ROS should include a mininum of ___ symptom in ___ systems
1 symptom in 2 systems
What goes under assessment?
- Restate CC with at least 3 DDx.
- Global assessment
- Second assessment in this order of preference: PMHx > SD not related to CC > Social history problem (smoker, etOh) > familty hx of ________
- Third assessment in that same order
- SOB: COPD, asthma, stable angina
- Mild depression
- SD thorax
What goes under plan?
- “Performed ___\__(name of technique)_______ (location)”
- Meds: changes or new meds
- Diagnostics (labs, EKG, radiology)
* Labs today: CMP, CBC, etc
* EKG today
- Diagnostics (labs, EKG, radiology)
- Self-care instruction (stop smoking, no weight breaing)
- Follow up and time frame
do we list EVERTHING we did for PE?
YES, no matter the outcome
OSE is an _____ finding. What must it include?
Objective
3/4 TART findings
Subtle glides and functional joint motions are ________ same as orthopedic assessment
NOT the same
How to document SD of the thorax in assessment?
SD thorax
How do I know if a case of a OMT case or not?
OMT is a medical procedure and should be offred everyt itme
How do you orally present patient?
Does it have to be in chonological order? Does it have to ofllow SOAP note format?
Make it brief (5 minutes) and give enough info to tell audience how you came to conclusion.
Yes and yes
when orally presenting the patient, what info must you include?
- historal events that led pt to make apt
- Risk factors, underlying medical conditions that may affect Dx.
- Assessment and plan
When presenting the patient, how in detail should you be for PMH/PSH and SH/FH?
PMH/PSH: only if important to reason for visit
SH/FH: if relavant to diagnosis
When presenting patient, what should you always include in PE?
- VS, general description, CV, lungs
- Findings that support your 1st differential (working dx or primary dx)
when documenting a R elbow pain findings, what do we always include?
1. Bilateral
2. grading scales
3. Inspection
4. Palpation
5. Vascular and neuro assessment
In assessment, when we have a SD we name the ____
region
FH MI
goes where?
assessment
what goes under “assessment #2 and #3”
anything that we have ID’d is new to the patient ORRRR problem or risk factors that are important to the long-term care of the patient
SD lumbar
FH MI
when offering OMT, it is important to do what?
introduce yourself as a student
when presenting the patient, should we go in great detail?
no; only talk about pertinent positives and pertinent negatives
can you use notecards for presenting the pt
only for reminders of factual data
entire presentation should be focused on what?
providing evidence
pros and cons
for your deficnition of the problem
