Week one Part two

At first, I liked the idea of being on my own finally when I see patients. Of course, as soon as I got to the ER, I realized, what/where do I write my SOAP note on? I later learned, it goes on a progress note sheet.

I entered the room and introduced myself as "student doctor Jennfer". I interviewed the patient and was surprised at how receptive they were, even though I was just a student. I later learned that patients actually see me as a doctor and assume that as well. kinda scary since I'm new at this. btw, I failed to mention to the patient that he's my very first real patient. :P well, after a thorough interview and a semi-decent physical exam, I went to an empty counter to write a SOAP note. Then I suddenly remembered a few more questions to ask the patient. So I went back in the room, and asked more questions. I only did this about 3-4 times. :)
After completing my SOAP note, I looked at it, noticing how disorganized and crappy it looked squeezing in additional info on the side. Oh well, I figured I'd do a better job on the second one.

Tuesday - Saturday, I managed to get to morning report as early as 6:59 and 30 sec. I've learned a few things and started to improve on my interviewing skills. Presenting cases is still something I need to work on. Let's see, some obvious interview questions I failed to ask a patient.
1. after reviewing labs of extremely high BUN & creat, I forgot to ask the patient, " have you pee'd lately?" (it turns out that the patient hasn't urinated for the last 3 weeks!)
2. after reviewing labs of anemia in a female patient, I forgot to ask "do you have heavy periods?"
3. after asking a patient, "do you smoke/drink alcohol/do drugs?" The response was a no. Then after looking the patient's toxicology report + for marijuana, the resident told me that some cultures don't consider marijuana to be a drug.
4. After asking a patient "do you smoke cigarettes?" The patient replied "no." But later learned that she didn't "currently" smoke, but did in the past. (she has COPD, which makes more since now that I know she had a Hx of smoking).