Pediatrics:Diarrhea, Epistaxis, Vomiting, Fever7. Such as,-How to do counseling of mother of 2 year old boy when epistaxis does not stop and she is worried about his son? In the middle of patient encounter-How to do counseling when patient ask for pain medicine? During physical examination-When patient yelled at you during physical examination what is next step?
During closure:-When patient insists to prescribe medicines for weight loss when you think it is not indicated. Disclaimer: www. Patient's names are for educational purpose and there is no relation with any living persons. Full Specifications. What's new in version 1. Release June 10, Date Added February 15, Version 1. Operating Systems. Operating Systems iOS. Additional Requirements Compatible with: iphone3gs, iphone3gs, iphone4, iphone4, ipodtouchfourthgen, ipodtouchfourthgen, ipad2wifi, ipad2wifi, ipad23g, ipad23g, iphone4s, iphone4s, ipadthirdgen, ipadthirdgen, ipadthirdgen4g, ipadthirdgen4g, iphone5, iphone5, ipodtouchfifthgen, ipodtouchfifthgen, ipadfourthgen, ipadfourthgen, ipadfourthgen4g, ipadfourthgen4g, ipadmini, ipadmini, ipadmini4g, ipadmini4g.
It's no any mistakes when others with their phone on their hand, as well as you're also. COMLEX Level 2-PE Review Guide covers the components of History and Physical Examination found on the COMLEX Level 2-PE The components of history taking, expected problem specific physical exam based on the chief complaint, incorporation of osteopathic manipulation, instruction on how to develop a differential diagnosis, components of the therapeutic plan, components of the expected humanistic evaluation and documentation guidelines.
Describes the humanistic domain for student understanding of the areas being evaluated. Decent By Brig Halpin This book is decent. Pros: good systematic method of approaching the encounters. Mnemonics are easy to remember and make sense. The strategies it continually goes over do come together to make a sound cohesive method to the encounter.
The complaints in the simulated cases are a lot of 'most commons' and probably more likely to show up on your PE. The cases include a blank soap note so you can practice writing them out. Cons: I expected some OMM suggestions for complaints and there are none.
Present the options slowly so that the patient can consider each as an accurate description of the pain. When I asked Mr. Cook to describe his dizziness, he stated that he just felt off balance. Other clues could have altered the differential had he described his dizziness as a sensation of the room spinning around vertigo, possible inner ear dysfunction , lightheadedness possible anemia , or the room going dark near syncope, possible cardiac arrhythmia.
A typical pain scale spans from 0 to 10, with 10 being the worst pain. Exacerbating and Remitting Factors Questions about exacerbating or remitting factors are straightforward. However, a common error is to ask the patient both types of questions in one sentence: Candidate: Does anything make your chest pain better or worse? Patient: Spicy sauces and wine seem to make it worse. Patients have a tendency to answer only the second half of the question; therefore, candidates should ask questions about exacerbating factors separate from remitting factors: Candidate: Does anything make your chest pain better?
Patient: Antacids seem to tame it down a bit. Candidate: Does anything else make it better? Candidate: Does anything make it worse? Candidate: Anything else? Patient: Not that I noticed. The candidate got a lot more information by asking each question separately but made another mistake by walking away from the line of questioning too quickly. For example, a more complete line of questioning in this case might be as follows: Candidate: Does anything make your chest pain better?
Candidate: How often do you take antacids? Patient: Every day. Candidate: How many times a day? Patient: Oh, four or five. Candidate: What is the name of the antacid? Patient: Whatever I get a hold of, mostly Tums. Candidate: How many do you take at a time? Patient: Oh, three or four. This is an inventory of symptoms that the candidate develops as diagnoses enter the differential.
This is frequently seen as students as everyone if they have fever, chills, nausea, or vomiting. Instead, as the candidate entertains thoughts of a possible diagnosis, he should ask symptoms related to that diagnosis to prove himself right or wrong.
The last occurrence was 1 year ago, when she was admitted to the hospital and treated for pneumonia. Immediately upon hearing this, the candidate considers another episode of pneumonia as a possible diagnosis. However, many conditions can cause SOB. The next diagnosis that the candidate entertains is acute coronary syndrome. He then asks if the patient is experiencing any sweating, nausea, pain going into the arms or neck, and numbness or tingling.
As soon as a new possible diagnosis arises, candidates should ask the appropriate questions to prove it right or wrong. For example, the patient volunteers that she has a pack year smoking history. The candidate adds acute exacerbation of chronic obstructive pulmonary disease COPD to the growing list of possible diagnoses and asks the patient if she can tell whether she has more problems getting the air in or getting it out.
He also asks if she has been wheezing. These medications are commonly used to treat heart failure. Though the patient denies a history of heart failure, the candidate must add it to the differential. To rule it out, he must ask about difficulty breathing while lying flat orthopnea , sudden shortness of breath while sleeping paroxysmal nocturnal dyspnea , dyspnea on exertion, and peripheral edema.
Anatomy-Based Questioning A second method for determining the appropriate symptoms associated should be based on anatomy and becomes practical to use in situations when the candidate is unsure of the diagnosis. After identifying the area of complaint, the candidate should work through organ involvement within the area.
Gwen is a year-old woman who presents with right upper quadrant abdominal pain. While taking her history, the candidate considers cholelithiasis as a possible diagnosis and has, therefore, asked about exacerbation after eating fatty foods, radiation of the pain into the shoulder blade, and clay-colored stools. However, the candidate remains unconvinced that cholelithiasis is the final diagnosis.
Consider which organs the arrow would touch as it passes through the body. In this case, the first point of contact is the skin. The candidate must recall which conditions could cause pain of the skin in the right upper quadrant location.
How about herpes zoster, shingles? The patient is not in the typical age group for this condition, but it is a possibility. The next points of contact are the subcutaneous tissues and the rib cage. Could this be a rib dysfunction or costochondritis? Does movement cause pain? Have you had any trauma? Do you have any shortness of breath? Next the arrow would touch the parietal pleura. Is there an acute peritonitis such as could occur with a rupturing gallbladder? Does it hurt to press in on your stomach?
The candidate continues by considering perforated viscous. Could this be a duodenal or gastric ulceration? The transverse colon stretches across both upper quadrants. Could this be colitis? Blood in your stools? The candidate has already considered the gallbladder, and next considers the rest of the biliary system: could this be distal obstruction, such as from a gallstone or pancreatic head cancer?
Night sweats? Left upper quadrant pain? Pain going into the back? Next comes the liver. Is it possible the patient has acute hepatitis? Many symptoms about which the candidate has already asked overlap, such as clay-colored stools, nausea, and vomiting. After the liver, the arrow would encounter the right kidney. Is this pyelonephritis?
Flank pain? Blood in your urine? Cloudy urine? Burning with urination? Foul-smelling urine? Finally, the arrow would pass through the inferior lobe of the right lung. Could this be pneumonia? Because the pain is anterior, renal and pneumonic etiologies are certainly lower in likelihood but can quickly be considered. Further, atypical etiologies exist such as a right upper quadrant appendix, but the candidate should stick with common and not atypical possibilities.
It is important for candidates to recognize that the symptoms associated are part of the history and are documented under the Subjective part of the note. Candidates will likely find themselves asking about medications much earlier in the patient interview when a historical clue prompts this line of questioning.
Once this logical flow ebbs, candidates can glance at their paper to see where gaps in the mnemonic need to be filled in. By filling in the gaps, candidates can complete a most detailed history.
Social History This S stands for social history. See Figure 4—1. For example, if a year-old male roofer presents with shoulder pain that resulted from grabbing a bucket full of nails as it slid off a roof, the candidate need not inquire about his diet represented by F for food. However, his E exercise habits might indeed be very important as would his O occupation. How is this injury going to affect his ability to play on the softball team and when will he be able to return to work?
In obtaining the social history, candidates should begin with the least sensitive questions first and advance into the more sensitive areas. For example, to take a history from Alyson Roth, a yearold girl with ear pain: although she presents only for ear pain, it is important to perform the social history screen.
Approaching Alyson, the candidate observes that she appears to be an appropriate weight, so he discards the food and exercise questions, although some candidates choose to ask questions in each area of the social history regardless.
Candidates must remember that they have only 14 minutes for each case in the exam. Next in the mnemonic is D for drugs. So, it is helpful for candidates to begin with the least offensive question in the drugs area such as about caffeine use, followed by questions about tobacco, alcohol, and then drugs. I ask the same questions of everyone. How much caffeine is in your diet including coffee, pop, and chocolate?
Candidate: Do you use any tobacco? Patient: I smoke a little. Candidate: How much is a little? Patient: One or two cigarettes a day. Candidate: Only one or two? I never buy them. My friends all smoke, so when they drive me to school they give me a cigarette and then they give me one on the way home too. Candidate: How long have you been doing that?
Patient: Just this year. Candidate: Do you drink any alcohol? Candidate: Do you use any street drugs or prescription drugs? Patient: Nope. By starting with the most benign questions such as about caffeine, the candidate is more likely to get honest answers as he progresses because the patient feels that these are just screening questions and not accusations.
Later, the candidate can return to the issue of smoking and the need for smoking cessation as part of the plan. The O for occupation should be screened for two primary reasons. The candidate can assume that Alyson, a year-old female, is a student and does not work, or he can doubt that her occupation has anything to do with her ear pain. However, he might ask about her occupation and find that she is a life guard. He might have also picked this up under exercise.
A little further questioning about her life guard duties reveals that after she finishes her shift at the pool, she soaks in the hot tub for an hour, and yes, she puts her head under the water. Perhaps a question about occupation was appropriate to ask after all. The second reason to review the occupation comes into play during development of the plan of treatment.
For example, physicians cannot send a daycare worker back to work with pinkeye until the infection has cleared. If Mrs. Dunley, an year-old woman, presents with a cough, the candidate need not ask her whether she is sexually active. However, if the same patient presents with vaginal discharge, it is an appropriate question. Dunley when her last period was. This should include acute and chronic medical conditions, injuries, and immunizations as appropriate. Have you been treated for any medical issues in the past?
Are you being treated for any medical problems? Have you had any injuries? Are your immunizations up-to-date? Allergies Allergy history should investigate three categories of allergies: foods, drugs, and environmental allergies. In addition, it is not enough to know that the patient has an allergy to something, the candidate must also find out what his or her reaction is: Candidate: Do you have any food allergies?
Candidate: What happens? This represents a true anaphylactic reaction, and the candidate must ensure that the patient has an up-to-date prescription for an epinephrine auto injector EpiPen. Candidate: Are you allergic to any medications? Patient: Penicillin. My mother just always told me never to take it. Here, the candidate cannot be sure whether the patient has a true allergy or not.
The candidate could avoid the use of penicillin as a first line, but if limited options remained, the candidate could test the patient to see whether a true penicillin allergy exists. Patient: Aspirin. Patient: It upsets my stomach. This is not a true allergic reaction, but rather an adverse reaction. Perhaps the patient has only tried non-enteric-coated aspirin at higher doses. Because he has diabetes, a trial of low-dose, entericcoated aspirin would be appropriate. Surgical History Under surgical history, candidates ask what was done and when it was performed.
If appropriate, the candidate can go into more specific detail such as the symptoms prompting the need for surgery, complications, and the outcome. Candidate: What did you have done? Patient: I had my appendix taken out. Patient: About 10 years ago. With the same patient the candidate might go further: Candidate: Have you had any other prior surgeries?
Patient: I just had a baby. Patient: About 5 days ago. Candidate: Was it a vaginal delivery or caesarian section? Patient: Vaginal. Here, the candidate must consider complications of the delivery including retained placenta.
Hospitalization History For hospitalization history, besides the approximate dates, candidates should inquire as to the reason, treatments incurred, and outcomes. Family History In the minute exam encounter, candidates must be wary of spending too much time in the family history area. They should base their questioning broadly, and then focus as appropriate. Candidate: Do any medical conditions run in the family?
For example, a year-old woman, Mrs. Green, presents with polyuria without dysuria. The candidate notes her body habitus shows truncal obesity. Green, does anyone in your family have diabetes or sugar problems? Also under family history candidates must consider contacts the patient may have had with others who have the same symptoms.
I went out to eat with several of my friends last evening. Jen has the same thing. Candidate: Did you eat the same things? Candidate: Did anyone else eat the rice and not get sick? If a patient presents for an acute musculoskeletal history, it would be much more appropriate to minimize the family history and focus on more high-yield data such as those found elsewhere in the history. Candidates must know the name of each medication and the dose and frequency that the patient has been taking it.
They should be sure to include prescription medications, over-the-counter medications, herbs, and vitamins as appropriate. Candidate: Did you take anything to try to make it better? Patient: I took some ibuprofen. Candidate: How much did you take? Patient: Two little brown pills. Candidate: How often did you take them? Patient: Just that once. Candidate: When did you take them? Patient: A couple of days ago. This frequency of dosing does not represent a therapeutic failure, but rather a failure to treat at appropriate doses.
It does not exclude nonsteroidals as a treatment option. Candidates should memorize these mnemonics and know what each letter represents. With the limited time frame of 14 minutes per case, the examination must focus on the principal complaints and diagnoses that the candidate is considering. There are two methods to consider when approaching the examination.
The recommended approach is a head-to-toe approach in which the candidate considers each system and whether examination of that system has bearing on the case.
The second method is for the candidate to approach the area of complaint first, and then spread the examination to adjacent areas. Both are discussed in detail in this chapter. Candidates must approach each encounter as if they are encountering a real patient and accept the physical examination findings for what they are. If the standardized patient has a murmur, candidates are expected to identify it during the exam.
Candidates must not simply go through the motions of auscultating the heart in the four valvular areas, but must truly listen for and document abnormal findings. Temperature, weight, and height measures never need to be repeated; however, measures of abnormal blood pressures, respirations, and pulse rates should be repeated. Candidates should accept the vital signs provided for the standardized patient as true findings.
In this case, the screening blood pressure must be addressed. Regardless of whether the patient is known to have hypertension or this is a new finding of elevated blood pressure, the candidate must accept the abnormal screening pressure as real and plan for follow-up return visits to recheck the blood pressure on two additional separate occasions.
See Figure 5—1. Ask the patient for permission to do so. Rewash their hands if they have contaminated themselves in any way. Ask for permission to expose areas of examination. Re-cover the areas of examination as soon as permissible. Assist the patient in position changes no matter what the age of the patient. Drape the patient from the waist down with the sheet provided if they will be exposing the abdomen.
Each is compared here. During the history taking, the candidate finds that he has not been following his diet, he has been using salt liberally, and he has stopped taking his diuretic because it makes him urinate too frequently. The patient has a cough, dyspnea on exertion, orthopnea, and peripheral edema with a pound weight gain since his last visit. He admits to chest pain, but localizes it to the rib cage bilaterally, which he attributes to his persistent cough.
He denies fever, chills, sputum production, nausea, vomiting, pain in the neck or arm, paresthesias, or diaphoresis. How should the candidate approach the examination? See Figure 5—2. Recommended Head-to-Toe Method of Examination The candidate has already reviewed the vital signs on the patient data sheet, noting tachypnea and a normal temperature. The candidate would only repeat the respiratory rate measure because the blood pressure and pulse rate are within normal ranges.
The candidate would not repeat the weight and would accept the reading as accurate. Reviewing and repeating the vitals takes less than 1 minute. When candidates approach the examination using the head-to-toe method, they must briefly scan the body system and ask themselves whether examining it contributes to the proposed diagnosis, a diagnosis of heart failure in this case.
Do not examine. Move to the next area. Eyes: No contribution. Ears: No contribution. Nose: No contribution. Mouth: No contribution. If the patient had admitted to symptoms of an upper respiratory infection URI , it would have been appropriate for the candidate to perform a head, eye, ear, nose, and throat HEENT exam. In this acute case, signs of hypertension do not affect the immediate treatment plan and should therefore not be evaluated immediately. If the candidate completes the examination, provides a diagnosis and treatment plan, and still has time left over, she could always go back and perform the ophthalmoscopic examination.
Further, the patient is known to have atherosclerosis with a history of myocardial infarction. Auscultation of the carotids is appropriate to assess for carotid bruits. Had the patient presented with symptoms of heart failure and was found to have a tachyarrhythmia, palpation of the thyroid would be appropriate.
The typical order of applying these techniques had been inspection, percussion, palpation, and then auscultation. However, there are noted exceptions to the rule, the neck should be auscultated prior to palpation to avoid compressing stenotic carotid arteries, and auscultation should precede palpation of the abdomen to avoid changing the pattern of bowel sounds which could occur if the abdomen is palpated prior to auscultation.
Merrine, a first-year medical student then presented this argument: Is there any system that would be adversely affected if auscultated prior to palpation, and if not, why remember an order of examination that requires adjustments under certain conditions? Why not use an order that does not have exceptions?
Being unable to find contraindications to auscultation prior to palpation in any systems, I currently recommend the order: inspection, auscultation, palpation, and percussion. Next, the candidate continues the caudad drift. Now the candidate is at the heart of the matter, no pun intended. The next two systems are the greatest contributors to the proposed diagnosis of heart failure. The examination should become focused and detailed, incorporating all four components of examination techniques.
For example, in this patient, the candidate first inspects the chest. Moving to auscultation, she finds the lungs are perfectly clear. All areas of auscultation show that breath sounds are full and clear without adventitious sounds or diminished breath sounds in the bases.
Because this is one of the primary areas of concern in this case scenario with a chief complaint of shortness of breath, the candidate continues through palpation and percussion. If these are negative, no special testing is required such as egophony tactile fremitus. The lung examination takes 90 seconds. No contribution. When the candidate has completed the examination, she can assist the patient back to a seated position.
The total time elapsed is summarized in Table 5—1. At this point, the candidate has completed the physical examination portion of a very complex encounter, doing so in just a little more than 4 minutes.
Most of the patient encounters are much more limited in complexity and require even less time for the examination. The Target Method The target approach incorporates a targeted area examination technique. Many medical students prefer this technique; however, it is likely that the standardized patients are trained to expect the candidate to perform the examination using the recommended head-to-toe method.
When the candidate approaches the patient with suspected heart failure in this case scenario using the target method, the examination again begins with reassessment of vitals, if abnormal, and the general assessment. From this point, however, the candidate can imagine placing a target over the area of primary concern.
This target area is also called the absolute area—the area that absolutely needs to be examined. For example, the absolute area is the heart in heart failure, the throat in a patient with a sore throat, and the shoulder in a patient with shoulder pain. In this case, the candidate then moves laterally to the first ring of the target to examine the lungs.
We have strict editorial control processes with active learner feedback to ensure question quality throughout the question bank.
Attention to detail on every aspect of the question ensures you are well-prepared for the actual exam. Our item writers pay attention to every detail of the question stem and interrogatory.
We use psychometric analysis to ensure our team items meet the highest standards of scrutiny. To make learning even more durable, we use figures, charts, and diagrams to explain difficult concepts. Track your performance in real-time and benchmark yourself against other OMS3 students across the country. Access to hundreds of OMM videos New! Start Testing.
0コメント