Step 2 CS physical exam minimums and note abbreviations

[rockydoc]

Two Questions:

1. I am getting mixed messages about the minimum physical exam that we need to do on every patient encounter in CS.

FA and my home school seem to think we NEED to do at least Heart/Lung/Abd exam on EVERY encounter and then add other focused exams per the history.

Then the USMLE Step 2 CS sample notes show them only documenting HEENT and Abd exam for a sore throat. but no heart/lung exam.

So which is it? Can we be super focused and leave out basic heart/lung/abd if it is not necessary?

2. Can we use abbreviations like:
Heart: RRR, no m/r/g, normal S1 S2
Lungs: CTAB
Abd: SNTND, BS+

Or do we write out "murmmurs, rubs, gallops" "good air entry bilaterally" and "soft, nontender, nondistended"


THANKS

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[Syncity]

Hey.

Two very reasonable questions there. For each encounter I think it's standard practice to listen to the heart and lungs. Carrying out a more extensive cardiac or pulmonary exam is excessive. An abdo exam on each patient is unnecessary. You also need to consider time and communication - have a system which focuses chiefly on their P/C and then give a cursory listen.

Secondly, USMLE has a list of standard abbreviations. It's absolutely fine to use them as long as they're on this list. I believe FA for CS also contains this list.

Good luck!