Doc_to_be
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Hey guys,
I have a Qn: let's say, the SP has a history of chronoc obstructive bronchitis... When you auscultate him, you hear only normal bronchial sounds and no crackles, wheezes, because SP can't imitate them, SO:
DO WE SAY ON THE PN THAT THE PATIENT HAS THEM NOT? YOU CAN'T DESCRIBE A POSITIVE SIGN IF IT IS NOT SIMULATED, BUT YOU HAVE TO CONFIRM YOUR HISTORY AND MAKE A RATIONALE FOR THE DD AND W/U
Please help, exam is in a week...
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| Doc750
transfer:step 3 prison
Topics: 52
Posts: 634
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In real life if you were on the wards, and had a known chronic obstructive bronchitis patient, that you auscultated and heard clear breath sounds, would you then write positive signs on your patient note?
no you wouldn't (I hope). So then why do it on the exam? Just write the down the findings you obtained, and don't make stuff up.
g'luck
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Experience is a hard teacher because she gives the test first, and the lesson afterwards.
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| xthine
Forum Senior
Topics: 3
Posts: 202
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^ I agree. If you do not note anything abnormal in the physical exam, then that's what you write in your patient note. Just write what you see/hear.
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'No one can avoid defeat. That is why it is better to lose a few battles in the fight for your dreams than to be defeated without even knowing why you are fighting' - PC
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| damselMD
Forum Senior
Topics: 8
Posts: 169
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exactly... they might try and mimic pain, so note that, otherwise, normal lung exam... and if you hear something, the SP might be trying to make a positive finding, so note that too...
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| wolverine9
Forum Senior
Topics: 14
Posts: 187
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Just write what you hear and observe...definitely don't make up stuff on your Patient Notes...
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