COMLEX PE Humanism Points?

[Epilepsy365]

Below is my typical SP dialogue. Please provide me feedbacks for any possible humanism mishaps for me and future readers. Thank you!

Doc: Knock the door (come in said the pt), biggest happiest smile, walk in, snatch ½ sanitizer, said, “Good morning, Mr. ___/ Ms. _____. It’s a beautiful day today! Did you have any trouble getting in? Well, thank you for your patience and waiting. Please let me know if you see anything to improve. I want my pts to feel like KING or QUEEN in my office. My name is Student Doctor ____ and I will be taking care of you today. Nice to meet you (shake hands). Mr. ____, what’s your preferred name? Ok, Preferred Name, how can we help you?
Pt: Well, I have been having ______ (my gosh, I’m very sorry that this is happening to you. That’s not fun at all!)
Doc: Please tell me more about _____. (Direct the pt to cover onset, duration, getting better/worse/stay the same, if worse or better make sure to ask how so, has this happened before, if so get diagnosis and treatment from before, trigger, anything that makes it better, anything that makes it worse, is there any pain, if pain, get quality/location/radiation/pain scale (if pt talks about pain scale of 7-8/10, “That’s terrible. I’m very sorry that this is happening to you. Well, let’s get this pain resolved quickly so that you could be yourself again)
Doc: How are these symptoms affecting your activities of daily living? (lean forward… nod… “I’m sorry. That’s terrible.) How are you feeling right now? (lean forward… legitimize their concern… touch their hands… reassure them and offer some resources for help) Will also address any social interaction or financial concerns and offer resources for help.

Doc: Well. I think I have a good idea of what’s bothering you, but please be patient with me while I’m asking these other Qs in order to do a thorough job

For gen, fever? Nausea? Vomiting? Headache? Vision change? Fatigue? Heat/cold intolerance? Wt changes?
For heart, chest pain? Funny heart beat?
For lung, difficulty breathing? Cough?
Pick one GI or GU. For GI, abd pain? Any abnormality with bowel? For GU, any abnormality with urine (blood, burning)?
Optional: Neuro – numbness? Tingling?; Msk – muscle weakness? Restricted ROM?

For any (+) ROS, make sure to prompt “Tell me more about that”

Doc: Thank you for giving me such a thorough history so far. We will be moving to other parts of your medical history
Meds: Tell me about the current meds that you’re currently taking
Allergies: Tell me about any allergies (if it’s an allergy to drug, “That must have been a frightful experience. You’re very brave for telling me this; if it’s an allergy to a food, “I’m very sorry about that. It’s hard to be limited to food options. My son has food allergies and it’s always a challenge the eat the right food while still enjoying the taste of certain dishes”
PSH: Tell me about any surgery that you have had. Any hospitalization?
PMH: Tell me about any medical conditions that you have been diagnosed with
Family Hx: Tell me the health of your family members. How are they doing? “I am sorry for the death of XXX. It’s hard” If it’s a young family member dealing with a health issue, “ask about how the family is coping with it.” (not likely on this exam)
Social Hx: Tell me about your lifestyle choices with regards to EtOH, drug, and smoking. How is your diet? Any exercise? “For these lifestyle choices, always congratulate them and encourage them if they’re doing good.” Tell me what do you do for a living? “WOW, that’s a cool gig” How are you enjoying your work? Tell me about your living situation at home? Any stress? What hobbies do you do for fun? “Make sure to connect the hobby to something you do or cool”
For a young female, always ask for LMP and whether it’s normal flow and duration

Doc: Thank you for being cooperative and giving me a thorough history. Do you have any questions for me right now? Is it ok to move to the physical exam? (grab hand sanitizer by stepping back with face and body facing the pt)

PE:
For heart, “Can you PLEASE lower your gown? I will be listening to your heart. I’m sorry that my stethoscope is a little cold.”
For lung, “I will be listening to your lung now. PLEASE breath in and out when I put my stethoscope on your skin.”
Focused exam: Explain to the pt the steps and possible discomforts. Let them know to stop you if there’s any discomfort or pain. Always check if the patient is comfortable as you move through each PE step. Make sure to help with positional changes. Make sure to have proper draping technique.

Closing:
“What do you think is going on?” Address any concern and provide reassurance. Discuss top ddx and pathophys. Will run these tests, and images to r/o other concerns. “How do you think we should best treat you?” Provide meds/ referral or OMT if prompted. Give up a f/u date. “Preferred name, what do you think of this plan? Can you repeat the plan for me?” “Do you have any question for me”? “Well, thank you for coming in and allowing me to be part of your healthcare team. We have a strong team, and we will do our best to get you back to normal.” SHAKE HANDS and get some hand sanitizer

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[BorntobeDO?]

Comments in red. I think you failed for touching hands without permission, as well as too many apologies. Also you present the plan to early. Basically your probably over the top too much.

Below is my typical SP dialogue. Please provide me feedbacks for any possible humanism mishaps for me and future readers. Thank you!

Doc: Knock the door (come in said the pt), biggest happiest smile, walk in, snatch ½ sanitizer, said, “Good morning, Mr. ___/ Ms. _____. It’s a beautiful day today! Did you have any trouble getting in? Well, thank you for your patience and waiting. Please let me know if you see anything to improve. I want my pts to feel like KING or QUEEN in my office. Too much. Replace with a 'How are you doing today?'

My name is Student Doctor ____ and I will be taking care of you today. Nice to meet you (shake hands). Mr. ____, what’s your preferred name? Ok, Preferred Name, how can we help you?
Pt: Well, I have been having ______ (my gosh, I’m very sorry that this is happening to you. That’s not fun at all!) Good
Doc: Please tell me more about _____. (Direct the pt to cover onset, duration, getting better/worse/stay the same, if worse or better make sure to ask how so, has this happened before, if so get diagnosis and treatment from before, trigger, anything that makes it better, anything that makes it worse, is there any pain, if pain, get quality/location/radiation/pain scale (if pt talks about pain scale of 7-8/10, “That’s terrible. I’m very sorry that this is happening to you. Well, let’s get this pain resolved quickly so that you could be yourself again) Good
Doc: How are these symptoms affecting your activities of daily living? (lean forward… nod… “I’m sorry. That’s terrible.) I agree with mirroring leaning in and expressing interest. Just use stuff more like 'uh huh' and head nodding, don't distract by putting too many comments.

How are you feeling right now? (lean forward… legitimize their concern… touch their hands… nOOOOOOOO NOOOOOOOO NOOOOOOOOOO! No touching the hands other than shaking them without permission. Only other touch should be physical exam and you should ask permission to do it.

reassure them and offer some resources for help) Will also address any social interaction or financial concerns and offer resources for help. - Save all this for when your subjective and ROS is complete at least. You are jumping ahead, better to wait till end or at least till after ROS. You need to make sure you know the problem before you offer solutions. I am wondering if you can even complete the cases with so much fluff.

Doc: Well. I think I have a good idea of what’s bothering you, but please be patient with me while I’m asking these other Qs in order to do a thorough job - Don't even go down the 'I have an idea' till ROS is done and you are summarizing the complaint.

For gen, fever? Nausea? Vomiting? Headache? Vision change? Fatigue? Heat/cold intolerance? Wt changes?
For heart, chest pain? Funny heart beat?
For lung, difficulty breathing? Cough?
Pick one GI or GU. For GI, abd pain? Any abnormality with bowel? For GU, any abnormality with urine (blood, burning)?
Optional: Neuro – numbness? Tingling?; Msk – muscle weakness? Restricted ROM?

For any (+) ROS, make sure to prompt “Tell me more about that”
Add 'anything else that I didn't ask you about that you would like to tell me?'

Doc: Thank you for giving me such a thorough history so far. We will be moving to other parts of your medical history - Shorten this transition, thanks is probably unnecessary.
Meds: Tell me about the current meds that you’re currently taking
Allergies: Tell me about any allergies (if it’s an allergy to drug, “That must have been a frightful experience. You’re very brave for telling me this; if it’s an allergy to a food, “I’m very sorry about that. It’s hard to be limited to food options. My son has food allergies and it’s always a challenge the eat the right food while still enjoying the taste of certain dishes” - Comments are too long, keep it short, you don't have time for this.
PSH: Tell me about any surgery that you have had. Any hospitalization?
PMH: Tell me about any medical conditions that you have been diagnosed with
Family Hx: Tell me the health of your family members. How are they doing? “I am sorry for the death of XXX. It’s hard” If it’s a young family member dealing with a health issue, “ask about how the family is coping with it.” (not likely on this exam) Too long, unnecessary, don't project feelings on them by saying 'its hard.' Just give them a 'I'm sorry to hear that', if its recent or unusual.
Social Hx: Tell me about your lifestyle choices with regards to EtOH, drug, and smoking. How is your diet? Any exercise? “For these lifestyle choices, always congratulate them and encourage them if they’re doing good.” Tell me what do you do for a living? “WOW, that’s a cool gig” How are you enjoying your work? Tell me about your living situation at home? Any stress? What hobbies do you do for fun? “Make sure to connect the hobby to something you do or cool” Timewise this is too much, borderline inappropriate for a medical exam.
For a young female, always ask for LMP and whether it’s normal flow and duration

Doc: Thank you for being cooperative and giving me a thorough history. Do you have any questions for me right now? Now is where you summarize what you think it might be. Talk about the physical exam you are planning to do, and ask permission to touch.
Is it ok to move to the physical exam? (grab hand sanitizer by stepping back with face and body facing the pt) - feel free to turn around and get sanitizer, just tell the patient what you are doing. Don't be weird and maintain intense eye contact. Normal is 50/50.

PE:
For heart, “Can you PLEASE lower your gown? I will be listening to your heart. I’m sorry that my stethoscope is maybe a little cold.” You apologize way too much, your destroying my confidence through the internet.
For lung, “I will be listening to your lung now. PLEASE breath in and out when I put my stethoscope on your skin.”
Focused exam: Explain to the pt the steps and possible discomforts. Let them know to stop you if there’s any discomfort or pain. Always check if the patient is comfortable as you move through each PE step. You don't need to repeat that each step. Make sure to help with positional changes. Make sure to have proper draping technique. - For some reason after the rest of this post I am worried about what you mean by 'proper' draping technique. Just protect their modesty, don't go overboard.

Closing:
“What do you think is going on?” - What you are doing this at the end? This should have been in the very beginning if your gonna ask it.

Give your plan, tell followup. On the PE everyone gets a followup. Address any concern and provide reassurance. Discuss top ddx and pathophys. Will run these tests, and images to r/o other concerns. “How do you think we should best treat you?” Provide meds/ referral or OMT if prompted. Give up a f/u date. “Preferred name, what do you think of this plan? Can you repeat the plan for me?” Too much time wasted for repeats. “Do you have any question for me”? “Well, thank you for coming in and allowing me to be part of your healthcare team. We have a strong team, and we will do our best to get you back to normal.” Your chik fila replace that phrase with 'It was a pleasure speaking to you today' SHAKE HANDS and get some hand sanitizer

 

[Epilepsy365]

Proper draping technique is:

1) Ask the pt to lie down
2) Ask if they need help lying down
3) Put the cloth over their abdomen and LEs for cover and ask them to pull up their gown to get visual of the abdomen. You need to look away while they're doing this
4) Use the cloth and then pull the edges of the cloth over their pants

Few big things that I want to ask:
For positional change help, should I ask them "Do you need any help"? Doing it, even if it's a nice gesture, can be sexual assault. I am debating this issue greatly.

For gown untying occasions for heart and lung, I normally just said, "Please, let me help you untie your gown." Thinking back, I feel that I screw this up also, and I am failing bc of sexual assault offenses. How about them pulling up their gowns after heart and lung? Should I just tell them "I'm done listening to your heart, you can put back your gown now, instead?

Thank you for all the great feedbacks

 

[BorntobeDO?]

Proper draping technique is:

1) Ask the pt to lie down
2) Ask if they need help lying down
3) Put the cloth over their abdomen and LEs for cover and ask them to pull up their gown to get visual of the abdomen. You need to look away while they're doing this
4) Use the cloth and then pull the edges of the cloth over their pants

Few big things that I want to ask:
For positional change help, should I ask them "Do you need any help"? Doing it, even if it's a nice gesture, can be sexual assault. I am debating this issue greatly.

For gown untying occasions for heart and lung, I normally just said, "Please, let me help you untie your gown." Thinking back, I feel that I screw this up also, and I am failing bc of sexual assault offenses. How about them pulling up their gowns after heart and lung? Should I just tell them "I'm done listening to your heart, you can put back your gown now, instead?

Thank you for all the great feedbacks

Yeah you need to say 'do you need help getting up/laying down. Anything else they should be able to do.

 

[Epilepsy365]

Quick question:

For a pt in extreme pain in the ED, is the goal actually trying to get through the HPI and PE as quick as possible, and dismiss some of the fluff to build rapport? Will you lose humanism points especially if the pt is in extreme pain and need medical management asap?

 

[BorntobeDO?]

Quick question:

For a pt in extreme pain in the ED, is the goal actually trying to get through the HPI and PE as quick as possible, and dismiss some of the fluff to build rapport? Will you lose humanism points especially if the pt is in extreme pain and need medical management asap?

Your goal is to get it right quickly. Yes you can lose some of the less relevent social things. But your ROS needs to cover biggest issues like MIs PEs Strokes,etc. Things that cause major damage or death.

 

[Epilepsy365]

So, after my history, I will say the following, "I'm done with your history. Is there anything else that you would like me to know?" Pt will say "No." "Well, I will do my physical exam right now to find out more, ok?" Pt will say "Yes."
Doc: "Ok, can you please lower your gown while I sanitize my hands for your physical exam"

Pt lowers gown and I sanitize my hands

PE
"Looking at your eyes and mouth right now. Not seeing anything"
"I am going to listen to your heart." Auscultate APTM
"Next, I'm going to your lung." Auscultate all six anterior spots.
"Would you mind hold up your arms, so I can listen to the side" Sneak the stethoscope underneath the undergarment and listen to the sides
Let's cover you back up and pull her gown up to cover her anterior body parts
"Now, I am listening to the back as well." Auscultate all six posterior spots

Key question: is there I'm doing that could get me docked with these movements? ESPECIALLY the sneaking the stethoscope to the side to hear lateral lung sounds

Next, "I'm going to examine your abd next. Please lie down."
Doc stays in the vicinity and arm below pt back to help in case pt falls. Doc gets the drape.
"I'm going to pull the drape up and cover you for now. Please pull up your gown exposing your abd" Doc looks away
Doc will say "flat and non distended," "I'm going to listen to your abd now." Doc listens to abd. "I'm going to tap your abd now." Doc taps the 4 quadrants of the abdomen. "I'm going to light palpate your abd, please let me know if there's any discomfort and I will stop." Light palpate 4 quadrants. Make sure to say sorry for any pain elicited. "I will push deep next. Please let me know if there's any discomfort." Deep palpation to elicit pain. "I'm sorry. One more ok?" Deep palpate and release and ask, "which one hurts more deep palpation or upon release?"

Is there anything that I can do better or some traps in my approach? Thank you.

 

[BorntobeDO?]

Red is my additions. I am looking at the West Virginia course and don't see availability, so you will have to make do with kauffmann videos/book. I would suggest you do them. Especially physical exam, you need to do what Kauffman does.

There is also the WolfPacc and SteptoIt course but I am not familiar with them so I can't give them the recommendation and neither appears to be available.

So, after my history, I will say the following, "I'm done with your history. Is there anything else that you would like me to know?" Pt will say "No." "Well, I will do my physical exam right now to find out more, ok?" Pt will say "Yes."
Doc: "Ok, can you please lower your gown while I sanitize my hands for your physical exam"

Pt lowers gown and I sanitize my hands - They shouldn't lower gown till you are standing right there ready to listen.

PE
"Looking at your eyes and mouth right now. Not seeing anything"
"I am going to listen to your heart." Auscultate APTM
"Next, I'm going to your lung." Auscultate all six anterior spots. - I did 4 and only uppers, did 6 on back (2 pairs on front, 3 pairs on back)
"Would you mind hold up your arms, so I can listen to the side" Sneak the stethoscope underneath the undergarment and listen to the sides Nope, have them lift up breast and you listen appropriately. No sliding of stephoscope under bras or underwear.
Let's cover you back up and pull her gown up to cover her anterior body parts
"Now, I am listening to the back as well." Auscultate all six posterior spots

Key question: is there I'm doing that could get me docked with these movements? ESPECIALLY the sneaking the stethoscope to the side to hear lateral lung sounds - The fact that your asking this means you already know its suspect. Cut out suspect exams or modify to make them above board.

Next, "I'm going to examine your abd next. Please lie down."
Doc stays in the vicinity and arm below pt back to help in case pt falls. Doc gets the drape.
"I'm going to pull the drape up and cover you for now. Please pull up your gown exposing your abd" Doc looks away
Doc will say "flat and non distended," "I'm going to listen to your abd now." Doc listens to abd. "I'm going to tap your abd now." Doc taps the 4 quadrants of the abdomen. "I'm going to light palpate your abd, please let me know if there's any discomfort and I will stop." Light palpate 4 quadrants. Make sure to say sorry for any pain elicited. "I will push deep next. Please let me know if there's any discomfort." Deep palpation to elicit pain. "I'm sorry. One more ok?" Deep palpate and release and ask, "which one hurts more deep palpation or upon release?" Too much apology. Otherwise seems good enough.

Is there anything that I can do better or some traps in my approach? Thank you.

 

[Lilyhopeless]

You can just sanitize your hand once when you walked in, I did it and it seems fine for me. I think it would be a nice gesture to untie the gown for them and ask them then to lower the gown for you and offer to retie the gown for them. But please take what I said with caution, I failed it the first time though in Biomedical...

I don't know how you would drape the patient. I always drape them whenever I am going to lay them. In fact, I draped them immediately even before they are laying down because I noticed that, sometimes, if they lied down before I draped them, the gown rode up high on their legs and exposed them more than necessary... I don't know if that is important or not but I just thought that if I were patient, I would not want that!

Also, you mentioned would you still want to do a complete interview if the patient is in pain. I would say yes. There was a case similar to that for me.

Patient: Doctor, please hurry up! I am in pain.
Me: I am so sorry that you feel that way! I promise you that we will get to the bottom of this but please let me get a good history so that I can help you better. However, if there is anything that I can do right now please tell me!

Then I proceeded to ask them all the history (CC, HPI, ROS, PMH, PSH, Med, All, FH, SH). I just don't do a complete SH that is all. Only ask them about EtOH, drug and tobacco. If any is positive, I will just say: "This is something we can talk later when you are better if you are interested" Just to show that I know I am not ignoring counselling.

Then I will write in my note that I will get a better history and counsel when patient is better.


For the heart and lung, this is how I did it:

Doc: Alright, if it is alright with you, I would like to do the physical exam now. (I always start with lung even in real life). I am going to check your lung first, okay? Let me help you to untie the gown if that is okay? (they always said yes). Please breath in deeply for me when you feel my stethoscope. (Do 6 listening posts post, I never bothered with lateral since it is rather awkward and I often forget). I am now listening your upper lungs, okay? All sounds good and clear to me. Now, I would like to listen to your heart. Can you please lower your gown for me? (Then I will listen the A and P valves) Now, could you please lower the gown and hold your left breast up for me? (Female obviously, and I just listened like that. You don't have to dig or put it even at the correct location. They won't know! Just mime it. I always thought the side entry or drop down the scope is just so awkward)

As well, for the PMI, I never check on any female even when it is pertinent and the case is heart case. I sacrificed that point since it can be rather awkward to do it with females. I just check the pulses and listen to their carotid.

Also please don't apologize too often, you will make a non-awkward situation sounds awkward. It sounds as if you are doing something when you are not!

I hope this is helpful!

So, after my history, I will say the following, "I'm done with your history. Is there anything else that you would like me to know?" Pt will say "No." "Well, I will do my physical exam right now to find out more, ok?" Pt will say "Yes."
Doc: "Ok, can you please lower your gown while I sanitize my hands for your physical exam"

Pt lowers gown and I sanitize my hands

PE
"Looking at your eyes and mouth right now. Not seeing anything"
"I am going to listen to your heart." Auscultate APTM
"Next, I'm going to your lung." Auscultate all six anterior spots.
"Would you mind hold up your arms, so I can listen to the side" Sneak the stethoscope underneath the undergarment and listen to the sides
Let's cover you back up and pull her gown up to cover her anterior body parts
"Now, I am listening to the back as well." Auscultate all six posterior spots

Key question: is there I'm doing that could get me docked with these movements? ESPECIALLY the sneaking the stethoscope to the side to hear lateral lung sounds

Next, "I'm going to examine your abd next. Please lie down."
Doc stays in the vicinity and arm below pt back to help in case pt falls. Doc gets the drape.
"I'm going to pull the drape up and cover you for now. Please pull up your gown exposing your abd" Doc looks away
Doc will say "flat and non distended," "I'm going to listen to your abd now." Doc listens to abd. "I'm going to tap your abd now." Doc taps the 4 quadrants of the abdomen. "I'm going to light palpate your abd, please let me know if there's any discomfort and I will stop." Light palpate 4 quadrants. Make sure to say sorry for any pain elicited. "I will push deep next. Please let me know if there's any discomfort." Deep palpation to elicit pain. "I'm sorry. One more ok?" Deep palpate and release and ask, "which one hurts more deep palpation or upon release?"

Is there anything that I can do better or some traps in my approach? Thank you.

 

[Lilyhopeless]

Also, a friend of mine who failed in the humanities section but passed on retake once told me that he thinks it is important that you sound confident. If you don't sound confident, you sound incompetent. I am sure in their checklist somewhere, competent is what they were looking for.
Too much apologizing makes us sound like we don't know what we are doing, which is not true at all!

 

[ciestar]

Also, don’t use the words “distended” “palpate” or anything else remotely medical. Keep it as simple as possible.

 

[Epilepsy365]

Just changed lung auscultation from 6 in the back 2 on the sides and 6 in the front to 6 back and 4 front, and literally shaved my SP time from 14 mins to 10 mins. I personally never understand why we were taught and forced to do 6 front, 6 back, and 2 sides at my school.

 

[Lilyhopeless]

Just changed lung auscultation from 6 in the back 2 on the sides and 6 in the front to 6 back and 4 front, and literally shaved my SP time from 14 mins to 10 mins. I personally never understand why we were taught and forced to do 6 front, 6 back, and 2 sides at my school.

I only did 2 in the front (the upper lung, above clavicles). Remember you will also listen to their heart anyway and they are also over the lung. As a male (I am assuming you are), I would try to cut down the contact at the "danger area" (female chest) to lower the risk for awkward touching or exposure.

 

[alprazoslam]

Below is my typical SP dialogue. Please provide me feedbacks for any possible humanism mishaps for me and future readers. Thank you!

Doc: Knock the door (come in said the pt), biggest happiest smile, walk in, snatch ½ sanitizer, said, “Good morning, Mr. ___/ Ms. _____. It’s a beautiful day today! Did you have any trouble getting in? Well, thank you for your patience and waiting. Please let me know if you see anything to improve. I want my pts to feel like KING or QUEEN in my office. My name is Student Doctor ____ and I will be taking care of you today. Nice to meet you (shake hands). Mr. ____, what’s your preferred name? Ok, Preferred Name, how can we help you?
Pt: Well, I have been having ______ (my gosh, I’m very sorry that this is happening to you. That’s not fun at all!)
Doc: Please tell me more about _____. (Direct the pt to cover onset, duration, getting better/worse/stay the same, if worse or better make sure to ask how so, has this happened before, if so get diagnosis and treatment from before, trigger, anything that makes it better, anything that makes it worse, is there any pain, if pain, get quality/location/radiation/pain scale (if pt talks about pain scale of 7-8/10, “That’s terrible. I’m very sorry that this is happening to you. Well, let’s get this pain resolved quickly so that you could be yourself again)
Doc: How are these symptoms affecting your activities of daily living? (lean forward… nod… “I’m sorry. That’s terrible.) How are you feeling right now? (lean forward… legitimize their concern… touch their hands… reassure them and offer some resources for help) Will also address any social interaction or financial concerns and offer resources for help.

Doc: Well. I think I have a good idea of what’s bothering you, but please be patient with me while I’m asking these other Qs in order to do a thorough job

For gen, fever? Nausea? Vomiting? Headache? Vision change? Fatigue? Heat/cold intolerance? Wt changes?
For heart, chest pain? Funny heart beat?
For lung, difficulty breathing? Cough?
Pick one GI or GU. For GI, abd pain? Any abnormality with bowel? For GU, any abnormality with urine (blood, burning)?
Optional: Neuro – numbness? Tingling?; Msk – muscle weakness? Restricted ROM?

For any (+) ROS, make sure to prompt “Tell me more about that”

Doc: Thank you for giving me such a thorough history so far. We will be moving to other parts of your medical history
Meds: Tell me about the current meds that you’re currently taking
Allergies: Tell me about any allergies (if it’s an allergy to drug, “That must have been a frightful experience. You’re very brave for telling me this; if it’s an allergy to a food, “I’m very sorry about that. It’s hard to be limited to food options. My son has food allergies and it’s always a challenge the eat the right food while still enjoying the taste of certain dishes”
PSH: Tell me about any surgery that you have had. Any hospitalization?
PMH: Tell me about any medical conditions that you have been diagnosed with
Family Hx: Tell me the health of your family members. How are they doing? “I am sorry for the death of XXX. It’s hard” If it’s a young family member dealing with a health issue, “ask about how the family is coping with it.” (not likely on this exam)
Social Hx: Tell me about your lifestyle choices with regards to EtOH, drug, and smoking. How is your diet? Any exercise? “For these lifestyle choices, always congratulate them and encourage them if they’re doing good.” Tell me what do you do for a living? “WOW, that’s a cool gig” How are you enjoying your work? Tell me about your living situation at home? Any stress? What hobbies do you do for fun? “Make sure to connect the hobby to something you do or cool”
For a young female, always ask for LMP and whether it’s normal flow and duration

Doc: Thank you for being cooperative and giving me a thorough history. Do you have any questions for me right now? Is it ok to move to the physical exam? (grab hand sanitizer by stepping back with face and body facing the pt)

PE:
For heart, “Can you PLEASE lower your gown? I will be listening to your heart. I’m sorry that my stethoscope is a little cold.”
For lung, “I will be listening to your lung now. PLEASE breath in and out when I put my stethoscope on your skin.”
Focused exam: Explain to the pt the steps and possible discomforts. Let them know to stop you if there’s any discomfort or pain. Always check if the patient is comfortable as you move through each PE step. Make sure to help with positional changes. Make sure to have proper draping technique.

Closing:
“What do you think is going on?” Address any concern and provide reassurance. Discuss top ddx and pathophys. Will run these tests, and images to r/o other concerns. “How do you think we should best treat you?” Provide meds/ referral or OMT if prompted. Give up a f/u date. “Preferred name, what do you think of this plan? Can you repeat the plan for me?” “Do you have any question for me”? “Well, thank you for coming in and allowing me to be part of your healthcare team. We have a strong team, and we will do our best to get you back to normal.” SHAKE HANDS and get some hand sanitizer

I think I threw up in my mouth a little bit reading the first paragraph. Did you fail for being fake as ****? Be more realistic not some clown with a fake smile. And stop apologizing that makes patients feel uncomfortable and makes you look like a fumbling waitress not a physician

 

[fldoctorgirl]

Comments in red. I think you failed for touching hands without permission, as well as too many apologies. Also you present the plan to early. Basically your probably over the top too much.

I once got yelled at by an SP for asking "how are you doing today?" because she said it just opened up the door for her to say terrible, obviously, since she's at the doctor's office.

Also, curious in general about the PE. At my school, they haven't ever spoken to us about or had us say anything about what we think could be going on or what our plan is. We are told to just end with something along the lines of letting them know what's going to happen next, so "I'm going to step out and pass all of this information back to your doctor, and he/she and I will be back in a few minutes with a plan to get you hopefully feeling better" or something like that. Is it expected on the PE that you discuss with the patient what you think the diagnosis is, and what you're thinking the plan will be?

Also, for the OP: as others have said, I think you're doing way too many lung posts for your exam. Our school taught us 2 on the front, 4 on the back. If it's a pulmonary case we are told we can do more on the back if we'd like, but I never do more than 2 on the front as it's awkward and time consuming.

 

[Lilyhopeless]

I once got yelled at by an SP for asking "how are you doing today?" because she said it just opened up the door for her to say terrible, obviously, since she's at the doctor's office.

Also, curious in general about the PE. At my school, they haven't ever spoken to us about or had us say anything about what we think could be going on or what our plan is. We are told to just end with something along the lines of letting them know what's going to happen next, so "I'm going to step out and pass all of this information back to your doctor, and he/she and I will be back in a few minutes with a plan to get you hopefully feeling better" or something like that. Is it expected on the PE that you discuss with the patient what you think the diagnosis is, and what you're thinking the plan will be?

Also, for the OP: as others have said, I think you're doing way too many lung posts for your exam. Our school taught us 2 on the front, 4 on the back. If it's a pulmonary case we are told we can do more on the back if we'd like, but I never do more than 2 on the front as it's awkward and time consuming.

In the PE, you are the attending doctor. So, they want you to debrief patient with the diagnosis, plan, counselling and follow up. You cannot say (or maybe you can but all the review books keep telling us otherwise) that you will bring it to the responsible doctor. You are the responsible attending.

Generally, let's say for a case like MI, I would like to close it like this and assuming this is the ED:

"Based on my examination and history, I am concerned that you may have a problem with your heart and heart attack is a possibility. However, this could be something as simple as reflux too. To be certain, I would like to order a couple of blood tests. I would also like to do an EKG that checks the rhythm of your heart and Chest Xray which is like taking a pic of your heart. When I have more information, I will update you more on what we together can do. Does this plan sound reasonable with you? The patient will say: whatever you think best, Doctor! Alright then, presently do you have any questions or have I addressed all your concerns? If you have played the game right, they should have nothing right now and they will say: No, everything is good. Alright then, whoever, we will talk more later okay? In the meanwhile, if you have any questions, just flag one of the nurses and they will come to get me! "

 

[fldoctorgirl]

In the PE, you are the attending doctor. So, they want you to debrief patient with the diagnosis, plan, counselling and follow up. You cannot say (or maybe you can but all the review books keep telling us otherwise) that you will bring it to the responsible doctor. You are the responsible attending.

Generally, let's say for a case like MI, I would like to close it like this and assuming this is the ED:

"Based on my examination and history, I am concerned that you may have a problem with your heart and heart attack is a possibility. However, this could be something as simple as reflux too. To be certain, I would like to order a couple of blood tests. I would also like to do an EKG that checks the rhythm of your heart and Chest Xray which is like taking a pic of your heart. When I have more information, I will update you more on what we together can do. Does this plan sound reasonable with you? The patient will say: whatever you think best, Doctor! Alright then, presently do you have any questions or have I addressed all your concerns? If you have played the game right, they should have nothing right now and they will say: No, everything is good. Alright then, whoever, we will talk more later okay? In the meanwhile, if you have any questions, just flag one of the nurses and they will come to get me! "

Ah, I see...thank you for this explanation!

 

[BorntobeDO?]

I once got yelled at by an SP for asking "how are you doing today?" because she said it just opened up the door for her to say terrible, obviously, since she's at the doctor's office.

Also, curious in general about the PE. At my school, they haven't ever spoken to us about or had us say anything about what we think could be going on or what our plan is. We are told to just end with something along the lines of letting them know what's going to happen next, so "I'm going to step out and pass all of this information back to your doctor, and he/she and I will be back in a few minutes with a plan to get you hopefully feeling better" or something like that. Is it expected on the PE that you discuss with the patient what you think the diagnosis is, and what you're thinking the plan will be?

Also, for the OP: as others have said, I think you're doing way too many lung posts for your exam. Our school taught us 2 on the front, 4 on the back. If it's a pulmonary case we are told we can do more on the back if we'd like, but I never do more than 2 on the front as it's awkward and time consuming.

They wont yell at you at chicago or philly. They might say really bad doc, in which case you can say I'm sorry tell me about it.

 

[alprazoslam]

They wont yell at you at chicago or philly. They might say really bad doc, in which case you can say I'm sorry tell me about it.

I’m so sorry here’s a box of tissues and some germ x don’t get tears on me you peasant

 

[Lilyhopeless]

I do not know how true that is. I have heard people mentioned that Philly is a tad more difficult than Chicago. Personally, I think this is hearsay. Yet, I have been told by people I know who unfortunately had to take the PE twice that the SPs at Philly is even more wooden than those in Chicago. I don't even know if that is even possible. I happened to do it both times in Chicago for convenient's sake. If it was not possible, I would have done it in Philly myself.

Please do not view this piece of info with any trepidation. Forewarned is forearmed. I just want the OP to know that when doing the exam if the OP feels as if the patients are not responding as well as they should, the OP should not be worried much about it as this may just be the location-quirkiness. Nothing at all about the OP themselves.

I hope other people can possibly say something more about this matter, preferably to debunk this myth.

 

[Mad Jack]

Just reading the OP gave me anxiety, this test is such a godforsaken dumpster fire

 

[Lilyhopeless]

Just reading the OP gave me anxiety, this test is such a godforsaken dumpster fire

You said it correctly! I HATE HATE HATE this exam. The score report that told me I passed has nothing useful at all for me. It told me nothing about my weakness or my strength or anything. I would have appreciated more info about my performance so that I can be conscious of it and try to be a better future doctor. My passing grade can be actually just one point away from failing for all I know.

Really, I want a full inventory and itemized list of where my 1300 was spent on!!!

As well, I just checked the NBOME website for any opened dates in Dec and obviously there are none. No surprised there. However, I was rather shocked to see that most of the dates for Jan are full too! I just checked the calendar as recently as this week Tuesday for an opening date, in case I failed. January then was mostly empty. It can mean either the 3rd year just rushed en masse to register for Jan date exam or that many 4th years just found out they failed and filled up January calendar. I would bet money on the latter!!!

Just thinking about this situation is giving me heartburn!!!

 

[Mad Jack]

You said it correctly! I HATE HATE HATE this exam. The score report that told me I passed has nothing useful at all for me. It told me nothing about my weakness or my strength or anything. I would have appreciated more info about my performance so that I can be conscious of it and try to be a better future doctor. My passing grade can be actually just one point away from failing for all I know.

Really, I want a full inventory and itemized list of where my 1300 was spent on!!!

As well, I just checked the NBOME website for any opened dates in Dec and obviously there are none. No surprised there. However, I was rather shocked to see that most of the dates for Jan are full too! I just checked the calendar as recently as this week Tuesday for an opening date, in case I failed. January then was mostly empty. It can mean either the 3rd year just rushed en masse to register for Jan date exam or that many 4th years just found out they failed and filled up January calendar. I would bet money on the latter!!!

Just thinking about this situation is giving me heartburn!!!

Mine was a mess, the computers broke down and I had to handwrite notes with a pretty significant tendon injury. Somehow passed, but I'm legitimately traumatized. Would have loved some actual feedback myself

 

[sunshinefl]

You said it correctly! I HATE HATE HATE this exam. The score report that told me I passed has nothing useful at all for me. It told me nothing about my weakness or my strength or anything. I would have appreciated more info about my performance so that I can be conscious of it and try to be a better future doctor. My passing grade can be actually just one point away from failing for all I know.

Really, I want a full inventory and itemized list of where my 1300 was spent on!!!

As well, I just checked the NBOME website for any opened dates in Dec and obviously there are none. No surprised there. However, I was rather shocked to see that most of the dates for Jan are full too! I just checked the calendar as recently as this week Tuesday for an opening date, in case I failed. January then was mostly empty. It can mean either the 3rd year just rushed en masse to register for Jan date exam or that many 4th years just found out they failed and filled up January calendar. I would bet money on the latter!!!

Just thinking about this situation is giving me heartburn!!!

Both sites are full until September currently. January has been full for a long time, but a smattering of extra sessions were added, which you apparently happened to catch when you looked. I’m a 3rd year with a January date, and many of my classmates have early dates as well. Our school lets us register for January 1st and later as soon as we pass COMLEX 1.

 

[Epilepsy365]

About this whole asking permission thing. In my OSCEs, I always said stuff like,

"Do you have any questions for me before we start the PE? I'm going to start the physical exam now, ok?"

"I'm looking at your eyes" (with light source) "Everything normal"
"Is it ok for me to unbutton your gown from the back? I'm going to listen to your lung" auscultate 6 back and 4 front
"I'm listening to your heart" auscultate AP "Can you lower your gown and move your breast tissue to the side and up?" auscultate TM
"I'm looking at your stomach. Normal." "I'm going to listen to your stomach." auscultate 4 quadrants. "I'm going to tap your stomach. Tap 4 quadrants. "I'm going to lightly push your stomach. Let me know if you feel any discomfort." Lightly push 4 quadrants of stomach. "I'm going to deeply push your stomach now. Please let me know of any discomfort." Deeply push 4 quadrants of stomach

Neuro exam:
"I'm going to look at your head for any trauma" Look through hairs with fingers
H test
Sensation test. I personally don't ask for permission here. Touch V1, V2, V3 dermatonies and ask "Everything normal and the same?" for each dermatome
"Smile for me. Close your eyes. Don't let me open your eyes. Open your eyes now. How many fingers I'm holding up?" "Turn your head against my hands" "Shrug your shoulders" "Open your mouth. Said ah.... Move your tongue L and R."
Doc: touch arm from top to down "Everything normal and the same?" for each dermatones
"Hold your hands out" Then check A&O Qs here
"Hold your hands out like this" "Push against my me" Check biceps, triceps, arm grips, etc...
Doc put hands on thighs "Push against me" Doc put hands on calves "Push against me" Doc put hands on ankles "step down like you're stepping on the gas pedal. Move your ankles up now."
"I'm going to check your reflex." Tap knee and achilles and babinski
Doc rub inner and outer knee areas and run down for dermatomes "Everything normal and the same?" multiple times

It takes me about 1-2 mins to run through a complete Neuro exam. However, I'm a very bit scared if I'm going this fast and getting auto fail here. If I ask for permission for every maneuver, it's going to take me forever. Please take a look and give me any feedbacks.

Is it automatically assumed that you can TOUCH them besides sensitive body parts (chest area and axillary portions for ladies, and inner and outside upper thighs), when you have their permission to perform a PHYSICAL EXAM?

Please give me your thoughts about this topic. Thank you.

 

[acapnial]

About this whole asking permission thing. In my OSCEs, I always said stuff like,

"Do you have any questions for me before we start the PE? I'm going to start the physical exam now, ok?"

"I'm looking at your eyes" (with light source) "Everything normal"
"Is it ok for me to unbutton your gown from the back? I'm going to listen to your lung" auscultate 6 back and 4 front
"I'm listening to your heart" auscultate AP "Can you lower your gown and move your breast tissue to the side and up?" auscultate TM
"I'm looking at your stomach. Normal." "I'm going to listen to your stomach." auscultate 4 quadrants. "I'm going to tap your stomach. Tap 4 quadrants. "I'm going to lightly push your stomach. Let me know if you feel any discomfort." Lightly push 4 quadrants of stomach. "I'm going to deeply push your stomach now. Please let me know of any discomfort." Deeply push 4 quadrants of stomach

Neuro exam:
"I'm going to look at your head for any trauma" Look through hairs with fingers
H test
Sensation test. I personally don't ask for permission here. Touch V1, V2, V3 dermatonies and ask "Everything normal and the same?" for each dermatome
"Smile for me. Close your eyes. Don't let me open your eyes. Open your eyes now. How many fingers I'm holding up?" "Turn your head against my hands" "Shrug your shoulders" "Open your mouth. Said ah.... Move your tongue L and R."
Doc: touch arm from top to down "Everything normal and the same?" for each dermatones
"Hold your hands out" Then check A&O Qs here
"Hold your hands out like this" "Push against my me" Check biceps, triceps, arm grips, etc...
Doc put hands on thighs "Push against me" Doc put hands on calves "Push against me" Doc put hands on ankles "step down like you're stepping on the gas pedal. Move your ankles up now."
"I'm going to check your reflex." Tap knee and achilles and babinski
Doc rub inner and outer knee areas and run down for dermatomes "Everything normal and the same?" multiple times

It takes me about 1-2 mins to run through a complete Neuro exam. However, I'm a very bit scared if I'm going this fast and getting auto fail here. If I ask for permission for every maneuver, it's going to take me forever. Please take a look and give me any feedbacks.

Is it automatically assumed that you can TOUCH them besides sensitive body parts (chest area and axillary portions for ladies, and inner and outside upper thighs), when you have their permission to perform a PHYSICAL EXAM?

Please give me your thoughts about this topic. Thank you.

I'm pretty sure the things you should ask permission for are 1) the physical exam itself and 2) lowering the gown. I definitely did not ask for permission to do every little thing when I did the PE.

Edit: Don't touch their inner thigh

 

[acapnial]

Mine was a mess, the computers broke down and I had to handwrite notes with a pretty significant tendon injury. Somehow passed, but I'm legitimately traumatized. Would have loved some actual feedback myself

How valuable would the feedback be though? These people are simulated patients, they're not evaluating you the way a real patient would. I had an SP in med school tell me not taking notes when she was talking about her symptoms made me seem arrogant. Contrast to the real world where patients complain about doctors who spend the whole visit staring at their computer and typing. It'd be at least 50% of that same kind of garbage feedback.

 

[AlteredScale]

Proper draping technique is:

1) Ask the pt to lie down
2) Ask if they need help lying down
3) Put the cloth over their abdomen and LEs for cover and ask them to pull up their gown to get visual of the abdomen. You need to look away while they're doing this
4) Use the cloth and then pull the edges of the cloth over their pants

Few big things that I want to ask:
For positional change help, should I ask them "Do you need any help"? Doing it, even if it's a nice gesture, can be sexual assault. I am debating this issue greatly.

For gown untying occasions for heart and lung, I normally just said, "Please, let me help you untie your gown." Thinking back, I feel that I screw this up also, and I am failing bc of sexual assault offenses. How about them pulling up their gowns after heart and lung? Should I just tell them "I'm done listening to your heart, you can put back your gown now, instead?

Thank you for all the great feedbacks

I always helped the patient to lie down and just said "let me help you there" and could read by their body language if they needed it or not.

Heart I just say "is it okay to move my stethoscope under you gown to listen to your heart AND lungs?". They will say yes. Move accordingly and don't be weird about it. It saves time having to have the patient adjust their gown themselves.

For the mitral valve post on women, ask them if they are comfortable moving their left breast up. They will say yes and do so accordingly.

So, after my history, I will say the following, "I'm done with your history. Is there anything else that you would like me to know?" Pt will say "No." "Well, I will do my physical exam right now to find out more, ok?" Pt will say "Yes."
Doc: "Ok, can you please lower your gown while I sanitize my hands for your physical exam"

Pt lowers gown and I sanitize my hands

PE
"Looking at your eyes and mouth right now. Not seeing anything"
"I am going to listen to your heart." Auscultate APTM
"Next, I'm going to your lung." Auscultate all six anterior spots.
"Would you mind hold up your arms, so I can listen to the side" Sneak the stethoscope underneath the undergarment and listen to the sides
Let's cover you back up and pull her gown up to cover her anterior body parts
"Now, I am listening to the back as well." Auscultate all six posterior spots

Key question: is there I'm doing that could get me docked with these movements? ESPECIALLY the sneaking the stethoscope to the side to hear lateral lung sounds

Next, "I'm going to examine your abd next. Please lie down."
Doc stays in the vicinity and arm below pt back to help in case pt falls. Doc gets the drape.
"I'm going to pull the drape up and cover you for now. Please pull up your gown exposing your abd" Doc looks away
Doc will say "flat and non distended," "I'm going to listen to your abd now." Doc listens to abd. "I'm going to tap your abd now." Doc taps the 4 quadrants of the abdomen. "I'm going to light palpate your abd, please let me know if there's any discomfort and I will stop." Light palpate 4 quadrants. Make sure to say sorry for any pain elicited. "I will push deep next. Please let me know if there's any discomfort." Deep palpation to elicit pain. "I'm sorry. One more ok?" Deep palpate and release and ask, "which one hurts more deep palpation or upon release?"

Is there anything that I can do better or some traps in my approach? Thank you.

So the bolded comes off aggressive to me, you're just telling them "I'm examining you now" instead of asking their permission. Ask them to adjust the gown as you go through your exam. Minimize the time they are exposed.

You're talking way too much. It's probably coming off super awkward.

 

[Espressso]

Way too much fluff in your encounter. My goodness. Get your points and move on, don't say sorry so much and don't chatter all that much. Be nice, show empathy, smile, help them lay down, and cover them with a drape. I feel like your original posted script could be trimmed up big time.

 

[crazyboi1993]

No offense to the OP, you sound really fake, instead of coming up with a dialogue, just be normal, and interact naturally, like to any patient. Smile, be empathethic, apologize when needed (don't go overboard), always offer help with positional changes, always say sorry for loss of someone if relatively recent, counsel when needed... I didn't prepare tbh, just be natural and CONFIDENT. You got this

 

[Epilepsy365]

Do you guys always take out the bed bar for pts when you help lay them down? The thought never entered my mind when it comes to these encounters bc our OSCE and hospital beds never have such a thing. Anyone who passes humanism without doing this for all encounters. Please give me your thoughts!

 

[Lilyhopeless]

Do you guys always take out the bed bar for pts when you help lay them down? The thought never entered my mind when it comes to these encounters bc our OSCE and hospital beds never have such a thing. Anyone who passes humanism without doing this for all encounters. Please give me your thoughts!

Lol, you really did not check the bed!!! It is only funny to me because I know for a fact that those beds at the NBOME have no bed bars that you can pull out for patients. This is unlike USMLE that they have bed bars.

That is why this is so funny on many levels: you are worried about not pulling the bed bars that don't even exist!!!

If you don't trust me, you can check their video at NBOME site! The attending in the video did not even pull out the bed bar for her very tall patient!

So, to answer your question, I passed the humanistic twice without ever pulling the bed bars even once!

 

[SOOyC52H1Sof]

Lol, you really did not check the bed!!! It is only funny to me because I know for a fact that those beds at the NBOME have no bed bars that you can pull out for patients. This is unlike USMLE that they have bed bars.

That is why this is so funny on many levels: you are worried about not pulling the bed bars that don't even exist!!!

If you don't trust me, you can check their video at NBOME site! The attending in the video did not even pull out the bed bar for her very tall patient!

So, to answer your question, I passed the humanistic twice without ever pulling the bed bars even once!

Perhaps youre more personable in real life compared to your online persona. This comment fails humanism for me. OP is trying his/her hardest and made a stupid mistake.


Sent from my SM-N950U1 using Tapatalk

 

[hallowmann]

Serious question: what the hell is a bed bar? Googleing did not help.

 

[Lilyhopeless]

Perhaps youre more personable in real life compared to your online persona. This comment fails humanism for me. OP is trying his/her hardest and made a stupid mistake.


Sent from my SM-N950U1 using Tapatalk

And that is what I was saying and what I found amusing. The OP did not make any stupid mistakes at all as the mistake did not even exist in the first place to make. The NBOME just doesn't have a bed bare for the OP to pull for the patients. How can the OP make any such mistake when they are not even there to be pulled?

I found the situation amusing as the NBOME has made a generally rational person questioned the most random thing. I would be the last person to crash talk the OP as I was in this situation myself before too.

Serious question: what the hell is a bed bar? Googleing did not help.

I think the OP was referring to the footrest in the gurney for the patients to rest their feet on when we lay them down for abd exam.

 

[Epilepsy365]

Pass this bad boy today. I want to thank all the sdn posters for their critiques. Will do a thorough writeup on this thing for future readers considering that I failed Humanism with above average proficiency on all sections of the Biomechanicals (Data Gathering, OMM, and Soap Note)

I’m going to graduate! That’s a huge relief.

 

[SOOyC52H1Sof]

i passed too!!

 

[Lilyhopeless]

Congrats!!! Enjoy that big burden off your shoulders! I have never felt so elated than when I passed this exam also!

 

[Epilepsy365]

Data Gathering (Interview and Physical Exam)

For HPI:
1) What can I do for you? What happened?
2) How long have you been having this for?
3) Any change since then? How so?
4) Has this ever happened before? If so, what happened (dx and treatment)?
5) What makes it better?
6) What makes it worse?


For pts c/o of pain, ask about quality of pain, location, radiation, pain scale from 0-10 "Tell me more about the pain"
1) Tell me more about the pain?
2) Where is it located?
3) Does it travel anywhere?
4) On a severity scale of 0-10 with 0 being no pain and 10 being the worst pain of your life, how would you rate it?
How have these new changes affect their quality of life? (Optional)

ROS (Any positive here will require further probe like “Tell me more about xxx”)
Gen: No/Yes fever, nausea, vomiting, headache, vision change, fatigue, heat/cold intolerance, weight change
Heart: No/Yes chest pain, palpation
Lung: No/Yes difficulty breathing, cough

Optional (I would usually pick one or two):
Neuro: Yes/No numbness, tingling

MSK: Yes/No restriction in ROM, muscle weakness
GI/GU: Yes/No abdominal pain, abnormality in urine or stool (content, color, smell)

Allergies: Any allergies? If so, f/u with what happened when pt takes xxx or is exposed to xxx.
Meds: What meds are you taking? Make sure to get the dosage here
PSH: What surgeries have you had? If so, f/u with what, when, and complication.

Hospitalization: Any hospitalization? If so, f/u with what and when?
PMH: What medical conditions have you been diagnosed with? If so, f/u with what and when.
Family hx: Tell me the health of your family members like father/mother and siblings? Will need age of living or decreased, alive and healthy, death and causes of death, or diagnosed conditions.
Social hx: Any drug?, any tobacco product?, how much alcohol do you drink?, Tell me about your exercise routine?, What’s your diet like?, What do you do for a living? f/u with How do they treat you?, and living situation (where they live and what kind of arrangement?)

Physical Exam

Outside of a msk or a Neuro complaint (hint: it will be an obvious OMT or Neuro case), the following three physical exams are required for all complaints:
1) Lung (auscultate ONLY posterior 6 lung fields) – I have been taught posterior 6, anterior 6, and lateral 2. It’s honestly a waste of time.
2) Heart (auscultate A – P – T – M fields) with radial/PT/dorsalis pulses check and squeezing the legs when you’re at PT/dorsalis pulses check for peripheral edema
3) Abdomen (Inspection, Auscultate (RUQ, LUQ, RLQ, LLQ, and midline for abdominal aorta), light palpation (RUQ, LUQ, RLQ, LLQ, and midline for abdominal aorta), and deep palpation – if the patient is tender on palpation, you MUST do rebound tenderness. The following special tests will be essential depending on complaint: a. Murphy if the patient is having tenderness on RUQ, b. McBurney Point palpation or External Obturator test for a possible appendicitis complaint, c. CVA tenderness tap for a patient complaining of abdominal pain with positive GU ROS findings

Optional:

For a patient with the age > 50 years old or high BP > 130/80, I will always do an ophthalmoscope exam (noting on my note for AV nicking and drusen) plus b/l carotids for bruits

For a patient complaining of respiration issue, I will always scan quick at the eyes and inside the mouth noting on my note for any discharge or abnormalities. Check the neck for LAD and check the sinuses for any tenderness. Look into the noses and the ears for anything. On the lung exam, verbalize how they breath and any chest defect. Percuss the posterior 6 fields, and then check for finger clubbing.

For a patient complaining of chest pain, I will always do an ophthalmoscope exam (noting on my note for AV nicking and drusen) plus b/l carotids for bruits. On heart exam, verbalize for no chest defect, palpate tender spot to see if it’s reproducible, and note for any JVD on examination. I skip PMI here, in order to avoid any awkward moment that will hurt my humanism

For a patient complaining of a rash, I will always check cervical LAD and skin exam of the area, noticing border, color, regular/irregular, bleed, and itch.

For a neuro complaint:
1) Lung (auscultate ONLY posterior 6 lung fields) – I have been taught posterior 6, anterior 6, and lateral 2. It’s honestly a waste of time.
2) Heart (auscultate A – P – T – M fields) with radial/PT/dorsalis pulses check and squeezing the legs when you’re at PT/dorsalis pulses check for peripheral edema
3) Complete Neuro exam

For a msk complaint (obvious OMT complaint):
1) Lung (auscultate ONLY posterior 6 lung fields) – I have been taught posterior 6, anterior 6, and lateral 2. It’s honestly a waste of time.
2) Heart (auscultate A – P – T – M fields) with radial/PT/dorsalis pulses check and squeezing the legs when you’re at PT/dorsalis pulses check for peripheral edema
3) MSK exam: Inspect and verbalize the area of complaint, above the area, and below the area b/l. Palpate and verbalize the area of complaint, above the area, and below the area b/l. Check for b/l active ROM. If there’s restriction, do passive ROM on the area of complaint. Check for sensation to light touch distal to the area of complaint b/l. Check for muscle strength distal to the area of complaint b/l. Check for DTR distal to the area of complaint b/l. Check for blood flow distal to the area of complaint b/l (You don’t need to think about this bc you should already done this with your automatic heart exam!).

For a psych complain:
1) Lung (auscultate ONLY posterior 6 lung fields) – I have been taught posterior 6, anterior 6, and lateral 2. It’s honestly a waste of time.
2) Heart (auscultate A – P – T – M fields) with radial/PT/dorsalis pulses check and squeezing the legs when you’re at PT/dorsalis pulses check for peripheral edema
3) Thyroid check
4) CN 2-12 check
5) Sensation to light touch throughout
6) DTR throughout

 

[Epilepsy365]

OMM 3-5 testing STATIONS
(2 Treatments here in order to max points here in order to compensate for weakness in data gathering or soap note). My go-to treatments are MFR and Pectoral traction/Lymph squeeze for 80% of the complaints. You will borderline pass this component if you appear confident and competent even with only one treatment

1. Talk the concept of OMM: “Osteopathic manipulation medicine is a concept about how the mind and the body are related for self-healing. So, if we can align the body back to its natural alignment, the body will self-heal itself.”

2. Do a quick hypertonicity or tissue/ROM restriction test on the area of complaint f/u by treatment: “Hm… there’s a lot of tightness there with some warm. (For MFR) I’m pulling the tissue up and down and it seems to be restricted up/down. Now, I’m pulling the tissue left and right and it seems to be restricted left/right. Now, I’m pulling the tissue clockwise and counterclockwise and it seems to be restricted clockwise/counterclockwise. Now, I will pull the tissue against all the three planes of restriction and leave it there for 30-60 secs. Hm… all better now.”

3. Retest by touching the area and poking on it “Hm… it feels more loose now and less heat. How do you feel? Try moving around a little bit” Patient will say feel a little better now.”

 

[Kerosene Hat]

For OMM, I have heard it is best to have the patient quantify their pain on the 0-10 scale both before and after OMM. If the OMM was appropriate, they will report relief, as you said, and you tell them, “I’m glad to hear that! I’d like to have you come back in a week to reassess - does that work for you?” Record everything in your SOAP note.

 

[Lilyhopeless]

For OMM, I have heard it is best to have the patient quantify their pain on the 0-10 scale both before and after OMM. If the OMM was appropriate, they will report relief, as you said, and you tell them, “I’m glad to hear that! I’d like to have you come back in a week to reassess - does that work for you?” Record everything in your SOAP note.

You are correct to do it that way! In any case, it is always a good practice, OMM or otherwise, to quantify their pain threshold pre and post-treatment. You should also try to follow up with patients post-treatment.

 

[Epilepsy365]

SOAP Note
This is my format.

Subjective Component:
CC: Whatever
HPI: 70-90% of my HPI format and all my ROS
Allergies: whatever. If so, side effects of exposure
Meds: whatever. If so, make sure to give the dosage
PSH: Whatever. If positive, give what, when, and complication
Hospitalization: Whatever. If positive, what and when
PMH: Whatever. If positive, give what and diagnosis date
Family hx: Need two generations here (preferably parents and siblings). Need to give age, alive or death status, healthy or died of what medical conditions or alive but has what medical conditions
Social hx: Will always have drug usage (what?), tobacco product (current or past user, since when, and ppd), ETOH (how much do you drink and what kind), exercise routine (how often and what kind of exercises), Diet (self-explanatory, take their words for it, no need to dig deep), Occupation + how the workplace is treating them, living situation (where they're living and in what living arrangement)
Optional: LMP for all females in their reproductive age, and whether it's normal flow

Objective Component:
Vitals: Write down all the vitals given to you. Do it quick. Spelling or exact format doesn't matter
General: WDWN, pleasant and cooperative
Heart: RRR with S1 and S2 noted without any gallops. Distal pulses intact 2/4 throughout
Lung: CTA
Abdomen: flat and non distended. Normoactive bowel sounds x 4 quadrants. Tympanic percussion throughout. Nontender to palpation. No organomegaly, bruits, or pulsatile mass.

MSK Complaint would be like this:
Vitals: Write down all the vitals given to you. Do it quick. Spelling or exact format doesn't matter
General: WDWN, pleasant and cooperative
Heart: RRR with S1 and S2 noted without any gallops. Distal pulses intact 2/4 throughout
Lung: CTA
MSK: No discharge, erythema, or bony defect at area of complaint, above area of complaint, and below area of complaint b/l. Nontender to palpation at area of complaint, above area of complaint, and below area of complaint b/l. No restriction in active ROM b/l. MSK strength distal to area of complaint 5/5 b/l. DTR distal to area of complaint +2/4 b/l. Sensation to light touch distal to area of complaint intact b/l

Assessment:
At least 3 ddx. I always have 4 ddx on mine

Plan:
Medicine: Do they need any?
OMM: Doesn't need to include this part if it's not an OMM case.
Tests (Labs + Images): Always have CBC for elevated WBC, CMP for electrolyte levels, Bun/Creatine, and liver enzymes
Humanism (Do they need a work/school note or you to call someone?): "School/work note offered but patient declined. Phone call help was also declined by patient."
Referral: Consult with Cardiology/Gastroenterology/Surgery/Infectious Disease/Neurology
Return plan: Return in 1 week (acute cases) Return in 4 weeks (not acute cases). Patient is welcome to come in earlier if symptoms worsen.

 

[Epilepsy365]

NBOME scoring: You have to believe me on this, but only 11/12 cases are graded for your biomechanics and humanism. They drop your lowest case in order to make you have 70%+ overall in both of your humanism and biomechanics cases.

SOAP Note is graded by three sections (Subjective, Objective, A/P) with a score of either 0, 1, 2, or three on each component. Max score for 11 SOAP notes with 3 in subjective, 3 in objective, and 3 in A/P is 99. So, it's to your benefit to have something in each portion to get a 1 instead of a 0.

 

[Epilepsy365]

NBOME Humanism Scoring:

This rubrics isn't NBOME state secret. It is found in this paper:

https://files.eric.ed.gov/fulltext/ED552870.pdf

Based on the check boxes, I would say that it covers 4 of their domains (Elicit information, Listening skills, Giving information, and Empathy to the T's)

Humanism is graded by 6 domains (In this section, anything not red is either my interpretation or Kauffman's interpretation)
1. Elicit information
a. Student used language that was easy to understand
b. Student elicited information effectively

2. Listening skills
Demonstrated attentive listening (eye contact, nodding, prompts to continue, leaning forward/facing patient, paraphrasing, repeating pt's words)

3. Giving information
a. Shared findings of physical exam with patient
b. Shared at least one possible diagnosis with patient (education/reasoning)
c. Explained the step steps
d. Educated patient regarding lifestyle modification
e. Closed the interview properly

4. Respectfulness
a. Collaborated with the patient in an open-ended way
b. Demonstrated respect for patient (non-judgmental, polite, did not interrupt, draped and positioned the patient appropriately, acknowledged patient discomfort, embarrassment, etc._

5. Empathy
a. Demonstrated empathy toward patient's current state (verbal with non-verbal)
b. Established and maintained a positive connection (preferred name, demeanor, humor, interest in patient's life station)

6. Professionalism
Appropriate word choices, organized, did not rush, no gum chewing, clean appearance, appropriate confidence, etc

 

[Kerosene Hat]

Thank you for taking the time to put this together! Unfortunately, it seems like, ahem, certain schools’ clinical education departments can’t see the forest for the trees and focus on irrelevant details.

 

[Epilepsy365]

14 Minutes Patient Encounter

0-0:20: Look at the patient chief complaint on the chart (If it’s a headache, it will either be a Neuro/Psych/MSK case. If it’s extremity pain or limitation, it will be a MSK case. Look at the vitals (If RR>20 or HR>100, it will be a cardiac or lung case. If BMI > 30, it might be a lifestyle counseling case. If Temp > 100, you need to start thinking about an infectious case here.) Look at the setting. If it’s the ER or urgent care, it’s probably an acute case and you will need to send this person to the ED or admit the person for a thorough workout. If it’s the office, it’s probably a counseling case.

0:20 – 0:25: Knock on the door and wait for a sound from the patient

0:25 – 0:30: Open the door and enter. “Mr.XXX/Ms.XXX? Hiii!” with a BIG SMILE! Note: Don’t say “How are you?” here in order to prevent possible dingus patients from telling you their entire HPI while you’re getting your hand sanitizer, struggling to sit down, and then listening to them. There are dinguses in like in Chicago. It just messes up with your entire encounter.

0:30-0:40: Go to the hand sanitizer and get a half pump, and rub your hands “Well, thank you for coming in. Did you have any trouble getting here?” Pt will say, “No, not at all or something.”

0:40 – 0:45: “I’m Student Doctor XXX, and I will be taking care of you today” with a BIG SMILE and extending my hand for a handshake. HANDSHAKE! Then proceed to sit down.

0:45-0:50: “So, Mr.XXX/Ms.XXX? or can I call you something else?” Pt will say, “You can call me, Whatever.”

0:50-1:00: Nod with a slight smile, “Ok, Whatever, what can I do for you today?” Pt will tell you chief complaint, “Doc, my chest is hurting really bad!” Change your facial expression to something or concern and nob (LEGITIMIZING their concern), and lower your voice and tone to something SOFT and CALMING for the REST OF THE ENCOUNTER. “Please tell me about your chest pain.”

1:00-4:30: Let the patient talk. Your job here is to direct them with OPEN-ENDED QUESTIONS, not to set the encounter into an interrogative process through CLOSE-ENDED QUESTIONS. "Please tell me more... What else..."While they’re talking, I’m jotting down notes for the following information that will make up the majority of my HPI, following the OPQRST mnemonic:

1. What happened? (O)

2. How long have you been having this for? (O)

3. Any change since then? How so? (O)

4. Has this ever happened before? If so, what happened (need to know dx and treatment here)? (O)

5. What makes it better? (P)

6. What makes it worse? (P)

For pts c/o of pain,

1. Tell me more about the pain? (Q)

2. Where is it located? (R)

3. Does it travel anywhere? (R)

4. On a severity scale of 0-10 with 0 being no pain and 10 being the worst pain of your life, how would you rate it? (S) Note: Any 7+/10 pain requires the following statement: “I see… with a sad emphatic face. Let’s finish this history and physical exam quick. We’ll come up with a diagnosis together, and make you feel better soon, okay?” With a sad emphatic face and more nobs “Just hang on tight!”

5. Optional for pts without pain, how are these new changes affecting your quality of life? (S)

6. Any recent trauma? (T) Any exotic traveling? (T)

4:30 – 5:00 “Well, I’m going to ask more questions about your condition. Please be patient with me.” I’m running through my ROS here (Any positive will require a “Tell me more about xxx”):

For general, “Any fever? Any nausea? Any vomiting? Any headache? Any vision change? Any fatigue? Any instance of feeling hot or cold all the time? Tell me about your weight changes in recent months?”

For heart, “Any chest pain? Any funny heartbeat?”

For lung, “Any difficulty breathing? Any cough?”

Optional (I would pick one or two depending on complaint):

Neuro: “Any numbness? Any tingling?”

MSk: “Any restriction in range of motion? Any muscle weakness?”

GI/GU: “Any abdominal pain? Any abnormality in urine or stool like content, color, or smell?”


5:00 – 5:10: “Well, I’m going to be moving on to other parts of the history. But, is there anything else that you would like to tell me that I haven’t covered yet?” At this instance, pt will say “Nothing at all” or give you the challenge question, “I think I have lung cancer/I’m very concerned… Am I going to be okay, etc.” The key to answer this question is to be honest with them (meaning there’s still not enough information. Don’t say crap like “Yeah, no worry. It’s blah… blah… we’ll make you feel better quick” bc that’s lying and not being professional), not expose yourself to the image of incompetence (i.e. “I’m not sure yet.”) but rather an image of confidence, legitimize their concern, and give assurance. My answer is the following: Stop whatever you’re doing. Nob with a sad emphatic face with those puppy eyes and say the following in an even SOFTER tone with SLOWER pace, “Whatever, I understand… Let’s find out more, okay? Let’s finish this history and physical exam quick. We will find out what’s the problem, and make you feel better soon, okay?” For the patient who says “Nothing at all,” I will respond, “Well, feel free to interrupt if something comes up, okay.”(nob head and smile)


For the rest of the history, please mix in some open ended questions in here, as evident by my sample
5:10-6:30: “Any allergies (if so, get the side effect after exposure)? … What medicines are you taking (if so, get the dosage)? … Any surgeries (if so, get what procedure, when the procedure, and any post-op complication)? … Any hospitalization (if so, what and when)?... What medical conditions have you been diagnosed with (if so, what, date of diagnosis)? … Tell me about the health of your family like your parents and siblings (need to get age, alive or death status, heathy or dx conditions)? … Any family that passed away from a not natural cause needs the following statement, “I’m sorry to hear that.”


6:30 – 8:00: “For your social history, any drug usage (if so, what and when)? Any alcohol usage (if so, what and how much)? Any tobacco use (if so, active or past user, how much did they smoke in term of ppd)?” This is another part of humanism grading. You need to appear NONJUDGMENTAL (e.g. don’t mumble around here and said crap like “Not bad. Totally normal”. Just nob and move through it quick! Any person drinking 3 drinks or more will require CAGE questionnaires. For any current smokers, I will always offer smoking cessation “Have you thought about quitting smoking? It could be related to your condition for xxx reason.” If they say, “Well, I never thought of that, but I will do whatever you say,” you will say “That’s fantastic. We’ll set up a follow-up appointment to talk about that, okay?” If they show signs of resistance, you will say, “That’s fine. Whenever you’re ready to quit, just let me know. I’m here for you!.”

“Tell me about your exercise routine”

“Tell me about your diet” If you feel they eat poorly, you can say, “Have you thought about changing your diet a little bit?” If they show signs of resistance, you will say, “That’s fine. I’m here for you if you need it!.” If they show openness but curious, say the following, “Your diet could be related to your condition for xxx reason. We can set you up with our nutritionist, who can optimize your diet. Are you interested?” At this point, they will say, “Whatever you think is best, doc.?

Any good lifestyle choices for ETOH, drug, smoking, diet, and exercise can be congratulated with, “Good! Keep it up!”

“What do you do for a living?” Pt will tell you their occupation. Respond with a smile and say, “Wow, that’s pretty cool.”

“How do they treat you?”

“Tell me about your living situation.” (where they live and what kind of arrangement)

“Before we move on to the physical exam, do you have any questions or concerns for me?” Patient will say, “None,” or present you with the challenge question if you haven’t asked. “Excellent! Is it ok for us to begin the physical exam.” Pt will say, “Yes”. “Okay, I’m going to go and get my hand sanitized right now.”


8:00 – 12:00

Begin with lung exam:

“Whatever, first I’m going to listen to your lungs in the back. Is it okay for me to untie your gown?” Pt will say, “Sure.” Untie the patient gown, and auscultate 6 posterior lung fields. “Ok, breath in and out. Again... Again... Again... Again… Again…” “Awesome, everything normal so far.”

Follow by heart exam:

“Whatever, next I’m going to listen to your heart, ok?” Auscultate the A – P heart fields. “Whatever, can you lower your gown down further so I can listen to your heart on the lower side?” Pt will lower the gown. “Whatever, can you lift up your left breast?” Auscultate T – M heart fields. Note: don’t ask SP to move breast to the left for T heart field, and then breast up for M heart field. I was taught this, and there’s a ton of awkwardness here and possibly opportunities for humanism points to get hit.

“Heart sounds good.”

Lift the patient gown up and cover their exposed chest area.

“Let me help tie back your gown.” Go to the back and tie the patient gown

Follow by abdomen exam:

“Whatever, next I’m going to check your stomach. Let’s have you lie down.” You don’t have to offer help to get them down, but you NEED TO BE THERE and SHOW SIGN of SUPPORT with your helping hand in case of fall.

Take the drape and hold it over the patient with your face turning away.

“Whatever, can you lift up your gown” Pt will lift up the gown.

“Okay, I’m looking at your stomach. Normal so far. Next I’m going to listen to your stomach, okay?”

Auscultate RUQ, LUQ, RLQ, LLQ “Normal so far.”

“Next I’m going to tap your stomach. Let me know if there’s any discomfort.”

Tap 4 quadrants.

“Next, I’m going to slightly push your stomach. Again, let me know if there’s any pain.”

Slightly push RUQ, LUQ, RLQ, LLQ

“Deep push this time. Again, let me know if there’s anything, ok?

Deep push RUQ, LUQ, RLQ, LLQ

If there’s no tenderness to palpation, you’re done. If there’s any tenderness to palpation, you must do rebound tenderness. If there’s any RUQ pain, you must do Murphy test. If there’s any RLQ pain, you must do external obturator test. If there’s any suspicious ROS complaint of pain radiating to the genital or testicles, you must do CVA tenderness tap.

“Everything is normal so far. You can pull down your gown” Take away the drape. “Let me help you get back up” and offer a helping hand

Key humanism points on the physical exam:

1. Talk through your physical exam maneuvers

2. Proper draping techniques

3. Positional helping for getting the pt on the table and getting up from the table

4. Be gentle at appropriate speed (humanism will be hit with rushing)

5. If the pt shows sign of discomfort like pain or trouble breathing, you need to stop, give the pt a few secs, and ask for confirmation, “Whatever, are you ok? Can you continue with the physical exam?” or something similar


12:00 – 14:00 Closing. Note: you must take the full 2 minutes to properly close with diagnosis, explanation of pathophysiology, and plan here. 50% of your humanism points will be here.

Plan component:

Medicine: what meds?

OMT: any OMT?

Test: labs and images?

Humanism: any work/school note? Any phone call?

Referral: Any referral to GI/Nephrology/Cardiology/Neurology etc…?

Return: acute case (return in 1 week). Not acute case (return in 4 weeks. Always give an option or patient to come back earlier if worsening conditions.

“Jane, I think you have XXX condition. What’s your understanding of XXX condition?”

Pt will either say, “Yeah, isn’t XXX condition this… this… this…” That’s awesome bc the pt just save you 20-30 secs of explanation. If not, they will say, “I don’t know anything about it

You will then say, “Well, XXX condition is bc of this… this.. this.. (pathophys explanation make it quick with 2 sentences.”

“But to be sure, let’s run some labs for confirmation, okay? We will also take a pic of your stomach/chest to make sure that everything is ok in those areas. Etc…”

The point here is to show signs of thoroughness and confidence while explaining stuff in laymen term. You don’t need to say EKG, CT, troponin trending, TSH, etc…

Give your treatment plan to the patient whether it’s composed of medicine, OMT, or referral.

Next,

“Do you need any work/school note? Or me to call anyone” Pt will say, “No.”

“Okay, let’s follow up in 1 week/4 week. But, if things get worse, please feel free to call and my staff can get you in sooner.”

“How do you feel about the plan?”
Pt will say, "whatever you think is best, doc."

“Do you have any other questions”

“Well, thank you for coming in. It was a pleasure meeting you.” Shake hands, smile, and walk out.

Red highlight points are major humanism strategies that I didn't do consistently on my previous attempt. I'm very positive that you will pass the humanism component if you nail these points on all of your cases.

 

[Epilepsy365]

Final Notes:

1) Get the COMLEX-PE videos from Kauffman through Truelearn
2) Practice every cases with your gf/bf/spouse at least 2 times per case in order to get the timing of the encounters down. This is very important to build an appearance of confidence and rid of any awkwardness
3) Videotape yourself, and get rid of any weird movement or quirks when you're nervous
4) Get critique from multiple people especially if you fail this component on your first attempt. For my second attempt, I had criticism from my spouse, a med school friend, my SP Director, and one of our SP actresses.
4) Most important is to practice consistently in order to build in muscle memory, so you can go on automatic mode when you're nervous

Best of luck to you as a reader. Failure of this exam doesn't define who you are. It's a trash exam. It's more of an acting performance than anything.

 

[Epilepsy365]

SDN Myth Busters:

1) You don't have to be a smiling monkey high on drugs at all times. The key is to be good at acting to make them think that you care about them in a professional and confident manner.

2) Philadelphia is harder than Chicago. False. I failed in Chicago and passed in Philadelphia.

3) Chicago SPs are racially diverse than Philadelphia. False. I had 3 SPs that are from the same ethnic group as me vs none in Chicago. I personally think that the NBOME has made an effort to increase racial diversity for SPs in Philadelphia in recent years due to criticisms from multiple students/residents/attendings on sdn.