I have done a lot of the things the same since I have begun my family rotation, so I guess it's time to document some of them.
My goal of this week is to make my SOAP notes more detailed, concise, and linear. That almost sounds like opposing objectives, doesn't it? In a nutshell, this is what a SOAP note is:
S: Subjective -- why the patient is there, what they're feeling, how long, and anything that could impact their current condition.
O: Objective -- what you, the examining physician/student find. Every doctor likes this done differently, which can be a bit frustrating.
A: Assessment: The diagnoses
P: Plan -- what is going to be done about A.
Filling these things out can either be easy--in many cases the patient will give you so much impertinent information you have to start figuring out what is and is not relevant--or maddeningly difficult. SOAP notes for patients coming in requesting refills for medications they have been on for years are more an exercise of necessity than usefulness, and are usually quite short.
Complicating the matter slightly is the fact that at the current clinic about 1/3 of the patients are Spanish speakers. While it works in their favor that I understand much more Spanish than I am currently capable of speaking back, it takes an extra minute or so because I cannot write as they are speaking. However, those are often some of my better notes because I have to get their full story before I even think about writing. Invariably, I get about 75-80% of the story because either I didn't quite understand one thing they were saying, and/or they were holding out on me and waited to save the full story for the REAL doctor, not the tall güero in the white coat who speaks really muddled Spanish. The Spanish-speaking nurses have given my Spanish a good mark in that it "isn't güero Spanish, it's pretty good," I do not have a definitive type of Spanish. The neighborhood my clinic is in has a great deal of Mexicans in it. Until now I have almost zero exposure to Mexican Spanish other than music. My Spanish teacher in high school was a Costa Rican who forever left me with a bad taste of the "ll" as a "y" pronunciation. I traveled to Costa Rica. When I lived on the island I was in Puerto Rico at least a dozen times. I lived in Miami, surrounded by Cubans, more Borricuas, Ecuadorians, Venezuelans, and Colombians -- and very few Mexicans. Not too long ago I traveled to Argentina, and found that their pronunciation of the "ll" (like "shuh") rolls of my tongue the easiest of all the "ll" pronunciations--and there are quite a few--so I tend to use that one. So, having said all of that I must sound like a Spanish mutt to a native speaker.
After three ever-improving attempts, today I nailed (wow, um, ok, perhaps a less-than-appropriate term) a pelvic exam. I found the cervix on the first try with the speculum, and the patient didn't scream in pain -- obviously I did something right!! (It should be noted that during none of my executions of a pelvic exam has the patient screamed...) Side note: anyone who ever makes jokes about gynecologists getting their kicks from doing pelvic exams has obviously never seen someone in a white room, draped in an oh-so-sexy gown fashioned from the latest and most luxurious brand of paper, with her feet in stirrups. There cannot be anything sexy about that in my mind, and if you do, then you probably have a few other creepy fantasies I'd rather not know about. So to those of you who make those jokes...those of us in the know think you're either an idiot, or a pervert. It's a vagina. Women have them, they serve more non-sexual functions than sexual, and most women aren't really keen on you seeing it, much less touching it. Grow up and stop being so creepy.
So here would be the appropriate place, I presume, to post some of the more interesting things (I think) I've seen and learned:
A liver that could be palpated almost at the left hip
TMP/SMX is an alternative to azithromycin for sinusitis
Mexicans think pinworms cause tooth grinding
Saw a patient that had had a left lung removed -- yet there were still breath sounds
Hip click in a newborn
Clonidine and concerta for ADHD
A patient with vitiligo...everywhere
Mycobacterium avia intracelulare
Observation of injection in the tympanic membrane and tonsils
Tonsiliths -- and I watched them being removed. Basically it involves taking a cotton swab and poking it into the tonsil just so...it's gag-inducing just to watch
The fact that one cannot be allergic to iodine, only it's biochemical ligand
A patient with a removed coccyx
Diagnosed a patient as carrying the HLA-B27 gene for ankylosing spondilytis (this one I must pat myself on the back for, as I suggested the doctor look for it!!!!)