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  #1  
Old 11-28-2015
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Default step 2 cs patient note query

hello all,
i have one doubt....
in patient notes, in DDs we support them with history finding s but most of the time patient does not have any positive physical exam finding so in such case if we left supporting physical exam finding blank does it lead to fail us??
need experienced opinion on it...
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  #2  
Old 11-28-2015
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Quote:
Originally Posted by coronary View Post
hello all,
i have one doubt....
in patient notes, in DDs we support them with history finding s but most of the time patient does not have any positive physical exam finding so in such case if we left supporting physical exam finding blank does it lead to fail us??
need experienced opinion on it...
Nope. Except for vitals and tenderness, there isn't a lot to write in the physical examination part of the note.
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  #3  
Old 11-28-2015
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Originally Posted by Durisetister View Post
Nope. Except for vitals and tenderness, there isn't a lot to write in the physical examination part of the note.
thank you so much for replying.. these days nobody is interested in replyng and giving any advice.. i really appreciate your help..
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  #4  
Old 11-28-2015
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Originally Posted by coronary View Post
thank you so much for replying.. these days nobody is interested in replyng and giving any advice.. i really appreciate your help..
No problem. Guess everyone must be busy studying for the exam. Hope I pass this one.
Good luck!
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  #5  
Old 11-28-2015
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Originally Posted by Durisetister View Post
No problem. Guess everyone must be busy studying for the exam. Hope I pass this one.
Good luck!
when did you give exam?
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Old 11-28-2015
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Originally Posted by coronary View Post
when did you give exam?
last week..was a nightmare, missed a lot of stuff..just hoping what I've done would be enough to get me through
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  #7  
Old 11-28-2015
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Quote:
Originally Posted by Durisetister View Post
last week..was a nightmare, missed a lot of stuff..just hoping what I've done would be enough to get me through
can you tell me your mistakes or stuff that you missed... we can discuss our mistakes
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Old 11-28-2015
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Originally Posted by coronary View Post
can you tell me your mistakes or stuff that you missed... we can discuss our mistakes
lol. okay

Things I missed:
1) forgot to mention rectal exam in 2 cases and pelvic exam in 1 case
2) did not have time to counsel for smoking in 2 cases
3) missed diagnosis in 2 cases (wrote the Dx in the patient note but did not inform the SP about it)
4) forgot to tie the gown back after the physical in 3 cases (damn!), in 1 case realized the mistake and apologized
5) could not answer SPs question properly in 1 case. Panicked and said we could discuss about it at a later date, SP did not seem impressed with that
6) Missed a lot of stuff in the physical which I cannot even remember right now
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  #9  
Old 11-28-2015
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Quote:
Originally Posted by Durisetister View Post
lol. okay

Things I missed:
1) forgot to mention rectal exam in 2 cases and pelvic exam in 1 case
2) did not have time to counsel for smoking in 2 cases
3) missed diagnosis in 2 cases (wrote the Dx in the patient note but did not inform the SP about it)
4) forgot to tie the gown back after the physical in 3 cases (damn!), in 1 case realized the mistake and apologized
5) could not answer SPs question properly in 1 case. Panicked and said we could discuss about it at a later date, SP did not seem impressed with that
6) Missed a lot of stuff in the physical which I cannot even remember right now
1. in one case i forgot to perform CVA tenderness which was essential to rule out DD, i am so angry on myself how ican i forget. but pt was kind of weird that freaked me out and forgot this test to do
2. i did perform tinel s and phalen s test but i totally forgot to mention i PN because that test came negative.
3. i did not add d dimer or doppler ultrasound in workup of a pt but i added CT pulmonary angio. which is more imp to confirm diagnosis,is it fatal not mentioning above thing?
4. i messed up DDs coz was not able to come up with most likely DD, there were so many possibility like more than 3 and have to put only 3 but my PE, PN, workup and encounter was good
5. is it require to perform neuro in case of depressed pt if we only do MMSE? coz i did nt perform neuro in that case
6. in one case forgot to counsel on weed but rest was fine
7. forgot to check for tremors in pt where i was suspecting hyperthyroid prob but rest i did everything
8. i was not able to add immunisation history in a case coz ran out of space and word limit
9. is it a mistake telling pt tht he might have cancer but will rule it out by workup ?

rest of the thing i did not left my PN blank, did everythng from knoking door, introduce, permission, transition sentence, making pt comfortable, drapping, putting gloves, closure, counselling, relevent question n focused exam, i mean i always did focused exm first if i hv tim then only heart and lung otherwise not... :toosad... and the list goes on.. everyday i remember new mistake...
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  #10  
Old 11-28-2015
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Quote:
Originally Posted by coronary View Post
1. in one case i forgot to perform CVA tenderness which was essential to rule out DD, i am so angry on myself how ican i forget. but pt was kind of weird that freaked me out and forgot this test to do
2. i did perform tinel s and phalen s test but i totally forgot to mention i PN because that test came negative.
3. i did not add d dimer or doppler ultrasound in workup of a pt but i added CT pulmonary angio. which is more imp to confirm diagnosis,is it fatal not mentioning above thing?
4. i messed up DDs coz was not able to come up with most likely DD, there were so many possibility like more than 3 and have to put only 3 but my PE, PN, workup and encounter was good
5. is it require to perform neuro in case of depressed pt if we only do MMSE? coz i did nt perform neuro in that case
6. in one case forgot to counsel on weed but rest was fine
7. forgot to check for tremors in pt where i was suspecting hyperthyroid prob but rest i did everything
8. i was not able to add immunisation history in a case coz ran out of space and word limit
9. is it a mistake telling pt tht he might have cancer but will rule it out by workup ?

rest of the thing i did not left my PN blank, did everythng from knoking door, introduce, permission, transition sentence, making pt comfortable, drapping, putting gloves, closure, counselling, relevent question n focused exam, i mean i always did focused exm first if i hv tim then only heart and lung otherwise not... :toosad... and the list goes on.. everyday i remember new mistake...
ha same here my friend.
All we can do is wait. when was ur exam
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  #11  
Old 11-28-2015
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Quote:
Originally Posted by Durisetister View Post
ha same here my friend.
All we can do is wait. when was ur exam
no but your mistakes are not that major as mine... my exam was on 3oth oct... anybody had exam on same date at LA???
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