Osteopathic Patient Care and Procedural Skills
The Osteopathic Patient Care and Procedural Skills domain tests the bedside work of an independently practicing physician: a hypothesis-driven history and physical, defensible documentation, informed consent, and the indications, landmarks, contraindications, and complications of procedures a Level 3 candidate is expected to perform or supervise.
Screening that appears in stems
USPSTF grade A/B examples: colorectal cancer screening starting at 45; mammography every two years through age 74; cervical screening starting at 21; low-dose CT for lung cancer at 50-80 with 20 pack-years and current or quit-within-15-years status; one-time abdominal ultrasound for AAA in men 65-75 who ever smoked; one-time HCV and HIV screening for adults; depression screening with PHQ-2/9; gestational diabetes screening at 24-28 weeks.
The procedure note
Every procedure stem rewards the same skeleton: indication, consent and capacity, time-out and sterile prep, local anesthetic, technique and landmarks, specimen handling, complications discussed, and post-procedure monitoring.
High-yield procedure facts
- Arthrocentesis: avoid puncturing through overlying cellulitis; send cell count with differential, crystals, Gram stain and culture, glucose, and protein. Septic fluid typically exceeds 50,000 WBC/mm3 with more than 90% PMNs, but gout can produce similar counts, so always look for negatively birefringent needle-shaped crystals.
- Paracentesis: a serum-ascites albumin gradient of 1.1 g/dL or more indicates portal hypertension; give albumin when more than 5 L is removed; relative contraindications include DIC, ileus, and abdominal wall infection.
- Thoracentesis: Light's criteria define an exudate (pleural-to-serum protein ratio above 0.5, LDH ratio above 0.6, or pleural LDH above two-thirds the upper limit of normal).
- Lumbar puncture: obtain CT first with focal deficit, papilledema, altered mental status, or new seizure; measure opening pressure.
- Abscess I&D: drain if larger than 2 cm, with systemic signs, or after failed antibiotics; pack and reassess.
Worked example
A 54-year-old man has a warm, swollen knee and a 3-cm cellulitis patch over the medial joint line. The differential is septic arthritis versus gout. The medial approach is avoided; fluid is obtained superolaterally through uninfected skin, and antibiotics are not delayed. Fluid shows 62,000 WBCs with 91% PMNs and no crystals. He is admitted for IV antibiotics and serial aspiration, with culture guiding therapy.
Traps
Proceeding to lumbar puncture before imaging in papilledema. Forgetting to document consent or complications. Sending no fluid, or delaying antibiotics until the tap.