patient is initially asx, and will rapidly kill the patient (like a PE).

Heart stuff is in a slightly different field. Patients can't tell when they are developing aortic stenosis (until they're symptomatic).

I've done the anterior lung exam on patients. Obviously if they're having SOB or any other possible lung pathology, you listen. I generally do posterior 6, then closer if they have audible pathology.

Also, a vast majority of physical exam techniques we are taught in our second year are there to be the foundation. I still think we should be taught them so that when we hear about some obscure sign in the future, we can either 1) know what it is, or 2) quickly re-understand what it means.

This goes in a similar fashion to the long-drawn out H&P (with mandatory work history, stressors, sexual history, extended FHx for non-related disease, diet and exercise, menstrual history) that we (or at least I) learned as second years. It's not so that we necessarily ask those questions to everybody who walks in thorugh the door, but we know when we need to ask those questions (ie - sexual history in gyn patients, work history in new SOB pts, etc.) I can't remember the last time I asked someone where they work in order to help with my differential. Maybe if I was curious or wondering about their stress levels (regarding depression and things), then maybe.