M2- WEEK TWELVE

SCHOOL
Since this blog is our journal- I thought I'd write a little bit about our exam we had this past week. Hopefully you'll find this somewhat interesting. We had an OSCE which is an exam that tests our clinical skills. UNMC hires people to act as patients and they, as well as a fourth year medical student, grade us on specific skills. This past week we had to complete a H&P (history and physical).

So my "patient's" story was they were in my clinic for a physical for a new life insurance policy. We have 5 minutes before we walk into the exam room to review their vitals and jot down any notes we want for ourselves during the exam. I scribbled nearly the entire history portion of the exam down onto my paper so that I could just plow through the list with the patient (and takes notes on what he said for the 2nd part of the exam). These exams are super nerve-wracking for me because I feel that these skills are some of the hardest to learn, as well as, some of the most important to be a good doc. If you cannot create a conversation with a patient where they feel comfortable opening up to you, it can be very difficult to provide them good care. So I usually leave these exams focused on the details I could have done better instead of being excited that I remembered so many others.

Anyway, back to the exam.. I knock on the door, enter the room, introduce myself to the patient, and wash my hands. Then the questions begin. Here is the rough list I used to guide our conversation: (know that I created this list from our grading rubric.. so, this combination of questions would vary slightly in real-life)

PAST MEDICAL HISTORY

Childhood illnesses:

Chronic/major illnesses:

Surgeries/major injuries:

Hospitalizations/transfusions:

Parenteral exposures, tattoos, body piercings:

* gravida/para:

* pregnancy and labor complications; type of delivery:

* age menarche/menopause:

* last menstrual period:

* menses frequency/regularity/duration/amount:

ALLERGIES

prescription medications:

latex allergy:

food allergies:

MEDICATIONS

Medication allergies:

latex allergy:

food allergy:

? FAMILY HISTORY/GENOGRAM

Assessed for high-risk conditions/diseases

HEALTH BEHAVIORS

Tobacco:

-  age onset/duration

-  type and packs/day

-  readiness to quit

-  prior quit attempts

Alcohol:

-  yes/no and type

Illicit drugs:

Nutrition:

-  typical day’s diet

-  fats, sugars, salt, and iron (F <50)

-  vegetables, grains, fruits, protein, and dairy

-  calcium

- caffeine

Physical activity:

-  type

-  duration/intensity

-  frequency

Safety:

- Seatbelt use:

- Smoke detector use:

- Occupational hazards:

- Domestic abuse:

- Neighborhood:

- Texting/drinking and driving?

Depression:

Sleep:

Dental health:

-  last visit

-  floss/brush daily

Immunizations:

-  last tetanus

-  influenza

Screening tests:

-  *last pap/pelvic (f)

-  *last mammogram (f>40)

-  *last lipid test/result (m>35)

-  last colorectal cancer screening (>50)

SOCIAL HISTORY

-  upbringing: location and relationships

-  education

-  employment/military

-  job satisfaction and goals

-  financial issues affecting health

-  average day

-  current living conditions

-  marital status

-  household members

-  relationships with spouse/family/friends

-  cultural beliefs affecting health

-  religion, spirituality

-  overall life satisfaction

Whew. A lot to remember! And to ask in a limited amount of time. Next came the physical exam. I decided to combine the "review of system" questions with the physical because I feel it flows better and saves time. So for example, as I looked in their eyes, I would ask them specific questions about their eyes. We were instructed to ask 3 questions for each system, 1 general and 2 specific:

REVIEW OF SYSTEMS

General: general health? recent weight change? fatigue?

Skin: skin problems? rashes? mole changes? 

Eyes: vision? blurred? double?  

Ears: hearing? pain? ringing?

Nose: nose? congestion? sinus pain?

Mouth and throat: mouth? sores? dry mouth?

Breasts: breasts? tenderness? lumps?

Cardiorespiratory: lungs or heart? cough? sob? chest pain?

Peripheral vasculature: circulation? swelling? cramps?

Gastrointestinal: digestion? heart burn? nausea? vomiting?

Urinary: kidney/urination? burning? increased frequency?

Genital-reproductive: libido? F: menopause? pms? 

Hematologic/lymphatic: bleeding? easy bruising? 

Endocrine: hot or cold? excessive thirst?

Musculoskeletal: bones, joints, muscles? painful joints? muscle weakness?

Neurological: headaches? numbness? fainting?

Psychiatric: mood? excessive worrying? irritable?

PHYSICAL EXAM

Vital signs: pulse, respirations, blood pressure

Head and face:

-  EYES light reflex, finger H + in, fundoscopic exam

-  EARS otoscope, hearing

-  NOSE nose and sinuses

-  MOUTH mouth, teeth, tonsils, throat

-  NECK lymph nodes, thyroid

Back: spine inspect/palpate

Lungs: auscultate front, sides, back. Percuss front, sides, back.

Heart: Palpate precordium. Auscultate bell and diaphragm 4. carotid bruits.

Abdomen: inspect, ascultate 4 quadrants, bruits, palpate: light/deep, liver edge, liver span, spleen.

Upper extremity: inspect and palpate. radial pulses. Musculoskeletal?

Lower extremity: inspect and palpate. posterior tibial and dorsalis pedis pulses.

Musculoskeletal/Neurological: ????

The ???? for musculoskeletal/neurological were because we were assigned one specific sets of tests when we were given the "patient" information during that 5 minute planning period. We were given 55 minutes to do the exam I outlined above. Then, we had 1.5 hours in a computer lab to complete the documentation.

Overall, I feel like the exam went well. I'm guessing we will have our grades back in a few days to know for certain that we passed. The worst part of the exam was sitting in the lab doing the write up and realizing you missed something. I totally spaced the ROS questions on genito/urinary and his dental history. Whoops.

So yeah.. that was our recent OSCE!

FRIENDS
Since you've hung in there to this point in this epic long post, I'll share two pictures from Saturday:

A friend and his son came over for the Husker game and we made soft pretzels to snack on. Full disclosure.. they were totally from a kit. (And yes, that is T's infamous Nerf gun. I stacked some laundry baskets in our utility room as targets.)

I forgot to take pictures, but tonight we also had some dear friends over for pumpkin pie milkshakes. We love living in this neighborhood where we can text friends minutes before we mix up something like milkshakes and they can be right over. And bonus! They come in their comfy clothes and don't mind my striped pajama pants. We love our friends :)