When I was a student, I had no idea what criteria they used to pass students. This book has it. You will not find the criteria online. Instead, you always hear vague "criteria" on what people think they did to pass. Just buy this book. You'll wont regret. Great last minute review for the PE! By RSJ Awesome book. It had everything I needed besides a few pertinent osteopathic treatments I reviewed from another book. I passed and it was the main resource I used!
Posting Komentar. Kamis, 28 Juni [M See all 27 customer reviews Candidates should pay as close attention to their physical appearance as they did when they interviewed for medical school. Their white coat should be clean and wrinkle free. Hygiene is important as well and sometimes it is easy to overlook any deficiencies in this area. Candidates should shower the evening before or the morning of the examination. Their hair should be well groomed, and men who do not have beards should be clean shaven.
Beards should be well trimmed and groomed. Although these guidelines seem too obvious and like they are just common sense, it is worthwhile for candidates to pay close attention to them. That is, was the candidate kind to the patient? If a patient presents in pain, the candidate must recognize it and discuss it directly so that the patient understands the pain is a priority for the candidate as well.
Candidate: Ms. Green, I can see that you are in a lot of pain. Table 2—6 Professionalism: Standardized Patient Checklist Was the candidate professionally dressed and groomed? Yes No Did the candidate demonstrate compassion?
Was the candidate kind? Yes No Did the candidate appear confident? Yes No Did you feel as if your conversation with the candidate would be kept confidential? Yes No Did the candidate appear ethical?
They can write the plan mnemonic MOTHRR on their patient information sheet, and work through it concisely, advising the patient of each component as they go. Clark, it looks like you have appendicitis. Gemma to come take a look at you because you might need to go to surgery. The nurse will be putting an IV in so that we can give you an antibiotic and fluids. As soon as Dr. Do you have any questions? These times often center around sensitive issues such as sexuality, infectious disease, and mental health, among others.
This tells patients that unless they give the physician permission, the physician will not share the information with anyone. We can work on this together. Is there anyone you would like me to share this information with?
Relationships must be on professional levels. For example, overly friendly gestures, such as touching a patient on the leg, could be considered flirtatious and inappropriate.
Though encounters with standardized patients will likely leave little room for unethical behavior, it should be guarded against. How would an ethical practitioner respond to this question? Patient: Dr. Do you think I could have a few more days off from work? Accessed December 6, Each examination room is equipped to meet the demands of a typical outpatient visit.
The only personal examination equipment the candidate is required to bring is a stethoscope. The case format for each patient encounter is the same: the candidate is given 14 minutes to complete the entire encounter, followed by 9 minutes to complete documentation of the encounter in SOAP note format. An overhead announcement advises the student when the minute patient encounter begins. After reviewing this information, the student enters the room and takes a history based on the chief complaint and performs a problem-specific examination.
Another overhead prompt alerts the student when 2 minutes are remaining in the encounter. At this point, the candidate should wrap up the current examination and proceed with assessment and plan, discussing a diagnosis with the patient and developing a plan of therapy. Candidates should ask the patient if he or she has any questions and express gratitude by thanking the patient. When the announcement is made that encounter time is ended, the student must immediately leave the room.
Another 2-minute warning is made as the session nears its end. After 9 minutes, the close of the documentation session is announced and the candidate must immediately stop writing. Failure to do so may result in invalidation of that documentation session.
For example, if the candidate completes her patient encounter and leaves the exam room with 4 minutes of the minute session remaining, she can begin the SOAP note and have a total of 13 minutes for documentation—4 left over from the encounter and 9 from the allotted SOAP note documentation time. Candidates must beware that once they leave the exam room, they cannot reenter the room under any circumstances.
Therefore, candidates might find that it is better to use any extra time in the patient encounter to further develop a patient—provider relationship. Other information may be found with the patient data sheet such as parental consent if the patient is a minor, laboratory values, radiographic images, or electrocardiographs ECGs. Would you prefer I call you Mrs. Smith or Linda? Office Setting The candidate should identify the type of facility where the encounter occurs.
Based on information provided about typical patient chief complaints, the types of facilities expected would be ambulatory primary care clinics, outpatient offices, or emergency rooms. For example, if the office setting is a family practice clinic and upon entering the room and performing the exam, the candidate determines that the patient may have acute coronary syndrome, his primary concern would be emergent transfer of the patient.
The candidate should explain this need to the patient. The SOAP note plan would demonstrate that the candidate is following Advanced Cardiac Life Support ACLS guidelines, which include administering aspirin, nitroglycerine, and oxygen while awaiting arrival of the ambulance.
The candidate would also notify the hospital of the pending transfer and any family members the patient would like to be notified. However, if the office setting were the emergency room, the plan would concentrate on diagnostic and treatment protocols.
The candidate would advise the patient of the need for admission and referral to the cardiovascular service, with the possibility of the need for cardiac catheterization depending on the results of the evaluation.
Of course, the candidate would place the patient on a monitor, perform serial ECGs, take a chest radiograph, and order stat lab work such as a CBC, chemistry, coagulation, and cardiac profiles. Reason for the Visit Often documented by ancillary medical staff, the patient information sheet will contain the reason the patient is there to see you. In clinical practice, the reason for their visit that patients give the nurse might not be the same reason they tell the physician.
Once confirmed, the reason for the visit is documented as the chief complaint in the Subjective S part of the SOAP note. Age and Sex Within the patient demographics, age and sex can allow for ranking of the possible diagnoses by likelihood. Using the previous chest pain example, if a year-old man presents with substernal chest pain, the candidate would rank acute coronary syndrome high on the list of possible diagnoses.
This diagnosis would be less likely if the patient were a year-old girl—although it is possible that she is having a myocardial infarction, it is highly unlikely. Race Race plays a role in the development of a differential diagnosis based on epidemiology of disease. For example, sickle cell disease is much more common in patients of African descent and must be considered with greater suspect in a year-old African American boy with acute left upper quadrant pain than it is in a year-old boy of European descent.
Race may also come into play during treatment planning. For example, when treating a hypertensive African American patient, a physician might choose a calcium channel blocker over a betablocker because this population is more responsive to the former. Vital Signs Vital signs often include height, weight, temperature, pulse rate, blood pressure, and respiratory rate.
Again, these values are typically obtained by ancillary staff before the patient sees the physician. It would, however, be prudent for candidates to repeat blood pressure, pulse, or respiratory rates when any of these values are abnormal.
On the patient information sheet, candidates may consider circling abnormal vital signs to prompt themselves to repeat these measures as they finish history taking and move on to the physical examination.
An overhead announcement tells them that they may enter the room. This is the beginning of the minute patient encounter. Before going into the room, candidates must open the wall unit and remove the information inside. In all, this takes about 15 to 30 seconds. It is the key to a comprehensive, detailed, yet speedy history. See Table 3—1. When the candidate enters the room, she must have the mind-set that this is a real patient that she is about to see and must treat him or her as such.
If candidates enter the room thinking that this is just a test with a programmed standardized patient who has the answers to all of the questions, they become mechanical, simply try to ask enough questions to pass the exam, and will fail in the Humanistic domain. See Chapter 2. Almost immediately, physicians can run into a problem. It is typical in the United States to greet most patients with a handshake. Unfortunately, if the physician does so prior to washing his or her hands, the physician has just contaminated the patient.
Although the candidate might have just washed her hands upon leaving the last room, she had to turn the door handle on the door to get into this room, so whatever is on that handle is now on her hands. Although it may seem awkward, candidates should knock, enter the room, stop, make eye contact with the patient, greet the patient using his or her name, and introduce themselves. Then, they can briefly excuse themselves to wash their hands in the sink in the examination room while explaining the need to do this before touching the patient.
The dialogue may go something like this: Candidate: Hello, Mr. Please excuse me a few seconds while I wash my hands. The patient will be more than happy to postpone the handshake until the candidate washes her hands. The hand washing period represents the next opportunity for developing the physician—patient relationship. A proper hand washing lasts at least 15 seconds.
See Table 3—2. If candidates recontaminate themselves such as by turning off the water with their hand, dropping a pencil on the floor and picking it up, touching their hair or face, or sneezing into their hands, they must rewash. Before getting down to the business of taking a history of the patient, the 15 seconds of hand washing can begin building a relationship. While candidates wash their hands, they might have the following conversation: Candidate: Mr.
Roth, do you prefer to be called Mr. Roth or John? Did you make it in okay today? Patient: Yes, no problem at all. Candidate: Great. I know Philadelphia can get slippery this time of year. The patient perceives that the physician has time for and interest in him or her beyond the sterility of an office visit. Turn on hot and cold water and adjust to warm. Take soap from the dispenser. Lather for 15 seconds. Rinse your hands. Take several paper towels to dry your hands, leaving the water running.
Throw the towels away. Take a fresh paper towel and turn off the water. Do not use this same paper towel to dry your hands further after turning off the water as this is a recontamination.
After candidates finish washing their hands, they can walk back over to the patient. What brings you in today? Accessed October 9, One of the keys to obtaining an accurate history is to allow the patient to tell his or her story first. As discussed previously, using an open-ended question, candidates should ask patients why they are there to see a physician so that patients can start to tell their story.
Candidates can use any open-ended opening statement they wish as long as it prompts patients to start their story. Also, candidates must avoid restating the reason for the patient visit as documented on the patient data sheet because the patient may state one reason for the visit to the nurse during screening, yet tell a different reason to the physician.
For example, Jim, a year-old man, may be embarrassed to tell the year-old nurse that he has difficulty maintaining an erection, so he says he has a problem with his cholesterol pill instead. I see you have a concern with your cholesterol pill. As the physician is about to leave the room, Jim says: Patient: One more thing, Doc. This was the true reason the patient was here to see the physician, and now the visit has to start all over again.
Patient: Hi, Doc, nice to see you too. Physician: I see the nurse noted you were having a problem with your cholesterol pill. Patient: Well, I thought that might be contributing to the problem, but honestly, this has been going on longer than I have been on that pill.
If a response fails to provide enough details, candidates can follow the original open-ended question with another open-ended question or statement. Patient: I have chest pain. Candidate: Oh, tell me more about that. For example: Candidate: Can you describe the chest pain? It just hurts. For example, if a year-old male patient presents with a possible ligamental injury to the knee incurred while playing basketball, obtaining a detailed family history in unnecessary because this information does not contribute to the case.
Candidates might also need to redirect patients if their story begins to diverge too far from the primary concern: Patient: Well, the first time I had chest pain was back in , when I was visiting my sister Gwendolyn in Florida. Lovely place she has really. Her house was built back in the s. Once she found an original painting by. If the candidate does not redirect this patient, he would need to have pizza sent in for dinner! Notice that this second question is more specific than the first.
For example, Candidate: Jack. Patient: I think I have pneumonia. Or Patient: Just getting my diabetes checked. Or Patient: I have a ringing in my ears. Typically, the reason the patient gives the candidate is the same one that the patient provided during the previsit screen, but occasionally these reasons may be different, as discussed earlier.
However, other conditions may have similar symptoms, and candidates must consider them. If the patient offers a diagnosis, candidates can add it to their differential diagnoses but must keep the differential open to other possibilities. The chief complaint may also include duration of time. By using duration of time, the candidate can rank diagnoses in the differential in order of likelihood. The sense of urgency for the patient reporting 3 hours of chest pain varies greatly from the patient with 23 years of chest pain.
Of course, there is an overlapping of possibilities, but urgency of evaluation is somewhat diminished in the patient with 23 years of chest pain as compared to that of the patient with 3 hours of pain.
During patient encounters in clinical practice, patients typically answer many questions before physicians can even ask. For example: Physician: Jack, what brings you in today?
Patient: I have this chest cold. My temperature was The standardized patients answer only the questions candidates ask. In Table 4—1, the picture changes in the scenario depicted. However, if the physician discovers that the patient had been in rehab six times over the last 2 years for alcohol abuse, she would immediately return to the original opinion that drinking on a daily basis is not appropriate for this patient.
Candidates must never abandon a question for which they have received an incomplete answer. If a patient admits that he has had the same abdominal pain twice in the past, the candidate must ask about those past occurrences. When were they? How long did they last? How did they get better? Social history screening Patient Yes. Positive screen Candidate How often do you drink?
Follow-up question to positive Patient Every day. Candidate How much do you drink in a day? Quantifier Patient Oh, only one glass of wine a day. The physician redirects when the patient strays too far away from the topic at hand and rephrases partially answered questions so that the patient can fill in any gaps. Have you ever had this before?
See Table 4—2. Occasionally, candidates find that they are running out of questions, yet they still do not have a probable diagnosis. The patient is a year-old man who presents with chest pain while playing basketball.
The pain is associated with shortness of breath. There is no radiation of the pain. Based on the history taken so far, the candidate includes spontaneous pneumothorax and musculoskeletal etiologies in the differential diagnosis. Because the patient is only 20 years old, the candidate may be tempted to skip asking about prior medical history, assuming none exists.
It may sound trite, but candidates should practice writing the mnemonic and what each letter stands for until they have memorized it. For the COMLEX 2-PE, once the beginning of the standardized patient timed encounter is announced, candidates should be able to write the mnemonic in less than 15 seconds.
Each component is discussed in more detail in the following subsections. With a positive: When was that? When the first time you had it?
How often does it occur? How long does it last? Did you seek intervention? Was there a prior diagnosis? What was the prior treatment? What was the prior outcome? What was the order of symptoms? O: Onset Occurrence When did the current symptoms start? What does it FEEL like? I: Intensity Scale On a scale from 1 to 10, how bad is the pain? How bad is it? How has the symptom affected your activities of daily living?
E: Exacerbating factors What makes it worse? R: Remitting factors What makes it better? S: Symptoms associated Concurrent findings For a cold: Do you have fever, chills, runny nose, sinus pressure, headache, nasal congestion, sore throat, cough, etc.? M: Medical history Have you had any prior medical conditions acute or chronic?
Which immunizations have you had? Have you had a mammogram Health maintenance? A: Allergies Food, environmental, drug—what happens? S: Surgical history What? H: Hospitalization What? F: Family history Do any medical conditions run in the family? Mother, father, siblings, family tendencies? M: Medications What are the names, doses, and frequency of the medications you take? Timing of an event has many components represented by both C chronology and O onset.
Although chronology is the first letter in the mnemonic, typically physicians address onset first in clinical questioning: Physician: Miss Alyson, when did this start? Or Patient: Yes, I started getting them 2 years ago. Patient: First, I see this fuzzy bright spot, and then I get a throbbing headache that makes me nauseated. The chronology can be thought of as two separate time sequences. Within this period of time, the candidate needs to know how the complaint has changed since it started.
The second time sequence is only applicable if the patient has had similar episodes before. If the same complaint has occurred previously, candidates should thoroughly investigate it because exploring the prior history of the complaint can yield valuable clues.
Candidates should find out the following information: 1. When the patient first had the symptoms How often they occur How long they last Whether the patient sought intervention Whether there is a prior diagnosis What the prior treatment was What the prior outcome was Whether there has been any change in the pattern of occurrence By using this line of questions, candidates might get a story along these lines: Candidate: Did you ever have this before?
Patient: I started getting them 2 years ago. Candidate: Did you see anyone for it? Patient: I saw the family doctor we had before I moved here.
Candidate: Did the doctor give you a diagnosis? Candidate: How did he treat you? Patient: Well, he wanted to give me some pills, but I hate to take medicine. So, instead he gave me some paper that told me what to avoid that might be causing the headaches and a diary to keep track of what I ate.
Candidate: Did you find out what was causing them? Candidate: Did you cut out the wine to see if they went away? Patient: Yeah, that seemed to work for a while. Patient: Well, Doc, I kind of slipped in watching the wine. By exploring the prior history of the same complaint, not only did the candidate find the likely diagnosis, but also found out how to treat the patient. Instead of placing her on an expensive medication with possible side effects, trigger avoidance seems most appropriate.
Another case that emphasizes the need for thorough exploration of past similar complaints is a patient who walked into my office at on a Friday afternoon. He was a year-old man complaining of dizziness. Upon hearing this chief complaint with its huge range of possibilities and intensities of evaluation, a differential diagnosis alarm was set off inside my head.
The questioning went like this: Physician: Mr. Cook, what brings you in today? Patient: I feel really dizzy. Almost falling down. Physician: Have you ever had this before? Patient: Yes, last year. Physician: Did you see someone for it? Physician: What did they do for you? Patient: They washed out my ears and fixed it just like that. With baited anticipation I grabbed the otoscope and looked in at a plug of cerumen.
Two minutes and a water evacuation later, he walked up and down the hall, stating the dizziness was completely gone. A thorough history often leads to a quick, definitive diagnosis and treatment.
For example, if the patient presents complaining of pain, a specific description of the pain could easily alter or enhance the presumed diagnosis. For example, a year-old man presents with chest pain: Candidate: Can you describe the chest pain? Or Patient: It feels like an elephant is sitting on my chest. Which of these descriptive answers is more likely to represent an acute coronary syndrome? Candidates should always begin with the open-ended question as shown, and then move into the closedended questions should the case require.
Candidate: Can you describe the chest pain? Patient: It hurts. Patient: It just feels bad. Candidate: Would you say the pain is sharp, dull, achy, a pressure, burning. 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. Complex 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.
The final chapter includes case examples providing practice scenarios that allow the students to practice the cases typically encountered on the Complex Level 2-PE These practice cases reduce the stress of the student by allowing them to experience the time constraints encountered during the Complex Level 2-PE.
This text is a one-of-a-kind resource as the leading Complex Level 2-PE board review book. Describes the humanistic domain for student understanding of the areas being evaluated.
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