COMLEX PE: Do you have to list treatment?

[toothless rufus]

CS doesn't have it. Just wondering if you are required to list drugs, and tell patients you want to give them drugs for PE. Like in OM, pharyngitis, HTN, etc. Thanks. Anybody NOT list/tell drugs and pass? The instructions regarding this are a little vague on the NBOME website.

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[peppy]

You're not supposed to come up with THE diagnosis. Just a differential.

 

[LeemerDO]

You need the first five of the problem list generated from the interview. Then afterwards, you can list not only treatment but additional diagnostic evaluations. Of course don't think too hard about this. Most of the problems are pretty straightforward and by no means complex.

Oh, and keep your OMM demonstrations simple. The more your hands are concealed, or the least amount of movement, the better.

 

[CTR]

Oh, and keep your OMM demonstrations simple. The more your hands are concealed, or the least amount of movement, the better.

Interesting thought... do you speak from experience?

 

[LeemerDO]

Interesting thought... do you speak from experience?

EXTENSIVE experience. And the ~$4000 hole in my pocket serves as witness.

 

[DD214_DOC]

Interesting thought... do you speak from experience?

I second this. Keep your OMT techniques SIMPLE. Verbalize what you're doing but try not to give them too much to evaluate. Stick to simple muscle energy/soft tissue stuff. I basically used paraspinal inhibition on everyone, and whatever that sinus thing is called.

As for the OP, you only need to generate a DDx and what additional labs/rads you would want to further help in the evaluation. I don't think specific treatments are necessary.

I remember I only came up with a ddx of two things for one patient. I still passed on my first try.

PE is more about how you interact with patients and how well you can interview to obtain information. Watch the demonstration video they have and do EVERYTHING they do, including the greeting, introduction, hand washing, and order of aforementioned. The cases provided can give you a pretty broad DDx (Abd pain, HA, Chest pain, SOB, etc), so as long as you have been paying attention the last year or so you shouldn't have to worry too much about it.

Also, you don't need to do OMT on every patient. There are specific, "OMT cases" and you will obviously know which ones these are, as the patients will mention something about OMT.

 

[CTR]

Thanks LeemerDO and HooahDOc for the tips regarding OMT techniques!

One thing I have been wondering about lately is proper examination technique for this test.

Patient modesty is heavily stressed, but I also understand that auscultating through clothing is discouraged. What is a good way to properly auscultate a woman's heart stethoscope-on-skin while preserving modesty? (Mainly I'd like to know how to do this while listening at the mitral region.)

Also, is it necessary to do everything (inspection, palpation, percussion, and auscultation) when examining a patient? For instance, if a patient complains of palpitations, do I need to inspect the chest (and state that I'm doing so), palpate the chest feeling for the PMI and any irregularities, percuss around the heart to determine its borders, and finally auscultate? Again, some of this seems like it might be challenging with a female patient. Or... would it be considered good enough if I simply listened to the heart at the A, P, T, M regions?

 

[DD214_DOC]

Thanks LeemerDO and HooahDOc for the tips regarding OMT techniques!

One thing I have been wondering about lately is proper examination technique for this test.

Patient modesty is heavily stressed, but I also understand that auscultating through clothing is discouraged. What is a good way to properly auscultate a woman's heart stethoscope-on-skin while preserving modesty? (Mainly I'd like to know how to do this while listening at the mitral region.)

Also, is it necessary to do everything (inspection, palpation, percussion, and auscultation) when examining a patient? For instance, if a patient complains of palpitations, do I need to inspect the chest (and state that I'm doing so), palpate the chest feeling for the PMI and any irregularities, percuss around the heart to determine its borders, and finally auscultate? Again, some of this seems like it might be challenging with a female patient. Or... would it be considered good enough if I simply listened to the heart at the A, P, T, M regions?

I don't remember ever listening at all of the cardiac points, but it has been awhile since I took the test.

I don't really remember having to do EVERYTHING like you did during your MS1 SP encounters (remember how silly you were back then?) A focused exam should suffice. You should have a short DDx based simply on the chief complaint which should guide your history and exam. You're going to do a much more detailed cardiac exam for a cardiac chief complaint than for a MSK complaint. However, you should still do the basics for ALL patients (Pulm, CV, GI)

To auscultate on a female, simply ask if you may untie the back of the gown (don't forget to ask!) and slip the bell of the stethoscope down the front from the top of the gown or from the LT side of the back for the mitral point. Be sure you ALWAYS ASK PERMISSION BEFORE DOING ANYTHING TO A PATIENT or at least inform them of what you are about to do.

I've never even heard of percussing the borders of the heart, so I can't help you there.

If you get the JAOA, this month there is an article about time per encounter vs performance outcomes for the PE exam. The study isn't very useful, but in the discussion portion they give quite a bit of information regarding how the exam is graded. It might be useful to read through it to get a better idea of what they will be looking for.

The PE is stupid but something we all have to do and is completely unrelated to how we actually practice on a day to day basis.

 

[CTR]

How much of the objective findings are supposed to be truly obtained from examining the patients? For example, imagine they give you a case of someone with a sore throat and the correct diagnosis is supposed to be strep pharyngitis... but the standardized patient doesn't actually have tonsillar exudates, tender cervical lymphadenopathy, or a fever (because they are just pretending to be sick). By examining a healthy person complaining of a sore throat, I would probably be more likely to diagnose them with a viral infection based on the physical findings. My SOAP note would also lack any objective evidence supporting a strep throat, and the assessment and plan will likewise be affected by what I can see on the patient. Anyone know how this works on the exam? Do they just expect you to rely on what you actually see on the patient, or will they give you findings that you are "supposed" to see when you perform that part of the physical?

 

[DD214_DOC]

How much of the objective findings are supposed to be truly obtained from examining the patients? For example, imagine they give you a case of someone with a sore throat and the correct diagnosis is supposed to be strep pharyngitis... but the standardized patient doesn't actually have tonsillar exudates, tender cervical lymphadenopathy, or a fever (because they are just pretending to be sick). By examining a healthy person complaining of a sore throat, I would probably be more likely to diagnose them with a viral infection based on the physical findings. My SOAP note would also lack any objective evidence supporting a strep throat, and the assessment and plan will likewise be affected by what I can see on the patient. Anyone know how this works on the exam? Do they just expect you to rely on what you actually see on the patient, or will they give you findings that you are "supposed" to see when you perform that part of the physical?

objective is just that, objective. Document what you see.

 

[nlax30]

Again, it's not about making the diagnosis so just document what you see for objective findings, NOT what would fit for whatever diagnosis you're entertaining. If you don't hear wheezing then you don't hear wheezing. They want to see that you can interact well with the patients, do a focused history and physical, can come up with a reasonable differential and plan, and accurately (and truthfully) present this info in a note.

As far as specific treatments, you don't have be list ou specific meds. For a bacterial infection I just put something like start Antibiotics or MAYBE a specific antibiotic it it was cut and dry, but not needed. For something HTN meds I'd think saying to the effect of starting a thiazide or ACEi would suffice.

Also agree with keeping OMT simple. I went into knowing I was just going to do muscle energy so I reviewed those techniques.

Verbalized what you are doing so the patient and the reviewers watching the tape know what you are doing. Probably not something you do typical on the wards so just be aware of it and practice beforehand if needed.

Thanks for the heads up on that JAOA article, will have to take a look.

I really didn't do any prep beyond reviewing some OMT and the OSCE review our school did at the end of 3rd year. Just found out yesterday I passed (1st try) so it's certainly not something to majorly stress over if you've been doing well in a clinical setting thus far.

The only part I was concerned about was having enough time to complete the exam and note. I was getting a little concerned during the test because I was consistently one of the first to come out of the exam room, at times with several minutes to spare, and this finished my note pretty early. Was getting worried that I was breeding through the exam but I guess that wasn't an issue. I had plenty of time to do a focused history and physical, give the patient a good wrap-up of what the next steps were and then write a note.

 

[CTR]

For those who have taken the test, did you repeat any abnormal vital signs? Is it worth repeating, for example, a blood pressure if the initial reading was high? Or would it be safe just to document in the plan to repeat blood pressure?

Right now I'm reading a book that suggests retaking any vital signs that are abnormal, but the NBOME website says to accept the recorded findings as accurate (although they also say you can retake certain vitals if doing so is indicated).

I just wonder if by retaking vital signs I would needlessly open myself up to a possible deduction in my score, if I were to perhaps not measure the blood pressure the right way, for example.

 

[nlax30]

I did not retake any vitals. Even something like a high BP personally I would just discuss it with the patient and maybe on the note mention a recheck somewhere.

I don't know, I read the same thing from the NBOME and couldn't think of an instance where I would recheck a vital so I didn't worry about it. I guess if I came across a BP that was just obnoxiously high or low I MIGHT but that's not really the purpose of this exam.

 

[tbone0705]

My sources tell me that if you have time, you should explain to the patient tests to be run and the possible diagnoses. Keep in mind that you are writing a SOAP note so you list the treatment in the Plan portion

 

[nlax30]

My sources tell me that if you have time, you should explain to the patient tests to be run and the possible diagnoses. Keep in mind that you are writing a SOAP note so you list the treatment in the Plan portion

You should do whatever you can to leave a little time at the end for a wrap-up with the patient. If you have to cut something else out so you can spend 30 seconds explaining to the patient what the next steps are then do it, it's an important step.

 

[Jello Logic]

Quick question.

When obtaining a ros, you only review the sys. pertinent to the cc right?
Also did you document the pertinent neg. and pos. in the HPI, or did you list
ROS under HPI?

 

[nlax30]

Quick question.

When obtaining a ros, you only review the sys. pertinent to the cc right?
Also did you document the pertinent neg. and pos. in the HPI, or did you list
ROS under HPI?

Yeah, I think I pretty much just did a pertinent ROS related to the cc.

I'm trying to to remember if I put it under HPI or just listed a separate ROS. Honestly I may have done a little of both. Both obvious related positives/negatives that are part of the cc I usually part some of those in the HPI out of habit. And then other less related items I'll just put in a separate ROS.

I think you're fine either way you decide to do it. Little practical issues such as that are not really what they're testing anyway.

 

[newbie04]

Question regarding the cardiac exam, specifically 30 degree examination...how is this possible since all of the exam tables are completely flat (only move up and down, do not tilt) at the Conshohocken testing center?

Thanks.

 

[voidlogin]

To the OP: you don't need to list medications but you can. In USMLE CS you can list only next diagnostic steps, such as echo, ekg. But in COMLEX PE you can list medications (just write antibiotics but not specific ones like vanco). Personally I would only list medications for things like UTI, cough but not for MI. Generally when I could not come up with 5 tests to do, i would list meds, and write omm treatment.