Found out last week I passed, which of course is awesome, especially considering that I convinced myself that I failed (see my post above someplace). And I'm NOT one of those people who usually leave a test feeling they failed (you know who you are folks). So, odds are, at some point during that 8-10 week wait, you will think you failed. When that happens, don't fret... don't spend time looking up on SDN (like I did) and waste time. Not worth it. Anyways, here's my experience/advice/whatever:
THE DAY IS CRAZY. It flies by. Rapid fire. A whirlwind. You will finish and be like "WTF just happened?" And when you're in that room, time does seem to morph and move at a rate you wished it would during day you spent at OB clinic (not offense to you future OB-GYNers, and God Bless). What does that mean? Everything you do needs to be focused. Keep your exam and your questions pertinent. Don't approach it like your just trying to hit checkpoints and rack points. Not only will you likely come off as disingenuous but you'll bleed precious minutes. History taking needs to be focused on the situation at hand and so does the physical, just like you would on your rotations.
Exam: as many have said, heart (don't forget carotids) and lungs on everyone! Everyone! Even the depressed lady who is worried that her husband is cheating on her and has an ulcer on his thang. As far as the gown goes, I always asked if it was ok to lower their gown (going in sideways seems to cumbersome and just plain awkward especially when they wear it tight) then I said something like "can I help you untie that?" Lower the gown only as far as you need. Ask the patient to move her breast if need be for MV auscultation. Give feedback when things sound ok for humanistic points (and you should do that in real life anyway). As far as lungs go, I only listened midaxillary on 2 patients and they were respiratory-related issues. They also had more of a focused lung exam with testing egophony and tactile fremitus. Also tie them back up as well. Just be nice!
KEEP THE EXAM FOCUSED AND PERTINENT! And look out for real findings. I heard murmurs, wheezes, saw clubbing, splinter hemorrhages, etc. Find them, tell the patient, and document. I'm thinking that's extra juice for your final tally.
If there's any heart issues/suspicion according to presentation---> full cardio exam, head to toe. So pulses b/l, capillary refill, check for aortic aneurysms, splinter hemorrhages (which I found on a pt), JVD, and if HTN then bust out the ophthalmoscope (IF you have time)! I DID NOT RECHECK ONE BP THE ENTIRE EXAM.
Head aches, concussions, dizziness, numbness, tingles, weakness, visual changes ---> neuro exam, especially EOMs, CNs, DTRs, and GAIT (don't forget to stand them, Romberg, and walk them). Bust out the scope if you have time for those.
Breathing issues---> focused lungs w T.F. and don't forget about extremities looking for clubbing (which I did find on a patient). Don't forget HEENT on these ones. But out the otoscope. Look up their nose. Let them give the good ol' aaaaahhhh! Feel glands. I noticed myself almost forgetting that in the haste of the moment.
MSK injury--> ROM active and passive, DTRs (i love the hammer), strength
Anything GI related--> full abdominal exam (listen, percuss, palpate shallow and deep) but again focused. m not looking for Murphy's on the Celiac patient but I think I would do one on everyone if I was there anyway. Odds are if you follow this order and hit all quadrants, the patient will feed you the info you need (sometimes obviously so) to lead you towards your diagnosis and plan. Don't forget to listen and palpate aorta and renal arteries while there (depending on case).
Physical patients: you may get one. Head to toe. Heart, lungs, HEENT, abdomen (don't forget to check for abdominal hernia), and age-specific counseling. Ask questions about how school is going, or what their hobbies are or whatever, are you sexually active (if teenager). Some of this may sound like smalltalk (which doesn't hurt) but it actually opened a few doors leading to questions that the patient had. So don't be shy.
OMM patients: some will be purely MSK issues with OMM. Some will straight up ask for it, others will hint, maybe one or two will not. If you think they could benefit, go for it. Ask them if they ever heard of OMM, give a quick spiel about the benefits of osteopathic medicine (browny points for the A.T.S. faithful who will be grading you) and dive in. Keep it simple. Know a technique for every body region. I prefer Still technique bc it's quick. Used myofascial a couple of times as well. ME is my favorite, but only do so if you have the time. That said, I had 3 patients I used ME on. ALWAYS REASSESS. As far as documentation goes, I kept it short and sweet. E.g. TART changes T5-T9 b/l. I didn't get all fancy in terms of rotations and side bending. Not once did I document flexion/extension. ROM should be documented though, if pertinent.
Which brings me to documentation: Pertinent positive AND negatives. There isn't time for anything else. You don't need to run through the entire ROS. Heart and lungs always. But from there it should focused according to the case at hand and pertienent. Don't go listing every negative you didn't find in the H&P. Only pertinent stuff!!! My advice is to run through it once without stopping. That is, if you find yourself blanking out on a section, move to the next part and come back to fill in the blanks. Don't rush but don't move slow either. When the brain farts, you move along. I found myself going back through my note for most of them. I probably only had one note where I felt like there was nothing else I could do. Most of them I would finish the bare bones and then go back and find what I missed (and I often found something). A few I was frantically trying to beat the buzzer. I did finish every note, that is, I never had a section blank and always had minimum requirement for A&P. I'm not a fan of going in and filling those in first, because that is not what I have done for the last year on rotations. That brings me to the next topic... preparation.
The best way to prepare for this exam is on your rotations during your everyday life as a medical student. Nail down the exam and the documentation while on your rotations. I really feel that this is why I passed. I did not practice with other students or family members beforehand. Not once. Always seemed to contrived to me plus I was probably too lazy. If you like practicing with friends, go for it. But the best bang for your buck (and you're paying A LOT of bucks) is to work on your skills day in and day out. When you write notes on the floors, see how quick you can hammer them out. (I feel for you guys writing paper notes on certain rotations because I know how it feels to fly through a note, realize you missed something, and DOH... no space!).
Kaufmann's book was go to for practice. I went through it the week before... most of it the last few days leading up to the test. I skipped all the b.s. at the beginning (since our schools gave us most of this info) and jumped right to the cases. I would run through a case in my head, talking out loud (my wife already knows I'm crazy), and think about what type of exam I would do. After that, I would jump to the NBOME practice SOAP
https://www.nbome.org/eSoap-Practice.asp and try to pump out the note in time. Keep practicing notes on there. It will make a HUGE difference on game day. Like I said, I was pretty much hustling to the deadline on everyone and this was with the practice. If you don't practice writing notes on that site, odds are you're making things harder for yourself.
All in all, it was a stressful day. I honestly hated it and I have told multiple people that it was hands-down my least favorite (and possibly worst) part of medical school so far. I'd take a crazy day in the hospital over this anytime. Real patients are so much cooler than the SPs. Oh that reminds me: Expect patients to act douchey. More than a few gave me blank stares, acted annoyed, seemed disinterested, pissed, unsatisfied, etc. It's all a part of the act. Designed to throw you off your game. Just keep doing your thing. Don't take it personally. I also NEVER washed my hands before shaking hands and ONLY did so before the physical exam. Worked for me. Kauffman books says otherwise, but you're wasting time if you're jumping back and forth washing (even though it's just the alcohol).
Well, that's all I have. I'm sure I'm missing something there. Feel free to ask any questions. Just remember, odds are you're going to pass this thing. And chances are you will think you failed! Hahaha! Good luck folks. You got this!
And some how it was the Data-Collection portion that did it to me...I'm doomed. I never had a single, solitary problem in any clinical exam review, video-taped history and physical, or otherwise on that part of my exam (just note organization which I passed). God help me.
