History Gathering Research Articles

Paranasal Sinus Mucoceles and their Ocular Impacts: A case report

Introduction: Paranasal sinus mucoceles are the build-up of mucous-containing, epithelium-lined, cystic lesions within the air-filled cavities in the bones surrounding the nasal cavity. An accumulation of mucous can occur in the sinus cavity when the normal drainage pathways are blocked, resulting in an increased volume of mucous. Case report: A 56-year-old Hispanic male complained of proptosis, periorbital edema, and pain in the right eye, accompanied by cluster headaches persisting for the past six months. Initial examination demonstrated uncorrected visual acuity of 20/20 in both eyes at distance and near. Clinical assessments further revealed Hertel exophthalmometry measurements of 21 mm in the right eye and 19 mm in the left (base of 108 mm), along with resistance to manual pressure in the affected right eye. Subsequent computed tomography imaging of the head and orbits identified a sizable, well-defined mass originating from the right nasal cavity, extending into multiple paranasal sinuses, and inducing structural alterations in the medial wall of the maxillary sinus, consistent with paranasal sinus mucoceles. Conclusion: Proptosis and lid edema can arise from various etiologies, encompassing intracranial masses, autoimmune disorders, or impaired venous return. This case report adds another consideration of a diagnosis in a patient with a history of sinus surgery. Comprehensive history gathering and meticulous clinical examination are paramount to discerning pathological manifestations in establishing an accurate diagnosis.

The Brief Observation of Symptoms of Autism: Validation study in a Latin American sample.

Autism spectrum disorder is a complex condition associated with significant impairments in social communication and behavioral functioning. Diagnosis is dependent on clinician expertise, gathering of developmental history, and observation of specific behaviors. The suggested protocols include tools rendered invalid during the pandemic, which created significant barriers for diagnostic assessments. Furthermore, there are additional barriers in low-income countries in access to screening tools and standardized diagnostic tests for autism spectrum disorders that were only exacerbated during COVID-19. The Brief Observation of Symptoms of Autism instrument was developed to improve access to diagnostic assessment via telehealth during this time. The current study sought to validate the use of the Brief Observation of Symptoms of Autism within two Latin American countries. A sample of 313 children and adults from Argentina and Chile were examined. Results showed valid sensitivity and specificity scores with good fit across modules using two factors (i.e. Social Affect and Restricted, Repetitive Behaviors). Preliminary results of the current study demonstrated that the Brief Observation of Symptoms of Autism is a valid instrument for Latin American population and shows promise to be used beyond the pandemic to ease the diagnostic process. This is a collaborative work with BRINCAR Parent Association, who defined the need in our country to run the validation of Brief Observation of Symptoms of Autism and gave us support as the stakeholders at Lancet Commission.

Nursing Care In Ny. W With Complaints Of Abdomial Pain At Kardinah Regional General Hospital, Tegal City

Abnormal pain is a general term encompassing various health complaints affecting the area between the chest and pelvis (including the abdominal wall and internal organs), with varying intensity, duration, and pain points. The research aims to identify the application of nursing care for acute pain by providing warm compresses to a patient with the initials Ny.W, who experienced abnormal pain in the Lavender ward at Kardinah Regional Hospital, Tegal City. This study applied a descriptive design. Data were collected through several stages, including anamnesis (gathering of medical history), direct observation, physical assessment, and documentation. The research findings indicated that the patient's issue was resolved on the third day, marked by a reduction in pain intensity. Overall, the nursing problem was managed within three days through the intervention of warm compresses as a nursing action.

A WELL KNOWN CARDIOMYOPATHY BEHIND A FAMILY DRAMA: A CASE REPORT

Abstract We report a case of a 55–year–old woman who came to our regional reference center for cardiomyopathies. Her cardiovascular risk factors were systemic arterial hypertension, dyslipidemia, family history of sudden cardiac death. Her first son –20 years old– had died of sudden cardiac death during a football match, at the peak of the exertion, one year before. The autopsy had showed biventricular, diffuse fibro–fatty replacement areas diagnostic for arrhythmogenic cardiomyopathy. DNA extraction in tissue was evaluated for genetic testing. According to 2022 ESC Guidelines, familial evaluation of descendents of patients died of sudden cardiac death should include: genetic testing, gathering of medical history and performing physical examination, standard and high precordial leads ECG, echocardiography and exercise testing, CMR and ambulatory cardiac rhythm monitoring. All of these were normal, except for cardio RM which revealed: aneurysmatic bulging of the right ventricular wall, most prominent at the apex and free wall with normal contractility. Absence of both left and right ventricular dilatation. Left ventricular and right ventricular ejection fraction measured 58% and 55% respectively. According to Padua’s criteria the woman had borderline arrhythmogenic cardiomyopathy. Instead, her 18 years old little son used to practice sports and used anabolics. His cardio–RMN demonstrated: reduced function of the right ventricle with mild dilation and biventricular bulging areas. The patient met the criteria for definite Arrhythmogenic Cardiomyopathy since he had two major criteria. In the meantime of the results of genetic testing, suspension of the smoking habit and reduction of strenuous physical activity were advised. Conclusions Arrhythmogenic displasia of right ventricle is characterized histopathologically by the extensive replacement of right ventricular myocardium with fibro–fatty tissue (dysplasia triangle). Involvement of the left ventricle has been documented on a lesser frequency and has a higher mortality. Different from other conditions, in arrhythmogenic cardiomyopathy, sports practice not only conveys arrhythmic risk to that specific moment (as it happens to the little patient) but also accelerates disease progression.

The effect of visitation restrictions on ED error.

EDs restricted visitors during the COVID-19 pandemic on the assumption that the risks of disease spread outweighed the psychological benefits of liberal visitation. But data suggest that beyond providing emotional support, family and caregivers can clarify history, improve patient monitoring, and advocate for patients-actions that can improve quality of care. Our objective was to assess whether removing visitors from the bedside contributed to errors in emergency care. We reviewed a database of medical errors covering visits from 11/15/17 to 7/30/22 at an urban, tertiary-care, academic ED for five types of error amenable to visitor intervention: inadequate history gathering, inadequate monitoring, falls, giving a medication to which a patient is allergic, and inappropriate medication dosing. These records were reviewed by two investigators to determine the likelihood visitor presence could have prevented the error. For those errors judged susceptible to visitor intercession, the number in each category was compared for the period before and after strict restrictions took effect. Our review found 27/781 (3.5%) errors in the pre-pandemic period and 27/568 (4.8%) errors in the pandemic period fell into one of these five categories (p = 0.29). Visitors prevented harm from reaching the patient in three of 27 pre-pandemic errors (11.1%), compared to 0 out of 27 peri-pandemic errors (p = 0.23). On review by two attendings, 17/24 (70.8%) errors that reached the patient in the pre-pandemic period were judged amenable to visitor intervention, compared to 25/27 (92.6%) in the pandemic period (p = 0.09). There were no statistically significant differences in the categories of error between the two groups; monitoring errors came the closest: 1/17 (5.9%) pre-COVID errors amenable to visitor intervention in these categories were monitoring related, whereas 7/25 (28.0%) post-COVID errors were (p = 0.16). While this study did not demonstrate a statistically significant difference in error between lenient and restrictive visitation eras, we did find multiple cases in the pre-COVID era in which family presence prevented error, and qualitative review of post-COVID errors suggested many could have been prevented by family presence. Larger trials are needed to determine how frequent and consequential such errors are and how to balance the public health imperative of curbing disease spread with the harm caused by restricting visitation.

THU175 Incorrect Age Causing Falsely Short Stature In An Afghan Immigrant Girl

Abstract Disclosure: J. Ing: None. M. Marinkovic: None. Background: Evaluation for short stature routinely includes screening for hormone deficiencies, chromosomal abnormalities, gastroenterological diseases, and inflammatory processes. “Incorrect age” resulting in falsely short stature, is not often considered in the differential diagnosis. Clinical Case: A young girl who recently immigrated to the United States from Afghanistan was referred for endocrine evaluation for short stature. At the time of her initial visit, she was listed in the electronic medical record at 10 years and 0 months old. Her medical history was significant for bowel injuries sustained three years prior in a bombing incident that required surgery and from which she completely recovered. Available growth charts from the preceding 6 months showed height and weight consistently less than the 1st percentile for her age but normal height velocity. On the exam she was prepubertal. Her measured height was 117.8 cm (0.06th percentile, Z = -3.24) and her body mass index (BMI) was 14.7 kg/m2 (12th percentile, Z = -1.18). The patient’s calculated mid-parental height was 155.5 cm (12.5th percentile, Z = -1.15). Laboratory work-up obtained by the pediatrician showed normal IGF-1, IGFBP-3, TSH, free and total thyroxine, tissue transglutaminase IgA, sedimentation rate, urinalysis, complete blood panel, complete metabolic panel, and a normal 20 cell count karyotype (46, XX). Her bone age was 5 years and 6 months and was interpreted as markedly delayed. Upon further history gathering using a Pashto interpreter, her father revealed there was an error in the processing of her immigration documents, resulting in being listed as three years older than her actual age. When corrected to that of a 7 year and 0 month old girl, her height improved to the 23rd percentile (Z = -0.73), and her BMI to the 31st percentile (Z = -0.5). Conclusion: This case demonstrates how children, through the immigration process, may have their age incorrectly documented and thereby are at risk for unnecessary and costly medical evaluation. It is possible that language barriers play a role in such errors. Therefore, it is important to verify the patient's true age, as parents may not think to provide this information voluntarily. Presentation: Thursday, June 15, 2023

FRI445 A Late Diagnosis Of Complete Androgen Insensitivity Syndrome

Abstract Disclosure: J. Muuse: None. R.J. Shah: None. P.A. Belany: None. Introduction: Complete Androgen Insensitivity Syndrome (CAIS) is a rare disorder of hormone resistance characterized by a female phenotype in an individual with an XY karyotype. Individuals with CAIS are born unambiguously female without any apparent abnormalities. They develop a short blind ending vaginal canal, with absence of Wolffian duct derived structures (vas deferens, seminal vesicles). Breast development advances regularly at puberty, while there is absent pubic and axillary hair, both due to peripheral conversion of testosterone to estrogen. Testes remain undescended in the abdominal cavity. Case: A 28 year old female with a past medical history of bipolar disorder presented to her primary care physician’s office with a chief complaint of fatigue. Blood work revealed an elevated testosterone level of 686, at which time she was referred to endocrinology for further work up. On further history gathering, she endorsed a life long history of amenorrhea. She saw an OB-GYN at 19 years old and was told she had a short vaginal canal. A pelvic ultrasound revealed no uterus and one left ovary. She was not given a diagnosis other than congenital absence of a uterus. She was lost to follow up until 28 years of age when she sought medical help for her fatigue. Physical exam was pertinent for a tall female with no signs of hirsuitism. Additional blood work revealed normal LH, FSH, and DHEA-S. A chromosomal analysis revealed XY. She was referred to gynecology for further management and assessment for orchiectomy. Discussion: This was an unusual case of CAIS, as this was diagnosed far past menarche. Most cases are diagnosed during puberty- which aids in an early approach towards the psychological and social well being of the individual as well as close follow up for evaluation of orchiectomy. Orchiectomy is recommended due to the increased risk of gonadal malignancy following puberty. The risk of developing malignancy increases with age, and has been reported to be between 15-22%. Thus it is important to identify this syndrome early in life to ensure this is addressed. It is followed by long term hormonal therapy with estrogen to maintain normal breast and bone development. This case highlights the importance of maintaining a high clinical suspicion of CAIS in females presenting with short vaginal canal and absence of a uterus in order to prevent malignancy and provide optimal psychological support to the individual. Presentation: Friday, June 16, 2023

Peer MD Coaching Partnership Outcomes Between an NCI-designated Cancer Center Genetics Service and a Community Cancer Network Hospital

Purpose Patients with cancer seen in rural and underserved areas disproportionately face barriers to access genetic services. Genetic testing is critical to inform treatment decisions, early detection of another cancer, and to identify at-risk family members who would benefit from screening and prevention. Methods We conducted a prospective cohort study to examine medical oncologist’s genetic testing ordering trends at Olympic Medical Cancer Center (OMCC), a community network hospital. Phase I focused on observation of clinic processes. Phase II incorporated peer coaching from cancer genetics experts from Fred Hutchinson Cancer Center (FHCC) for OMCC medical oncologists. Number of genetic testing tests ordered was compared between phases. Results Of the total patients with cancer, 29 out of 415 (7.0%) received genetic testing in phase I and 25 out of 219 (11.4%) in phase II. Although it did not reach statistical significance (p=0.057), uptake of genetic testing increased by 22% between phases. 4 out of 19 (21.1%) patients with pancreatic cancer and 6 out of 35 (17.1%) patients with ovarian cancer received testing when NCCN recommends offering genetic testing to 100% of these patients. Conclusion Peer coaching intervention from cancer genetics experts led to increased ordering of genetic testing by medical oncologists. Efforts made to 1) standardize gathering of personal and family history of cancer, 2) review biomarker data suggestive of a hereditary cancer syndrome, 3) facilitate ordering tumor and/or germline genetic testing every time NCCN criteria are met, 4) encourage data sharing between institutions, and 5) advocate for universal coverage for genetic testing will help realize the benefits of precision oncology for patients and their families seeking care at community cancer centers.

Assessment of a Peer Physician Coaching Partnership Between a Designated Cancer Center Genetics Service and a Community Cancer Network Hospital

Patients with cancer seen in rural and underserved areas disproportionately face barriers to access genetic services. Genetic testing is critical to inform treatment decisions, for early detection of another cancer, and to identify at-risk family members who may benefit from screening and prevention. To examine medical oncologists' genetic testing ordering trends for patients with cancer. This prospective quality improvement study was performed in 2 phases over 6 months between August 1, 2020, and January 31, 2021, at a community network hospital. Phase 1 focused on observation of clinic processes. Phase 2 incorporated peer coaching from cancer genetics experts for medical oncologists at the community network hospital. The follow-up period lasted 9 months. The number of genetic tests ordered was compared between phases. The study included 634 patients (mean [SD] age, 71.0 [10.8] years [range, 39-90 years]; 409 women [64.5%]; 585 White [92.3%]); 353 (55.7%) had breast cancer, 184 (29.0%) had prostate cancer, and 218 (34.4%) had a family history of cancer. Of the 634 patients with cancer, 29 of 415 (7.0%) received genetic testing in phase 1, and 25 of 219 (11.4%) received genetic testing in phase 2. Of the 29 patients who received testing in phase 1, 20 (69.0%) had germline genetic testing; 23 of 25 patients (92.0%) had germline genetic testing in phase 2. Uptake of germline genetic testing increased by 23.0% between phases, but the difference was not statistically significant (P = .06). Uptake of germline genetic testing was highest among patients with pancreatic cancer (4 of 19 [21.1%]) and ovarian cancer (6 of 35 [17.1%]); the National Comprehensive Cancer Network (NCCN) recommends offering genetic testing to all patients with pancreatic cancer and ovarian cancer. This study suggests that peer coaching from cancer genetics experts was associated with an increase in ordering of genetic testing by medical oncologists. Efforts made to (1) standardize gathering of personal and family history of cancer, (2) review biomarker data suggestive of a hereditary cancer syndrome, (3) facilitate ordering tumor and/or germline genetic testing every time NCCN criteria are met, (4) encourage data sharing between institutions, and (5) advocate for universal coverage for genetic testing may help realize the benefits associated with precision oncology for patients and their families seeking care at community cancer centers.

Survivor-Centered Care in Gender-Based Violence Treatment Protocol for Healthcare Providers: A Medico-legal Review

The gender-based violence (GBV) treatment protocol for healthcare providers (HCPs) is an essential element for building the capacity of HCPs to provide better quality care to the survivors. A protocol helps to ensure that all survivors of GBV regardless of their age, background or ethnicity receive appropriate and effective care when they enter a health facility. Concern for patient welfare extends to ensuring that patients’ dignity is respected after an assault that may leave them feeling humiliated and degraded. Additionally, medical and forensic services should be provided in a manner that minimizes the number of invasive physical examinations and interviews of the patient. Rape management is generally considered as a medical emergency and the provision of medico-legal services thus takes secondary importance to general healthcare services [such as trauma treatment, evaluation and management of pregnancy and sexually transmitted infections (STIs)]. Performing a forensic examination may be considered as a negligent practice without meeting the primary healthcare needs of the patients. Health facilities are often the first entry points for GBV survivors – so, it is crucial for HCPs to be skilled and well-equipped to manage the care to the survivors. A protocol emphasizes the importance of providing survivor-centered care with an empathetic attitude to people affected by GBV includes identifying GBV, taking medical history, maintaining privacy and confidentiality and gathering medico-legal evidence. J Monno Med Coll June 2022;8(2): 53-56

Маски абдоминальной боли у детей дошкольного и раннего школьного возраста

Abdominal pain, one of the most common complaints of patients visiting pediatrician and gastroenterologist, is a multifactorial syndrome. Thus, physicians often need to generate challenging differential diagnoses. Thorough gathering of the medical history and physical examination are the best tools for making diagnosis. However, in some cases it is necessary to use laboratory tests and instrumental methods. In some cases, the search for effective treatment of abdominal pain becomes a difficult task requiring a multidisciplinary approach for developing symptom management strategies. The article presents a literature review focused on the issues of acute and chronic abdominal pain in children and summarizes the latest trends in performing patient examination and making differential diagnosis. Emphasis is made on the differential diagnosis of conditions considered as the most common causes of abdominal pain and functional gastrointestinal disorders classified according to Rome IV Criteria. The article elucidates the latest therapeutic approaches to the management of pain abdominal syndrome and considers mechanisms that may be involved in its pathogenesis. KEYWORDS: children, acute abdominal pain, chronic abdominal pain, functional gastrointestinal disorders, irritable bowel syndrome, functional dyspepsia, abdominal migraine, Rome IV Criteria, trimebutine. FOR CITATION: Medvedeva E.A., Khavkin A.I. Abdominal pain masqueraders in preschool and primary-school-age children. Russian Journal of Woman and Child Health. 2023;6(2):175–183 (in Russ.). DOI: 10.32364/2618-8430-2023-6-2-175-183.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Rheumatologic Perspective on Persistent Right-Hand Tenosynovitis Secondary to Mycobacterium marinum Infection.

Rheumatologic conditions share many symptoms with infectious processes. The immunosuppressive therapies used in rheumatology unfavorably impact any underlying infection. Nontuberculous mycobacteria (NTM) are difficult to grow in culture media and may affect the musculoskeletal system, developing manifestations that may imitate rheumatic inflammatory arthritis. For this reason, surgical debridement and biopsy culture are essential in cases where suspicion remains high. We present the case of a patient with progressively worsening right-hand tenosynovitis who was evaluated for rheumatic conditions given initial negative synovial tissue biopsy cultures. He was finally diagnosed with Mycobacterium marinum infectious tenosynovitis after repeated surgical debridement. Our case reinforces the vital role of history gathering in establishing diagnoses and underscores the value of clinical suspicion in patients unresponsive to standard treatment for inflammatory arthritis. Tissue biopsy with culture for acid-fast bacilli is crucial for accurate diagnosis in NTM infection, which may imitate rheumatic inflammatory arthritis. Physicians should be keenly aware of this fastidious, indolent organism in the setting of persistent localized tenosynovitis.

Haphephobia: a rare specific phobia of being touched

IntroductionHaphephobia is a morbid fear of being touched or touching. The symptoms of Haphephobia are very similar to other specific phobias.ObjectivesPresentation of a case of haphephobia due to childhood sexual abuseMethods Mrs. X., A 22-year-old Bangladeshi female, presents to the psychiatric consult service with an intense fear of being touched by her husband. She told that whenever her husband comes closer to her, her heart starts to pound fast, she feels discomfort in the chest, a burning sensation on her whole body, and loses control over the environment. Furthermore, she can’t sleep properly for the fear of being touched. Her in-laws’ parents concluded that some ‘evil spirits’ might cause the symptoms. So her husband brought her to a Psychiatrist. On an in-depth assessment session, ensuring all the confidentiality issues, she told the Psychiatrist that she has a history of brutal sexual abuse followed by the threat to kill her by her stepfather at the age of fourteen.Results After a thorough medical workup and history gathering, her consultant psychiatrist could elucidate the source of the presenting picture and told her that she developed haphephobia, and suggested taking psychotherapy along with prescribed medicines.Conclusions Fear of being touched is a particularly difficult fear to cope with. Patients with haphephobia after sexual assault should be handled very cautiously by the experts keeping confidentiality issues in mind. Cognitive-behavior therapy, Exposure therapy, Virtual reality exposure therapy, practicing mindfulness, using daily coping strategies, and medications like beta-blockers, anxiolytics, antidepressants can help a person to overcome haphephobia.DisclosureNo significant relationships.

Ibrutinib induced atrial fibrillation complicated with massive hemoptysis

Background: The oncologic patient faces multiple adverse effects with cytotoxic medications, from tissue damage and intoxications that could be evident from muscle damage, neurologic to cardiac toxicity. Case: This is a case of a 79-year-old female who presented to our ED with the complaint of hemoptysis for one day, denied any associated cough, fever, chills, chest pain, SOB, nausea, vomiting, or abdominal pain. No history of trauma. Her medical history includes hypertension, uterine cancer status post-resection. The patient denied prior similar episodes, family history of similar complaints. Chest X-ray showed extensive bilateral infiltrates and cardiomegaly. CT chest ruled out pulmonary em-bolism but showed extensive multifocal pneumonia vs. ARDS, lymphoproliferative changes. While in the ED, the patient started having bloody nasal secretions noted, requiring nasogastric lavage revealing dark blood secretions, and then started having massive hemoptysis and rapidly decompensated requir-ing endotracheal intubation hypoxic respiratory failure. An emergent bronchoscopy was performed, which showed suspected alveolar hemorrhage (Figure 1). The CBC showed severe anemia requiring multiple transfusions due to active bleeding (Table 1). The patient was admitted to ICU. The patient’s PCP was contacted to obtain further information that reported a new history of atrial fi-brillation on rivaroxaban recently started, CLL on ibrutinib, and Coombs Hemolytic Anemia. The hospital course was complicated by distributive shock and ARDS. She was covered with broad-spectrum antibiotics and required fresh frozen plasma due to persistent bleeding. The patient improved after anticoagulation and ibrutinib were held. The patient was eventually extubated, required physical therapy for deconditioning, and then was discharged. Conclusion: This case represents clear evidence of how an appropriate assessment on time and the collateral gath-ering of medical history could impact the outcome of our patients. The literature review has shown new-onset atrial fibrillation and bleeding events related to ibrutinib. Given the risk for bleeding with rivaroxaban, their combination could present with massive alveolar hemorrhage that could become fa-tal if not recognized early.

Preferences in Oncology History Documentation Styles Among Clinical Practitioners.

Clinical notes function as the de facto handoff between providers and assume great importance during unplanned medical encounters. An organized and thorough oncology history is essential in care coordination. We sought to understand reader preferences for oncology history organization by comparing between chronologic and narrative formats. A convenience sample of 562 clinicians from 19 National Comprehensive Cancer Network Member Institutions responded to a survey comparing two formats of oncology histories, narrative and chronologic, for the same patient. Both histories were consensus-derived real-world examples. Each history was evaluated using semantic differential attributes (thorough, useful, organized, comprehensible, and succinct). Respondents choose a preference between the two styles for history gathering and as the basis of a new note. Open-ended responses were also solicited. Respondents preferred the chronologic over the narrative history to prepare for a visit with an unknown patient (66% preference) and as a basis for their own note preparation (77% preference) (P < .01). The chronologic summary was preferred in four of the five measured attributes (useful, organized, comprehensible, and succinct); the narrative summary was favored for thoroughness (P < .01). Open-ended responses reflected the attribute scoring and noted the utility of content describing social determinants of health in the narrative history. Respondents of this convenience sample preferred a chronologic oncology history to a concise narrative history. Further studies are needed to determine the optimal structure and content of chronologic documentation for oncology patients and the provider effort to use this format.

Medical History Taking Using Electronic Medical Records: A Systematic Review

Background: The relationship between digital tools and medical history taking (classically referred to as anamnesis) in clinical settings is problematic. We explored the medical history taking context, how data is managed by physicians and patients and which tools are used, particularly electronic health record, to gather, organize and record patient’s medical history and related health data. Materials and methods: Systematic review of the literature following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines, using published studies in English-language available from PubMed and Cochrane databases, using a combination of Medical Subject Headings and keywords. Our search yielded 162 citations of which 18 corresponded to our criteria and were included, regardless of study design, sample size or measurement type as a variety of perspectives and methodologies was deemed useful for an exploratory review and under a socio-technical research epistemology. The small number of publications related to the topic conditioned our analysis. Discussion: This review shows the paucity of relevant studies in the area of interest. Even thought it was possible to evaluate context changes in history taking that relate to EHR implementation and usage. Also, multiple challenges, benefits, risks and workflow adaptations have impacts on medical history taking. A potentially useful workflow adaptation is the access to the EHR previously or during the patient encounter with him or her. Conclusion:With the ever-increasing adoption of EHRs and its varying influence in clinical practice, physician’s adaptability was strained. Multiple workflow challenges and necessary changes regarding EHR use have been identified. Improving anamnesis practice is possible through better documentation, EHR templates and tools. Yet a new aspect of anamnesis – Digital anamnesis – benefits from better conceptualization and integration with classic anamnesis still taught in traditional medical schools. This study points to implications for medical schools and medical education in general. Highlights: Electronic Health Records implementation transformed clinical practice and redesigned workflows, improving patient safety and care within a multidisciplinary care setting. Some concerns surfaced concerning information privacy, quality of documentation and doctor-patient relationship, however many studies developed implemented and evaluated tools, templates and mnemonics to mitigate such distresses. “Digital anamnesis” is a proposed concept and refers to the process of medical history and information gathering using digital tools. This will be evermore important in the future, since technological development increasingly adds relevant features and functions to Electronic Health Record.

The TeleHealth OSCE: Preparing Trainees to Use Telemedicine as a Tool for Transitions of Care.

Telemedicine holds promise to bridge the transition of care between inpatient and outpatient settings. Despite this, the unique communication and technical skills required for virtual encounters are not routinely taught or practiced in graduate medical education (GME) programs. To develop an objective structured clinical examination (OSCE) case to assess residents' telemedicine-specific skills and identify potential gaps in our residency program's curriculum. As part of a multi-station OSCE in 2019, we developed a case simulating a remote encounter between a resident and a recently discharged standardized patient. We developed an assessment tool comprising specific behaviors anchored to "not done," "partly done," and "well done" descriptors to evaluate core communication and telemedicine-specific skills. Seventy-eight NYU internal medicine residents participated in the case. Evaluations from 100% of participants were obtained. Residents performed well in Information Gathering and Relationship Development domains. A mean 95% (SD 3.3%) and 91% (SD 4.9%) of residents received "well done" evaluations across these domains. A mean 78% (SD 14%) received "well done" within Education/Counseling domain. However, only 46% (SD 45%) received "well done" evaluations within the Telemedicine domain; specific weak areas included performing a virtual physical examination (18% well done) and leveraging video to augment history gathering (17% well done). There were no differences in telemedicine-specific skill evaluations when stratified by training track or postgraduate year. We simulate a post-discharge virtual encounter and present a novel assessment tool that uncovers telemedicine-specific knowledge gaps in GME trainees.

The Electronic Health Record Objective Structured Clinical Examination Station: Assessing Student Competency in Patient Notes and Patient Interaction.

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Voice and Lifestyle Behaviors of Student Singers: Impact of History Gathering Method on Self-Reported Data

This study described voice use and lifestyle information about student singers with a focus on describing differences in self-reported information at study intake compared to data from 21 consecutive days of a voice Log. Twenty-seven student singers estimated voice and lifestyle behaviors at study initiation including daily speaking time, singing/performance time, vocal warm-up, and cool-down minutes; fluid intake; perceived effort when talking, and when singing, among other items. These same parameters were tracked for 21 consecutive days in a voice log kept by the singer at home. Study intake data was compared to the median estimates from the 21-day voice log on each variable using nonparametric statistics. Student singers reported warming up the voice regularly at study intake (100%), but several logged ≥ 7 days out of 21 without warming up even though all days had singing minutes. Less than half reported voice cool downs at intake, and even fewer logged minutes of cool down in the daily tracking. High occupational voice demands not involving singing were reported by 37%. Large percentages of students reported frustration (63%), worry/anxiety (41%), and depression (26%) regarding their voice in the prior 2 weeks. Estimates at study intake statistically overestimated daily speaking minutes, effort during singing and number of nights eating within 2 hours of sleep compared to the 3-week log. Student singers reported several voice use and behavior items that could impact vocal health. Additionally, how the information was obtained (intake estimate vs. daily log) did alter what was reported for some parameters.