I don't doubt for a minute lilnoelle that you are thorough and doing a wonderful job. And as noted above, I'm not so sure that as a young medical student that you need to be focusing on efficiency...after all, you need to get the basics down first. But since you asked, here are some additional thoughts:
- a focused exam is just that; unless the patient has H&N symptoms/complaints or obvious signs, I would not do anything more than look for icterus, extraocular movement impairment, etc. (now in my practice I DO examine the neck, but that's because of the high possibility of nodal disease)
- its easy to listen to the heart and lungs at the same time and most patients won't need provocative exercises, percussion, etc. Obviously if this is their system of complaint you spend more time here.
- abdomen; well as a surgeon I often am dismayed at the lack of attention to this system, particularly exams which seem to involve not actually LOOKING at the belly. Patient do forget what surgeries they've had...while it sounds like an urban legend its not rare to find a patient who says he's got no medical problems and find a median sternotomy scar or midline laparotomy scar. If the patient presents with abdominal symptoms, it will help your differential a lot if you see a scar which might represent lack of an appendix or gallbladder.
- extremities; a quick look (to make sure they're there), and feel for warmth is fine, unless the patient is a vasculopath, then you might want to check for pulses (but again, if this is not the system involved, then you are going beyond the focused exam)
So the basics I would consider are:
- overall appearance; does the patient look sick? Are there any outstanding findings - scleral icterus, smell of tobacco, tremor?
- heart and lungs; standard examination. Expand if this is the system of complaint.
abdomen - look for scars, palpate the quadrants; listening for bowel sounds is not necessary unless this system is involved
- ext; as above, look for their presence or absence; warmth, signs of chronic vascular disease
Expand your examination as you see fit based on patient complaints and your findings.
Where do you think you are slower - examination or ROS? The list of ROS questions can be quite lengthy and you have to learn to separate out what is likely and what isn't. Doing the ROS simulataneous with your examination will save some time.
The suggestion above about looking through the patient's old chart is an excellent one; it can help you guide the conversation. Finally, a good skill is to be able to lead patients back to the problem at hand. Its hard to interrupt people but frankly some patients will start to tell you about their childhood medical history which has no relation to their acute problem or will go on and on about a family member.
At any rate, you will get faster as you gain more experience and I wouldn't worry about it right now unless your faculty has said something about it. Who's to know whether or not your classmates are doing a good job, just because they're faster than you?
