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Section I: Examination components
In this section, we are going to give a brief summary about the 3 elements of the exam that you are required to pass. It is important to consider the 3 elements equally in your preparation because a high performance in 2 of them does not compensate a poor performance in the third. It is generally known that the most challenging element for IMGs is the “communication” part. However, the good news is that it is the best part to be improved with efficient practice.
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Because TOEFL examination is no longer a requirement for ECFMG certificate, this element has been added to the final score sheet. It is intuitive to mention that this element is addressed by the SP. This part should not be horrifying for the IMGs because what is really needed is to: Understand the SP and make the SP understand you. In brief, this is what you should know to help you with this part of evaluation: You do not have to pretend an American accent if you do not really have it. Accent is not part of your evaluation. If you are not 100% fluent in English (which is usually the case for IMGs), speak slowly. Slow speech minimizes the impact of your homeland accent and makes your words easy to recognize. Clear pronunciation is what really matters. When the SP talks, you should listen carefully and pay attention to understand. It is usually not difficult but because sometimes the SP describes an event with multiple sentences, you should not be lost. Do not distract yourself be thinking in the next question or trying to write down his words in the same time. Listen, listen and listen. During your practice, try to fix the way you ask the routine questions to feel familiar with and recall easy. This includes introduction and closure sentences, review of systems (ROS), past history, family history, …… Use the simplest question formulation (e.g. do you have, did you have) as long as it is applicable. As detailed later, you will summarize the history to the SP at the end of information gathering, this will help you a lot to recognize any misunderstood information. If you practice English with an English speaking community, you can judge your performance in this part. In general, this part is not challenging and what you need is to speak English fairly. Again, do not be afraid of your accent, but try to speak clearly.
There are over 20 points that the SP is asked to check after you leave the encounter. You should pay attention to each one of them and consider them all each time you practice. Print this checklist and ask your study partner to evaluate your performance at the end of each case practice. It is a common mistake that candidates concentrate on asking all relevant questions in their practice and never receive a feedback for their communications skills.
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Once you finish reading the door note, your first step is to knock the door. It is hard to miss that because all the examinee will be knocking the door at the same time. Once you are invited to enter the room, you can open the door and begin the encounter. You should dress formally. Classic shirt and pants, a tie and a clean white coat (medical or lab) are appropriate for the exam. It is another item that is easy to fulfill. However, you should never smell sweaty. A deodorant stick or spray is mandatory in the day of the exam. On the other side, strong perfumes are also disliked. Look professional, clean and do not smell. That is it. Once you are in the room, your first sentence should be close to that: Hello/Hi, Mr Y? My name is X, I am the physician in the office today, nice to meet you Then shake SP‟s hand. Continue your introduction by introducing your rule: I am here to ask you some questions and do a brief physical examination, is that okay? So to fulfill this part, you should introduce both yourself and your rule. You should be smiling at that part. Please feel free to choose the introductory sentences that are comfortable for you and fix them in your practice. This part should be easy with you. Never use sentences like e.g. How are you? Are you okay? because this may motivate the SP to talk about his complaint immediately and disturb your introduction. This may be the most challenging part in the communication section. That is because you need to keep comfortable eye contact with the SP and to write down occasional notes in the blue sheet. These are some hints that may help you:
Your eye contact should be comfortable. Look kindly and do not stare! If you feel uncomfortable to keep eye contact with a person. Try to look to the SPs forehead. This could give the same impression!
If you need to have a look on your blue sheet or to write down some notes, try to do this quickly and intermittently. Most importantly, do not look or write except when you and the SP are not talking. If loss of eye contact is mandatory at moments, it should not be while the SP is expecting you to listen and pay attention.
As mentioned earlier, only write the positive points in history taking and in brief, use (X) if all the data are negative e.g. Family History: X, Allergy: X.
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When you leave the SP to wash your hands, do not turn your back to him, try to keep looking to him while washing your hands. It is a good policy to keep one question to ask while washing your hand. It is a good time to keep eye contact as well.
During PE (physical examination), you may be looking to the part you examine. However, you need to talk to the SP before each step to explain what you are going to do. It is generally advisable that you should not talk to him while the SP is not seeing your face (e.g. standing behind him or giving him your back).
At the door note, the last name of the SP is provided. It is a very common mistake that you forget to write it on your sheet. Do not forget that! After knocking the door, this will be your first question before introducing yourself: Mr/Mrs X? Once he/she says YES, you will begin to introduce yourself. You need to keep the last name in front of your eyes. Try to address SP‟s last name at different occasions e.g. taking permission to do the PE, transition from part to part in history taking, encounter closure. We covered this part under “eye contact”. Your target is to listen carefully to the SP. Do not pay attention to any distracters while the SP is talking. Do not turn your back to him. When the SP is asking you to address his/her worries, you should be completely focused on respond to his/her concerns satisfactorily. Do not take this lightly. The SP impression about your care, kindness and attitude is the essence of the examination. It is also important to recognize SP impression and discuss their worries whenever you recognize that. Your default facial expression should always be a SMILE. Keep smiling unless it does not make sense (e.g. SP is telling bad news, SP was exposed to assault). You should show empathy at appropriate situations. Examples include:
When the SP states his complaint, you should express empathy e.g. I am sorry to know what you have been through. I will do my best to address your problem
When the SP starts to cry while recalling a bad memory, you should stop asking and keep silent, show appropriate facial expression and offer a tissue and a glass of water. You may also apologize for the stressing question. Do not continue asking unless the SP permits you to do.
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When the SP shows worry or concern about a serious medical and social issue, you should offer your understanding of his/her concern. Answer these questions in a way that relieves SPs stress if appropriate (avoid false reassurance).
You should show a respectful attitude towards the SP. Use neutral words in response to SP‟s history and examination e.g. okay, all right and avoid judging words e.g. nice, good, great, and excellent. Do not express your own judgment or give unnecessary reactions while you are trying to take some time to think of the next question. Practice is important to adjust your mind to neutral words. Do not express a negative attitude towards SP habits or behavior. All SPs are draped. The following is required to deal with draping appropriately:
You are required to take permission before untying the gown or lifting it to expose any part.
You are allowed to expose the part you examine only. For example: do not expose the abdomen and then go to examine the leg. Once you are done, tie the gown immediately.
Do not overexpose any part you examine. If you are going to examine the abdomen, lift the gown and cover appropriately with the drape in a stepwise manner to avoid inappropriate exposure.
Do not examine over the gown, any part you examine or touch should be exposed. If the SP covers his/her arm or leg with a dressing or a stocking, you should ask the SP to remove it and expose the whole limb.
In general, draping reflects your respectful attitude. Try to do it in an appropriate manner even if you are running out of time.
Throughout each encounter, you are required to ask few open ended questions. Usually, the SP will respond verbosely. NEVER interrupt him/her. Listening appropriately to the SP is part of your evaluation. The most useful situations for open ended questions are:
After you introduce yourself, you ask the SP: How can I help you? Then when he addresses his/her complaints, you may respond with: Can you tell me more about this?
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When you finish data gathering and summarize information to the SP, you will then ask him: Do you have any other complaints/concerns that you have not told me about? This is actually important not only to address another open ended question but to motivate the SP to mention information that you forget to ask about!
You should avoid leading questions which you usually ask to obtain a certain answer. This does not mean that you will not ask focused questions. You just need to avoid questions that reflect that you expect/want to receive a certain answer. You should ask: Do you have headache? and not: you have headache. right? You have chills? Am I correct? This is another easy point that you can overcome with careful practice.
Do not use multiple questions in one sentence to save time. Example: do you have vomiting or diarrhea? As mentioned above, you should avoid interruption of the SP. You should put in mind that the SPs may be more verbose at some encounters. This is usually intentional and is part of your evaluation. Always remember that communication challenges may impact your score more than the questions or PE that you miss due to SP verbosity. Paraphrasing means that you repeat SP particular answer in his/her own words. You only need to paraphrase for few times to fulfill this item. It is also useful when you need to check that you understand the SP‟s last words correctly. This is another challenging point that can be overcome with practice. Avoid medical terms (e.g. dysuria), and medical items (e.g. past medical history, family history) and use simple words instead (e.g. pain with urination, your health in the past, questions about your family). If it is essential to mention a medical term e.g. a possible disease or a diagnostic approach, you should explain it in a simple language. Always provide your explanation before the SP asks you about it.
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Section II: Management of the encounter
In this section, we are going to illustrate how the encounter is generally managed. Some encounters may vary according to the complaint of the SP. However, there are general principles that you need to follow during your practice to feel familiar with at the time of the real exam.
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Once the exam begins, you will be asked to stand in front of the door that corresponds to your number. You are not allowed to slide the door note cover unless you hear the announcement. You will be provided with 12 sheets, 2 pens that you better hold in your coat pocket and a stethoscope. Always remember to keep the stethoscope on your shoulder and do not forget it at your desk. You better bring your own stethoscope because the number of stethoscopes in each center may be limited. You are not allowed to write on the blue sheet before you hear the announcement. Once you hear the announcement, slide the cover. You will find a door note that contains SP‟s last name, age, complaint and vital signs. Unlike AMGs, IMGs do not enter the encounter immediately. Instead, you may spend 3060 seconds in front of the door. You may shorten this period with efficient practice and calmness. Do not panic for losing these seconds. These few seconds could help you to concentrate, organize your thoughts and write notes and mnemonics that will guide you to manage the encounter efficiently. If your blue sheet is well written, you will save a lot of time recalling questions inside the encounter and will avoid disorganized questions and unprofessional presentation. There are many ways to prepare your blue sheet. We are going to suggest one of them here but you may modify it according to your needs. You should know that the blue sheet is not that large and there are some words printed over it (adjust your expectations and practice accordingly!). Once allowed to write, you may divide your sheet into 4 parts and a header:
Use the header to write the SP‟s last name (NEVER FORGET IT) and age on the left side. On the right side of the header, you may write any abnormal vital signs. It is optional that you write the system that you are going to examine to keep it in front of your eyes. If you forget or do not recognize vital signs, you may re-check them again on your computer when you finish the encounter. However, it is better that you recognize abnormal vital signs prior to the encounter because this may confine your expectations inside the encounter.
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In the first quarter, you may write HPI (analysis of the complaint). The questions for each complaint may vary and you may need to cancel or add some questions. However, the form is suitable for most cases: O = Onset P = Progress C = Consistency F = Frequency D = Duration A = Alleviating factors A = Aggravating factors A = Associated factors In pain cases, you should add 4 essential questions: S = Site S = Severity Q = Quality R = Radiation
In the second quarter, you may write the mnemonics/figure/possibilities for the differential. This is the part that you need to fulfill in the best way.
In the third quarter, you may just write (ROS). Do not write anything in this part unless you receive positive information because in the patient notes, you will address ROS as negative if nothing is there. You do not need to recall ROS questions because you will ask them briefly and systematically from above downwards. Practice helps you to recall these questions without effort.
In the fourth quarter, you need to write the mnemonics of the rest of history: P = Past history A = Allergy M = Medications H = Hospitalizations S = Sleep F = Family O = Occupation & OBGYN history S = Social history S = Sexual history A = Appetite W = weight E = Exercise and diet T = Travel
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Once you prepare your sheet, knock the door. The SP will call you to come in. You can open the door now. Always remember, smiling is your default unless indicated. A smile should be your first presentation. When you open the door, ask about SP identity e.g. Mr. X? Then you can enter the room.
Begin the encounter by a sentence to introduce yourself. For example: „Hello, I am Dr. X the physician in the office today, nice to meet you‟. Shake SP‟s hand…. „I am here to ask you some questions about your health and do a physical examination. Is that okay?‟ Keep smiling….. „Do you feel comfortable in the room?‟ You will be answered YES „So Mr/Mrs X. How can I help you today?‟ Choose your way to express these 4 sentences but fix them and keep practicing to feel familiar with them. Do not use questions like: how are you? Are you fine? Once you listen to SP‟s complaint, express empathy by facial expression and words like: „I am sorry to hear about what you experience‟ and show support: „I will do my best to help you with this.‟ After showing empathy and support, ask your first open ended question: „Can you tell more about that?‟ In some encounters, the SP will respond with much information that may answer some of your questions before you ask. Follow the SP and do not interrupt. If you feel that you did not catch all the information, you may ask the SP to summarize by asking HPI questions.
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Next, start asking questions to analyze the complaint: O = Onset: When did this pain start? Do you remember any particular event that precipitates this complaint? P = Progress: Is it getting better or worse? C = Consistency: Is it continuous or coming and going? (Ask about F & D if it comes and goes) F = Frequency: how many times/how frequent do you have this complaint? D = Duration: How long does it last each time? A = Alleviating factors: Is there anything that alleviates this complaint? A = Aggravating factors: Is there anything that aggravates this complaint? A = Associated factors: Did you notice any others troubles at the same time? In pain cases, you should add 4 essential questions: S = Site: Please, can you point to the site of pain? S = Severity: on a scale from 1 - 10, 10 being the worst, how can you rate your pain? Q = Quality: What Does It Feel Like? R = Radiation: Does this pain travel to other parts of your body? Then, ask specific questions for each differential diagnosis (see later). Do not forget to do paraphrasing. For pediatric cases, ask if the SP is the legal guardian of the child Remember, sheet quarters help you not to forget transitional phrases. When you move from a quarter to another, address this to the SP. Begin the third quarter by: “I want to ask you some questions about your health in general, is that okay?” Unless you feel confused about the case, you may only ask 1 or 2 questions for each system to cover it. Frequent irrelevant questions do not improve your score and waste your time. However, be sure to cover all systems. Sometimes, you may be surprised by an extremely important data that you forget to ask about! The systems you need to cover are:
General: fever, tiredness Cranial: weakness, numbness, dizziness, headache, blurring Chest: pain, cough - Heart: heart racing, shortness of breath (SOB) GIT: change in bowel movement, blood in stool Urinary: changes in urination, blood in urine, change the color of urine Musclo-skeletal: joint pain Dermatologic: skin and hair changes
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Patient name – Age
| Abnormal vital signs (if any) – Type of exam DD (a case of watery diarrhea)
O P
A
C
P
F C D G
A A
I
A
L
S
T
S Q R ROS
P A M H S F O S S A W E T
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Section III: Clinical background
In this section, we are going to provide a summary of clinical knowledge that can refresh your mind. In general, you do not have to go deep in clinical reading as you may have done in the CK exam. Instead, you just know about the presentation of the common differentials. We strongly recommend that you read this section before practice.
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Cholecystitis
Female, 40s in age, obese RUQ pain, related to heavy fatty meal Nausea and vomiting Pain radiating to the right scapula
Ascending cholangitis
Forty, female, obese Intermittent RUQ pain Fever and jaundice History of asymptomatic gall stones
Acute hepatitis
RUQ pain
Recent travel outside the US Fever Anorexia Nausea and vomiting Dark urine and pale stool
RUQ tenderness Positive Murphy‟s sign
RUQ tenderness Jaundice
Peptic ulcer disease
Burning epigastric pain Pain relieved with meals and antacids and aggravated with hunger History of NSAIDs and stress
Epigastric tenderness
Gastritis
Epigastric pain aggravated by meals Nausea and vomiting History of NSAIDs
Epigastric tenderness
Non-ulcer dyspepsia
A diagnosis of exclusion
Perforated ulcer
Severe epigastric pain/diffuse
Tenderness, rebound
abdominal pain Nausea and vomiting Heavy smoker, NSAID use Past history of peptic ulcer pain
tenderness Guarding
Gastric cancer
Loss of weight Loss of appetite Low grade fever
Splenic rupture
LUQ pain radiating to the left scapula History of infectious mononucleosis (mono) History of trauma to the abdomen
Pancreatitis
Severe epigastric pain radiating to the back Pain improves with leaning forward.
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Anorexia, nausea and vomiting Frequent alcohol intake Pancreatic cancer
Old patient Dull epigastric pain radiating to the back Weight loss Dark urine and pale stool Heavy drinker and smoker
Mesentric ischemia/infarction
Acute severe crampy pain Pain aggravated with meals Vomiting Dark stool History of cardiac diseases, AF
Rectal examination, stool for occult blood U/S-abdomen
Upper endoscopy Non-invasive H pylori testing (serology for antibodies) AST/ALT/bilrubin/alkaline phosphatase HIDA (hepatobiliary scan)
Jaundice
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Appendicitis
RLQ pain aggravated with movement It starts as dull pain around the umbilicus Low grade fever Nausea ± vomiting
Low grade fever RLQ guarding RLQ tenderness and rebound tenderness Positive Rovsing‟s sign Positive Psoas sign
Pelvic inflammatory disease (PID)
Low grade fever Nausea and vomiting Vaginal discharge
Low grade fever LQ tenderness
Unprotected sex with multiple partners History of previous STD Ectopic pregnancy
Period of amenorrhea Vaginal spotting Lower abdominal pain, exacerbated with movement Nausea and vomiting No efficient contraception
RLQ guarding RLQ tenderness and rebound tenderness
Ruptured ovarian cyst
Sudden pain History of ovarian cyst
RLQ guarding RLQ tenderness and rebound tenderness
Adnexal torsion
Sudden pain History of ovarian cyst
Gastroenteritis
Low grade fever Nausea, vomiting Diarrhea
Abortion
Amenorrhea (usually > 6 weeks) Lower abdominal cramp Vaginal bleeding
Endometriosis
Chronic pelvic pain (acute severe pain may be due to rupture of an endometrioma) Dysmenorrhea Dyspareunia Infertility
RLQ guarding RLQ tenderness and rebound tenderness
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Pelvic examination Urine hCG Cervical cultures U/S-abdomen/pelvis CT-abdomen/pelvis CBC
UA Laparoscopy
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Section IV: Data gathering and closure
In this section, we are going to exhibit the most important questions for each case and how to memorize them. It is essential that you do not miss important questions and not to be redundant as well. Furthermore, it is a poor strategy that you use mnemonics for all cases. It will be difficult for you to recall above 50 mnemonics and it will be impossible to remember the meaning for all the “A”s, “E”s, “S”s and so!. Accordingly, you will look confused while trying to recall the full names and your attitude will not look professional. Instead: (1) keep mnemonics for challenging cases only (2) use a mixture of mnemonics for some cases and figures (illustrations) for the others to rest your mind. (3) use a mnemonic/figure that is apparently related to the case, so that you can recall the suitable one for the suitable case and not to get lost. The stress of the actual encounter makes things harder than they feel in the practice. So, try to use the easiest approach for you.
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Analysis: OPCFDAAA + SSQR Differential diagnosis: ask about:
GERD Aortic dissection
Pulmonary embolism Costochondritis Pneumothorax
Hemothorax Pneumonia MI/Angina/Cocaine Pericarditis MI/Angina: shortness of breath/sweating/heart racing/relation to exertion? Cocaine induced: taking recreational drugs/relation of last dose to pain? Aortic dissection: hypertension? Uncontrolled? Pericarditis: recent flu/relation of pain to position? Relation to breathing? Pneumothorax/hemothorax: shortness of breath/chest trauma? Pulmonary embolism: leg clots/prolonged recumbence (recent surgery-flights)/OCPs? Costochondritis: recent flu/relation to breathing? Acute chest syndrome: history of blood disease/repeated blood transfusions
PAMHSFOSSAWET: emphasize on drugs – medical history (HTN, DM, hypercholesterolemia) Examination: Neck (carotid auscultation - JVD) Extremities Full CV/Chest (inspection, auscultation, palpation, percussion) Abdominal examination (inspection, auscultation, palpation)
Closure: Give your impression about the causes Explain possible investigations Education about diet (if the SP is a potential cardiac patient on unhealthy diet), cocaine cessation, exercise/effort, stoppage of OCPs (if DVT is suspected)
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Analysis: OPCFDAAA + ABCO (Amount: amount of blood “fills teaspoon, tablespoon, a small cup or more?” – Blood: Blood relation to urine “before urination, after urination or mixed with it” – Color: color of urine – Odor: odor of urine)
Differential diagnosis: mnemonics for differential diagnosis: HITTERS H = Hemorrhagic: do you bleed from other sites, do you bruise, drugs? I = Infection: change in urine frequency, feel urge to urinate, pain or burning with urination, wake up at night to urinate “nocturia”, fever, flank pain? T = Trauma: exposed to trauma? T = Tumor (renal cell carcinoma, bladder cancer): change weight or appetite, difficulty initiating urination, maintaining urine stream, weak urine stream, small caliber of urine, dribbling of urine? E = Exercise: Recent vigorous exercise? R = Renal diseases (PCK or GN): leg swelling (lower limb edema)?, flu like symptoms (IgA nephropathy), family history of kidney disease? S: history of stones, flank pain?
PAMHSFOSSAWET: emphasize on drugs – exercise – family history Examination: While sitting: General examination + Chest and heart + CVA tenderness “do it gently” While lying flat: abdominal examination + lower limb edema
Closure: Counsel about possible causes Counsel about work-up, most importantly: - Genital and rectal examination (you may ask about their value, you may be even asked by the SP) - Cystoscopy (if necessary, describe it as a tiny camera on a thin tube that is inserted through the urethra to have a look on the interior of the bladder) - Urine analysis and imaging
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Analysis: OPCFDAAA + SSQR Differential diagnosis: (1 figure for differentials and the other for questions) Eye Disc herniation
Joint Fracture
Metastasis, multiple myeloma
Lifting heavy objects/ Exercise/ Trauma
Loss of weight
Spinal canal stenosis
Paraspinal muscle strain
Urinary difficulty/incontinence Stool incontinence Erectile dysfunction DEXA scan
Hotness, swelling, redness/stiffness, restriction of motion
Ankylosing spondylitis
Numbness, weakness, tingling
PAMHSFOSSAWET: family history Examination: General examination Back exam (inspect of the back and range of motion, palpate for tenderness) Lower limb examination: inspection, palpation for pulses – straight leg raising test Neurological examination: motor – sensory – DTRs (including Babinski sign) – gait Chest and heart (auscultation)
Closure: Counsel about possible diagnoses Counsel about diagnostic work-up: - Rectal examination (for urinary symptoms), breast examination (for possible cancer) - Imaging of the back (X-ray and MRI) Education about: -
DEXA scan (once for life), Ca and vitamin D for postmenopausal women
- Need for rest (if disc herniation is suspected), including a note for the employer
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Analysis of pain (if present): OPCFDAAA + SSQR Analysis of accident (or any major trauma): ask about: Before accident: were you under the effect of recreational drugs/alcohol? During: when did that happen? What happened exactly? After accident(sequences): cover these 4 elements: - Injuries: did you have head injuries, any other injuries? - Neuro: Did you have LOC – seizures – confusion – lack of concentration – changes in vision – vomiting? - Blood: Did you bleed from the nose, mouth, ear? – do you have bloody stool or urine? – do you have weakness, numbness, tingling? - Pain: Do you have headache? pain in the limbs, chest, belly?
PAMHSFOSSAWET: emphasize on recreational drugs Examination: Minimental state examination (MMSE) + Neurological examination Full examination of any affected system Examination of the extremities (inspection for any injuries, bruises and testing range of motion) Chest/heart/abdomen examination
Closure: Give your impression about possible diagnoses Offer diagnostic work-up (particularly bone imaging, sonographic imaging of internal organs) Inform the SP about OBSERVATION; he/she should be under observation particularly if the SP exhibits any symptoms related to head trauma or any significant injury.
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Analysis of positive pregnancy test: Always remember, if you receive an email that your spouse is pregnant, it is a SPAM! P: Pregnancy test (when did you have this test? Did you do it by yourself?), Planned pregnancy (is it planned or not?) M: Menstrual history (OBGYN history): CLARC BPPP - C: Cyclic (days of menses/length of the cycle) - L: LMP - A: Age at menarche - R: regularity - C: Contraception - P: Pads or tampons/day - B: Bleeding between cycles - P: Pain during menses/between menses - P: Pregnancy and abortions - P: PAP smears (last PAP, normal or not, history of previous abnormal PAPs) S: Symptoms of pregnancy: from above downwards: - Do you have nausea/vomiting? - Do you notice any breast changes? - Do you have bloating? Weight changes (gain)? A: Abnormal pregnancy: - Belly pain? back pain? - Vaginal bleeding/spotting?
PAMHSFOSSAWET: medical history, family history, social history (domestic violence), travelling, immunization, exercise (All could be points of COUNSELLING)
Examination: General examination: do not forget pallor and thyroid Chest and heart Abdominal examination
Closure: Explain impression (pregnancy, ectopic pregnancy or abortion according to context). Prescribe diagnostic workup: repeat pregnancy test, do breast and pelvic exam, do pelvic U/S, you may counsel for early pregnancy screening (Pap, urine, cervical culture, screening for infection, cervical culture) Offer education: (teratogenic factors) -
Advice regarding cessation of smoking, any medications, vigorous exercise
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- Advice regarding unplanned pregnancy: she may need to discuss this with her partner, and you would like to meet them to help them with their decision. If they decide to continue, offer them a program that helps her to know more about planning for a family.
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Analysis of diabetes: DC FAT D: Diabetes: when was diabetes diagnosed? How? which type? Is the child still having these troubles? C: Complications: - Parent: how did this affect you as parents? - Child: Psychological: how did the child respond to that? Physical: fainting, visual, itching, infections, WNT, weight changes, urination and thirst F: Follow up: - How do you follow up blood sugar? Who does? - Average readings? Last reading? - Regular check-ups? A: activity: is he playing and exercising? LOC while playing? T: treatment: - Diet? - What type of treatment? Treatment schedule? Compliance to treatment? Who is th treatment provider? Site of injection?
Closure: Give your impression about the efficiency of diabetes control (according to symptoms and glucose readings) Explain diagnostic work-up Offer education: SHEE (Empathy – Education – Hypoglycemia – Support) - First: Empathy: emphasize that diabetes could be controlled by diet, exercise, insulin - Second: Education: offer diabetes classes for the parents and the child - Third: Hypoglycemia: explain hypoglycemia and its symptoms and how to avoid it (proper timed meals, moderate exercise, availability of sweets) - Fourth: Support: the family and the school should be oriented about the child problem to offer proper help if needed
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Analysis of complaint: OPCFDAAA + SSQR ± analysis of major trauma (if present) Differential diagnosis: Rotator cuff injury
Violence
Osteoporosis
DEXA
Hotness, swelling, redness/stiffness, restriction of motion
Trauma, exercise
Myositis, strain Arthritis
Angina
Numbness, weakness, tingling
Dislocation Fracture
PAMHSFOSSAWET: emphasize on social history (to exclude domestic violence) For exclusion of domestic violence, ask: who do you life with? SEAR: S: SAFE: Do you feel safe at home? E: Exit plans? Do you have exit plans? A: Alcohol? Is your partner alcoholic? R: Relation? How is your partner relation with you? With others?
Examination: Examine the neck for range of motion Examine both extremities for comparison: - Inspection (for bruising & range of motion) - Palpation (for tenderness – arterial pulse) - Neurological for upper limbs (motor, sense, DTRs) Chest and heart examination
Closure: Give diagnostic impression and explain workup (XR, MRI) Counsel for domestic violence (offer contact information for support groups – offer a social worker assistance to arrange for senior living communities, any related sibling abuse should be reported to child protective service )
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Section V: Patient notes
In this section, we are going to provide the full form of patient notes and the common abbreviations that you are allowed to use. Note that you will note write the full patient note in the exam. You need to report only the primary system in details.
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General Rules Now you will sit on the desk beside your encounter, enter your number to open the note. You have 2 strategies to use. Either to start from above (begins with history) or below (begin with differentials). In general, the part you start with is the part that you spend much time for. Your decision to choose one of these strategies depends on your typing speed, the time you save by leaving the room early and your convenience according to your default practice. The differential is the most critical part because it needs some time to think and is the part of the note that presents your thinking most.
To address your history in a proper way, you should start with analysis of the complaint, then proceed to the differentials; present positive information first beginning with data that is most significant or relevant to the differentials you expect. Then you better write some negative information that you did not find. You do not have to write all the questions you asked, but at least you should mention some negatives that exclude common diagnoses and make your differentials in the bottom of the note reasonable. The summation of positives and negatives that you write usually cover most differentials. This reflects your understanding of the clinical background of the case.
A good blue sheet helps you a lot. You may use this memory to recall data but generally, this may not be efficient in actual examination as it is in practice particularly when you are at the late encounters where you are not sure if this information belongs to this SP or not. Your blue sheet should not contain much hand writing, only focused few well written brief words that indicate positives. Negatives will be the „X‟s you made in front of each question or differential. Because you usually write the mnemonic of questions/differentials in the blue sheet at the door, you will be able to check your sheet and write the positives and negatives accordingly.
While writing differentials, consider age and sex as factors that could support your diagnosis e.g. cluster headache is more common in males
The “2 minutes left announcement” should mean that you are at the second differential or more.
When you write you diagnostic work up, prioritize the investigations that are directly relevant to the differentials you select. So always have a look on the differential.
You should get familiar with the allowed abbreviations and avoid using unknown ones. You can use this official link (P. 13): http://www.usmle.org/pdfs/step-2-cs/cs-infomanual.pdf
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ADULT SHEET
HPI: ----- yo M c/o ------------. The pain started ------------ (mention all positives and negative in complaint analysis and differential diagnosis) …. No previous similar episodes.
OB/GYN:
G1P1
Menarche at age 14
Has regular periods 5/30
LMP
Not painful (associated with cramps)
Last PAP smear 6 months ago and was normal, no history of abnormal PAP smears
1 child, 3 years old, uncomplicated vaginal delivery
Contraception
ROS: negative except as above
Allergies: NKDA (no known drug allergies), OR pencillin causes rash
Medications: mention the drugs (and may be the dose or indication)
PMH: Hypertension + for 5 years + treated by diuretics + controlled
PSH: appendectomy 10 years ago
SH:
Cigarette smoking 1 PPD (pack per day) & for 20 years & stopped 3 years ago +
Occasional EtOH (ethyl alcohol) & for 10 years (or 1-2 bears at the weekend) & CAGE 0/4 +
Occasional cocaine & for 2 years (or no recreational drugs) +
No regular exercise +
No particular diet (or not adherent to diet control or vegetarian) +
Works as …… +
Married, live with her husband and 2 children, has good support system (family, friend)
Heterosexual, has one partner in the last 2 years, use condoms, no history of STDs,
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FH:
Father died of lung cancer at age 70 +
Mother is alive and well (or has diabetes) +
There is history of ovarian cancer (her aunt) at 45 years
OR: noncontributory
Diet (in relevant cases e.g. weight gain)
Patient is in severe pain/acute distress/ mild distress due to back pain
VS:
BP ----/---- mmHg, pulse ----, RR ----/min
OR: WNL (within normal limits) except ---------
HEENT:
Head: NC/AT (normocephalic atruamatic), no bruises
Eye: o No pallor or icterus o PERRLA (pupil equal, rounded, reactive to light and accommodation) o No fundoscopic abnormalities (no papilledema) o EOMI (extra-ocular movements intact) without diplopia or lid lag, visual fields full to confrontation o No nystagmus (or vertical gaze nystagmus)
Nose: No nasal congestion
Ear: o No redness to ear canal, no cerumen, TMs (tympanic membranes) with light reflex o no tenderness to auricle or periauricle, o Weber test without localization o + Rinne test (air conduction > bone conduction) o Negative tilt head
Mouth: No pharyngeal edema or exudates (± no tongue trauma)
OR: nose, mouth and pharynx WNL
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Section VI: Challenging situations
In this section, we are going to address some situations and questions that you may be confronted with in the real encounter. Understanding these points helps you to manage a variety of similar situations during the exam
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The SP begins to cry on recalling a bad experience: Stop questioning, show an appropriate facial expression. Keep silent and only offer the SP a tissue. You may pat on his/her arm supportively. The SP will then stop crying and ask you to continue. You may apologize for the question and explain that it was necessary and express you are sorry for her bad experience. Be sure that she is ready to continue. The SP is having severe headache: After introducing yourself, express your empathy for the agony that you notice the SP has. Offer to turn the light down (there is a separate button for this) and offer a glass of water. The SP is asking for immediate medication for pain: Express that you would like to prescribe him/her a medication, but address that you need to ask some questions and do a brief examination first to be able to let him/her know what is going on and prescribe a medication that is right for his/her problem The SP want to leave/refuse to be admitted because he/she cannot afford treatment costs, has insurance issues, leaves her children at home: Always express that leaving without complete knowledge of the actual diagnosis is serious. Then you can offer him/her a social worker contact that will help to solve these financial issues, confirm that her children will be taken care of at the time of admission. If the SP is not sure whether insurance may cover these expenses, you should not answer that. Just explain that you are not sure but in cases he/she is confronted with any financial issues, a social worker may be involved to figure this out. The SP asks if it is necessary to inform her partner/parents about a STD or a possible pregnancy: For a minor, you do not have to notify her parents about pregnancy, contraception or STDs. For partners, you should advise her to inform the partner in case of STDs because he/she may be the source of infection and may need to be treated and HIV cases, he/she should be protected against transmission as well. The SP is asking you why you ask me this: You should be familiar with this. Each question or examination step should have an explanation in your mind. You do not have to supply complicated medical explanation. Rather, you may just explain this broadly as long as you do not have a strong relation with SP‟s complaints. Example: I am checking your neck for swellings; sometimes swollen nodes in your neck indicate hidden infection or tumors. Generally, be honest and do not lie to hide your intention. If you ask about domestic violence and the SP interrupt you to ask, tell her/him that you are concerned about her safety and want to be sure she/he is not subjected to any kind of violence.
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Section VII: Summary
This summary can be used to revise your knowledge in the last days prior to the exam. This part addresses the most important questions, the specific examination that should not be forgotten in each case, major points of closure, and the relevant workup
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Case 1: Chest pain Analysis: OPCFDAAA + SSQR Differential diagnosis:
MI/Angina: shortness of breath/sweating/heart racing/ exertion
Cocaine induced: recreational drugs/last dose
Aortic dissection: uncontrolled hypertension
Pericarditis: recent flu/relation to position or breathing
Pneumothorax/hemothorax: shortness of breath/trauma
PE: leg clots/prolonged recumbence (surgery-flights)/OCPs
Costochondritis: recent flu/relation to breathing
Acute chest syndrome: history of blood disease
PAMHSFOSSAWET: drugs – exercise – diet Examination: neck (carotid - JVD) – extremities – full CV/Chest Closure: causes – investigations Work up: ECG – CPK-MB, troponin I – TTE/TEE – CXR – cholesterol panel – Urine toxicology – Upper endoscopy
Case 2: back pain Analysis: OPCFDAAA + SSQR Differential diagnosis:
PAMHSFOSSAWET: family history Examination: Back exam (inspect, palpate, range of motion) - Neuro – pulses for all extremities – Leg raising test
Closure: rectal examination –imaging Work up: rectal exam (saddle sens exam) – XR-L-spine – MR-L-spine – PSA – Serum/Urine protein electrophoresis
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Case 3: Bloody urine Analysis: OPCFDAAA + ABCO (amount – blood: how did you know, clots, relation to urine – Color - Odor) Differential diagnosis: HITTERS
H: bleeding from other sites, bruising, drugs
I: frequency, urgency, dysuria, nocturia, fever, loin pain
T: exposed to trauma
T: change weight or appetite, difficulty initiating, maintaining stream, weak stream, small caliber, dribbling
E: Vigorous exercise
R: edema, hypertension, flu like symptoms, family history
S: history of stones, flank pain
PAMHSFOSSAWET: drugs – exercise – family history Examination: CVA tenderness Closure: gential and rectal examination – urine analysis and imaging Work up: Gential/rectal exam – Renal U/S – urine analysis/culture – Cystoscopy – CT abdomen – pelvis – BUN/Cr
Case 4: diabetes follow-up Analysis of diabetes: DC FAT
D: Diabetes – when it was diagnosed, how, which type, is the child still having these troubles
C: Complications:
fainting, visual, itching, infections, TIAs/stroke, heart racing, bowel changes/discomfort, urine changes, sexually changes, foot infection, WNT, weight changes
F: Follow up: How do you follow up blood sugar? Who do? Average readings? Last reading? Checkups? (eye – foot)
A: activity: is he exercising/active? LOC, hypoglycemic symptoms
T: treatment: Diet? Exercise? What type of treatment? Schedule? Compliance to treatment? Provider? Site?
PAMHSFOSSAWET: family history, exercise, diet Examination: HEENT (fundoscopic), JVD, carotid, Neuro, extremities (peripheral pulses, inspect foot) Closure: You follow your medications correctly (need to adjust ….). I can give you a refill today. Run some tests to check everything is ok. Counsel for exercise and diet
Work up:Serum glucose, HbA1c, UA, urine microalbumin, BUN/Cr, nerve conduction studies DD:of all complaints
