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  #1  
Old 06-23-2012
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Hammer and Otoscope Physical Exam Findings in the New Patient Note

Hi all:

Let's say if today there is a pre-employment case with cough (like FA case 41). In the PE, the patient has clear bilateral breath sounds, no rhonchi, rales, or wheezing; tactile fremitus normal.

Then in our DDx PE findings, what can we write down?

Thank you!
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Old 06-24-2012
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You can write :
Lungs- CTA&P/BL(Clear To Auscultation & Percussion Bilaterally)
This Format saves you time or you can write.
Lungs-Normal Breath sounds, No rhonci wheeze or rales, Tactile Fremitus WNL.
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Old 06-24-2012
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Default can we put down normal healthy findings to support our diagnosis?

Thank you for your reply:

but i mean the PE findings in the NEW patient note

Can we still write CTA&P/BL when we want to say he has COPD/ chronic bronchitis? In short, can we put down the healthy findings under the column of PE findings in every differential diagnosis?
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Old 06-24-2012
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The New Patient Note
http://www.usmle.org/pdfs/practice-m...tient-note.pdf does not only mention the physical findings, it also mention history findings, so your patient has cough, and you can leave the physical findings blank.

Also, in the pre-employment cases, you won't be filling the regular patient note, you will be given a form by the SP and you have to fill that specific form only, you won't be typing a Patient Note.

In other regular cases, the SP would definitely emulate for you something such as harsh breathing or wheeze if he/she wants to tell you about pulmonary pathology.

-
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  #5  
Old 06-25-2012
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Quote:
Originally Posted by Sabio View Post
The New Patient Note
http://www.usmle.org/pdfs/practice-m...tient-note.pdf does not only mention the physical findings, it also mention history findings, so your patient has cough, and you can leave the physical findings blank.

Also, in the pre-employment cases, you won't be filling the regular patient note, you will be given a form by the SP and you have to fill that specific form only, you won't be typing a Patient Note.

In other regular cases, the SP would definitely emulate for you something such as harsh breathing or wheeze if he/she wants to tell you about pulmonary pathology.

-

Thank you for your reply Sabio:

But let us say today it is not pre-employment case and it is regular cough case and we hear the SP has clear breath sounds bilaterally, however, we still suspect he/she has COPD just based on the history he has given me.

so under the physical exam findings in each differential dignosis, can we still write down clear bilateral breath sounds even though we want to say the SP has COPD???
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Old 06-26-2012
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hi,i think we need to mention only the postive physical exam findings that would support that particular DD we have chosen....

But we can write whatever physical findings we are getting (both normal and abnormal) in the above box meant for documenting Physical Examination.
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Old 06-26-2012
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if the patient is blwoing from his mouth when i am listening to his chest .. what does it mean?
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Old 06-27-2012
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Quote:
Originally Posted by heman466s View Post
if the patient is blwoing from his mouth when i am listening to his chest .. what does it mean?
it means COPD : )
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Old 06-27-2012
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Quote:
Originally Posted by chienpolska View Post
it means COPD : )
ya..i too think so..can be what they call 'pursed lip breathing' as in emphysema
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Old 11-17-2012
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I was also confused about this issue for the new patient note, because many of the physical exam findings would be difficult to fake in order to support the most likely diagnoses. I just finished my CS exam, and unfortunately, I still do not have the answer to this question. If the SPs were faking coarse breath sounds or decreased breath sounds, I did not pick up on it. The only supporting physical exam findings I was able to use was often vitals, tenderness/pain with certain maneuvers, or decreased sensation. Most of my supporting exam findings were left blank, although I do not know if this is correct. Will someone who already passed CS this year comment on what they did?
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