Adult Rheumatology — Transition to Discipline

TTD1b Performing histories and physical examinations in uncomplicated patients with rheumatologic disease, including documenting and presenting findings - Part B: Assessment and Documentation

Key Features:
- The focus of this EPA is the use of an organized approach and appropriate technique for musculoskeletal (MSK) history and physical examination.
- This EPA includes a review of systems as it relates to rheumatologic diseases, enquiring for symptoms of extra-articular manifestations, documenting the findings in an organized and well synthesized presentation, and structuring clinical notes for patients with rheumatologic disease.
- The EPA also includes demonstrating appropriate technique for joint examinations, including small joints, large joints, temporomandibular joints (TMJs), peripheral and axial joints, and differentiation of inflammatory from non-inflammatory pain.
- This EPA does not include interpretation of findings or accuracy of findings.
- Observation of this EPA is divided into two parts: history and physical; assessment and documentation.

Assessment Plan:
Indirect observation by supervisor
Use Form 1. Form collects information on:
- Type of observation (select all that apply): case presentation; clinical note
Collect 2 observations of achievement
- At least 1 case presentation and 1 clinical note
- At least 2 assessors

Form

F1: Observation

Milestones

• COM 2.1. Use patient-centred interviewing skills to effectively gather all relevant information

• ME 2.2. Interpret findings of the MSK physical exam to differentiate between inflammatory and non-inflammatory pain

• ME 2.2. Synthesize patient information from the clinical assessment for the purpose of written or verbal summary

• COM 5.1. Document the essential elements of a rheumatologic history and MSK physical examination using a structured approach

Context Variables

• Type of observation (multiple-choice)
  • case presentation
  • clinical note

Requirements

• Collect 2 observations of achievement (minimum 2)
• At least 1 case presentation (minimum 1)
  • Only counts when Type of observation is case presentation
• At least 1 clinical note (minimum 1)
  • Only counts when Type of observation is clinical note
• At least 2 assessors (minimum 2)
  • Counted once per distinct Assessor