Serious Q...............Please answer.. - nflores02cu

[ArchivalUser]

in the encounter with the SP with Pneumonia for example......
U are going to do physical exam and of course u won't find nothing because the SP is in real life health...no??
and then my question is...........In the PN I will write in the physical exam resp like normal or i need to put something like rubs or crackles to give strong my diagnostic for pneumonia????

[ArchivalUser]

Hi doc..well I do understand your concern...well when u hv a case of pneumonia...say right-sided..he will say he has right-sided chest pain...he will act as though he has less movement on d right side ...when u auscultate...and will make added sound when u listen to him and on percussion...REMEMBER he is only an actor...just write wt he acts...

[ArchivalUser]

...I understand , but is difficult to recognized what the sp try to imitate.........Is more easy write something in the patient note that with complete diagnostic????/