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JennyYang1: USMLE Step 2/CS考经
作者:dokknife
发表时间:2011-05-31
更新时间:2011-05-31
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发信人: JennyYang1 (Jenny), 信区: MedicalCareer
标 题: CS考经
发信站: BBS 未名空间站 (Wed Feb 23 17:02:40 2011, 美东)

昨天刚考完CS, 虽然不知道最后结果如何,但是有些经验体会和大家分享。

第一个体会就是,经过这个考试,觉得自己向医生的职业又迈进了一步。因为以往的考试都是埋头看书、做题,CS的复习和考试让自己觉得更像个医生,也更有自信可以在美国做个临床医生。所以,如果可以的话,多花时间练习,练得越熟练越好,不仅是为考试,也为以后的临床做准备。

而且在考试里面,没有什么时间让你思考,完全是靠着本能在问诊和回答病人问题,熟能生巧就显得很重要了。我大概花了7周练习,前面的4周,每天大概2个小时,过了一遍FA的case和UW的一部分case。后来的2周,大约每天5个小时,过了第二遍FA和UW,把FA的PN写了一遍,对照修改记了些笔记。最后1周,是全天大约10个小时,每天和考友们skype练习
问诊,然后和先生在家模拟考试,用UW的case,每次连续做5个,问诊后写PN,看自己对时间的掌握。我觉得这样的准备是必须的,一点也没有over prepare。

第二个体会是,早些开始练PN。我刚开始复习的时候,只练习patient encounter。到最后closure的时候就胡说一通,随便捏个病了事。到最后两周练PN的时候,才发现这个问题挺严重的,病名拼写的不对,或者压根就不知道是什么病,或者是写的病名不规范,弄得自己还有些紧张。如果同时练PN就不会有这样的问题,可以让你把每一个case都能够弄透彻。另外推荐早些看FA的mini cases,可以在一开始准备复习的时候就去看,对问诊、体检都很有帮助,也让你知道大部分的疾病的典型症状体征。FA的cases很复杂,真正的考试没有那样的病例,但是FA的case对整理问诊的思路很有帮助。最后考试的case更像UW的case,阳性体征少,体检的要求也不是那么多。

第三个体会是,一点要镇定和自信。考试时候难免有的情景你是预想不到的,但是不要慌张,要冷静沉着。回答病人的问题要自信,我考试的时候可能有些问题也回答的不是很理想,但是充满信心的回答每个问题,SP也没有追究。FA基本覆盖了所有的case,所以如果时间紧,只看FA就好了。但是FA的case复杂,体检做的也很多,很难在15分钟内做完。真正考试的时候,我按照前辈们的经验,本着简单问,简单体检的原则,有些问题一下子想不起了,就算了,不去追究。

体检也是要focus,有几个考友是去上过kaplan的课的,特别强调这点,先做阳性体征的部位和你DD相关的部位,这样基本就拿到credit了。其他的如果有时间,你又很想做,也可以做。但是不是很必须,因为时间非常有限。我基本每个case都提前1-2分钟出来,发现已经有一半左右的人在埋头写PN了,很惊讶。因为考试还是以美国医学生居多,估计他们的策略也是这样吧。

我是在LA考场。SP们训练的很好,有的很nice,有点故意很冷漠,有的躺着呻吟,但是我感觉到他们都在仔细的观察我。本来我练习的时候是很难笑的那么亲切的,结果由于他们实在是很像以前在临床上的病人,不知不觉的,就对他们笑的很自然亲切了。一旦你真正的入戏,他们好像就表现出很释然的样子。而且他们很愿意回答你的问题,所以推荐多问open
question。

我是习惯问完主诉相关的OCDFPPAA就问伴随症状,Do you have any other discomfort? 练习的时候有的考友说病人不会告诉你的,要一点点的自己问。但是真正的病人在看医生的时候,肯定是努力告诉医生自己不舒服的地方。在考试里面,我问这样的open question,SPs给我很多的信息,当然你需要顺藤摸瓜的追究一下,但是有了线索,就知道方向了。

最后,要大力感谢先生的支持,给我许多的鼓励和建议,百忙中给我扮演病人,帮助我练习,还开车5个多小时,陪我上考场。还要好好感谢一众考友兄弟姐妹们,一起练习、一起切磋,共同进步。还有两位考友马上就要考试了,祝她们一切顺利!我的Protocol见下文。

--

发信人: JennyYang1 (Jenny), 信区: MedicalCareer
标 题: 我的protocol
发信站: BBS 未名空间站 (Wed Feb 23 17:08:30 2011, 美东)

 First Sight on door-way information.
 Knock 3 times with confidence, a smile, walk in and say:

INTRODUCTION:

 Hello, Mr/Ms ------- , I am Dr.xxx,the physician on duty
today.
 Nice to meet you. (Shake hands only if the pt wants to. Don’t
shake hands with SPs in severe pain).
 Is everything in the room all right for you?
 Let me make you a little more comfortable. (open up the drape ..
.OPEN IT COMPLETELY... cover the legs in the beginning as it seems more
courteous...)

 How can I help you today?
 I understand it must be very difficult for you. (Or, I know you
must be very concerned about that.) I will try my best to help you. I will
need to ask you some question and do a physical exam on you to get a
complete picture of the problem.
 Can you tell me more about that? (open end Q 1)

Present History
Chief Complaint (No matter what)

O.C.D.F.P.P.A.A.A.F.F.A.W

 Onset: When did it first start?
 Constant: is it constant or does it come and go?
 Duration: How long does it last? (If applicable)
 Frequency: How often does it happen?
 Precipitating: Do you know what brings it on?

Details: Pain: LIQR
Non-pain: SP (severity, pattern): Does it interfere with your
daily activities?

PAIN/ LIQR
 Location: Can you show me where your pain is?
 Intensity: On a scale of 1-10, with 10 being the worst pain in
your life, how would you rate your pain?
 Quality: Can you describe it for me? (sharp/dull/burning/
pulsating/cramping /pressure-like)
 Radiation: Does the pain travel anywhere?
Then
 Progress: Is it getting worse?
 Aggravating factor: Does anything make it worse?( position,
activity level,
exertion, food, time of the day, medication)
 Alleviating factors: Does anything make it better?
 Associated symptoms: Do you have any other discomfort besides
that?

When you finish with them...then start with questions specific for diagnosis
/differential diagnosis 5 or 6 in number...
Then ask,

 Fever: Do you have a fever? Did you measure your temperature?
Any chills/sweating?
 Fatigue: Do you feel weak?
 Appetite: How is your appetite?
 Weight: Have you noticed any weight change recently?

With headache, it is important to ask:
H – Headache type
E – Eye visual symptom, such as an arc of sparkling (
scintillating) zig-zag lines or a blotting out of vision or both.
A – Anticipatory, related to menses or stress?
D – During (events), accompanied with rhinorrhea, lacrimation,
nasal congestion, nausea or vomiting?
A – After (events), weakness, numbness or speech difficulty?
C – Constant, chronic and causes
H – High temperature (fever)
E – eye pain, red eye

 Does your headache relate to your period/stress?
 Do you notice any change in you vision before/during/after your
headache?
 Do you notice any weakness before/during/after your headache?
 Any numbness before/during/after your headache? Any difficulty
in speech?


If it is arm/knee/back pain, remember to ask for the numbness/loss of
sensation or weakness as well as paralysis. Need to ask trauma history as
well.


Back pain also needs to pay attention to urination or fecal abnormality.

If it is knee pain, ask for symptoms of other joints, function/redness/
swelling of the joint as well as morning stiffness/duration. Sexual history
is important here to rule out septic arthritis.

 Do you have pain in any other joints?
 Do you have morning stiffness in your joins?

If there is trauma, ask for the description of the trauma and whether there
is loss of consciousness.

If it is an elder, ask for his living condition and his/her relationship
with others in the household.

If it is chest pain,
"CHEST P"

C – Cough: Is it a dry cough or a productive cough? Is it foul smelling?
How much is it? PPD/HIV status, ill-contact (Does anyone around you have
similar problem?)
H - Hemoptysis
E - Emesis (Vomitting) & Diarrhea
S - Shortness of Breath (SOB), Sweating, Syncope
T - Temperature (Fever), Tenderness on the chest ( chondritis) + Tenderness
of Legs (suggestive of DVT that can predispose to Pulm. Embolism)
P - Palpitations - "Any heart pounding or racing ?"

If it is a female with pain during sex, ask for vaginal discharge as well as
gynecology & sex history. Also think about domestic violence,
psychological/physiologic trauma.
 A (Amount and frequency)
 B (Blood)
 C (Content, Consistency, color)
 Odor
 Itching and sores

Depression case: SIG E CAaMPSs

 Sleep: Do you have any problem falling asleep/staying asleep/
waking up? Do you wake up early in the morning?
 Interest: What interests do you have? Do you enjoy them?
 Goal/Guilt: Tell me about your future goals. Do you feel guilty
about anything?
 Energy: How is your energy level?
 Concentrate: Do you have difficulty concentrating?
 Appetite/Activity: How is your appetite? Can you still perform
your daily activities?
 Mood/unhappy Memory: Any memory problems? How is your mood most
of the day?
 Psychomotor:
 Suicide ideation: Do you have any thoughts of harming yourself/
others? Any plans for that purpose?
 Support: Is there anyone that you can talk to when you are in
distress?
 Others: Have you had any traumatic episodes recently? Heat/cold
tolerance? Willing to get help? Realizing of the problem? Dilusions/
hallucinations?
 Do MMSE

Dementia/Headache/Dizziness etc Mnemonics:
HSS LP FT VD GUMS
Headache
Speech
Seizure (shaking)
Lightheadedness (faint)
Pass out
Fall
Trauma

Vision
Depression

GI incontinence
Urinary incontinence
Motor
Sensory

Domestic Violence:
SAFE GARD

Safe
Afraid of hubby
Family, Friends
Emergency plan

Gun @ home
Alcohol
Relationship with hubby
Drug, depression

Pass out
Before------------
• Did you feel lightheaded before you passed out? (Ask one question at
a time)
• Did you see (or smell) anything unusual before you passed out?
• Did you feel heart racing before LOC?
During---------
• How long did you pass out?
• Did you bite your tongue?
• Any shaking of your body?
• Did you pass any urine? Any stool? (Pause between each question)
• Did you hurt your head?
After----------
• Did you feel confused after you gained consciousness?

Past History
PAMHUGSFOSS
 P Mr/Mrs --- , now I would like to (gonna) ask you few questions
regarding your health in the past. Is that OK with you? (transitional Q 1)
• Have you had similar problems before?
• Do you have any other major diseases?
• Can ask about HTN, DM, High cholesterol in all the patients if
you think they are related to the CC.
 A Do you have any allergies?
 M Are you taking any prescribed medications? Are you taking and
over-the-counter medications? Could you spell the name for me, please? I
can read the labels if you have the prescription with you?
 H Have you been hospitalized before?
• Have you had any surgeries before?
 U Have you had any problems with your urination?
 G Have you had any problems with your bowel movements?
 S Do you have any problems sleeping?
 F Mr/Mrs --- , now I would like to (gonna) ask you a few
questions regarding the health of your family. Is that OK with you? (
transitional Q 2)
• Does anyone in your family have similar problems?
• Are your parents alive? Are they in good health?
 O Mrs --- , now I would like to (gonna) ask you few questions
regarding your gynecological health. Is that OK with you? (transitional Q 3)
• When did you have your first period?
• Are your cycles regular?
• How long does your cycle last?
• Have you ever bled between cycles?
• How many pads/tampons do you use in a heavy day?
• Do you have abdominal cramps/pain with your period?
• When was your first day of last period?
• Do you have vaginal discharge? What color? Any odor?
• Have you ever been pregnant before? How many times?
• Any miscarriages or abortions?
• Any problems with your pregnancy?
• Any problems with your delivery?
• Have you had pap smears before?


 S Mrs --- , now I’d like to (gonna) ask you some questions
about your sexual life. All the information will be kept confidential. Is
that OK with you? (transitional Q 4)
• Are you sexually active?
• Who is your sexual partner?
• How many partners do you have during last year?
• Do you use any kind of contraception?
• Have you ever been diagnosed for STD/HIV?
 S Mrs --- , now I’d like to ask you some questions about your
life style. Is that OK with you? (transitional Q 5)
• S Do you smoke? How many packs a day? For how many years?
• A Do you drink alcohol? How much alcohol do you drink? If more
than two drinks /day male, one drink/day female, then CAGE.
Have you ever tried to cut down on your drinking?
Have you ever been annoyed by criticism on your drinking?
Have you ever felt guilty about your drinking?
Do you drink alcohol early in the morning?
• Do you use any recreational drugs? D
• Do you work? What do you do? O
• Do you exercise regularly? E
• Do you have any stress from work/your family/home? S
• Have you traveled recently? T
Pediatrics Mnemonics:
PAM HUGS FBI CD

 Birth: Was your pregnancy full term? Was it a vaginal delivery
or a C-section?
 Feeding: Did you breast-feed your child? When did your child
start eating solid food? How is your child’s appetite?
 Immunization: Are your child’s immunizations up-to-date?
 Checkup: When was your child’s last routine checkup?
 Development (Day care)


Brief Summary
Ms(Mr) XXY, you have xxxxx, associated with xxxx.
Did I miss anything?
 Ms(Mr) XXY , thank you for answering all these questions. Now I
would like to perform a quick general physical exam, and then take a close
look at your ---------. Is this OK with you? Excuse me for a moment, I need
to wash my hand first.------- Wash hand----
When doing PE,
In minor <18 yo, before PE, ask “Do you have permission note from your
parent for me to perform the physical examination on you?”.

In neuro exam, if light touch is intact, no need for sharp/dull sensation.

I will need to do a rectal exam/pelvic exam/breast exam on you later today.
Closure:
&#61656; Thank you, Ms Mr. XXY, I have finished my physical exam, now I
would like to sit down and talk over what I am thinking so far. Base on
what you told me, and my physical examination. I think that you may have
XXXX disease (medical term), which is (explain in lay words). However,
there are other possibilities which may also cause your symptoms. So we need
to run a few test on you to confirm the diagnosis and rule out more severe
diseases. Also, I will order some blood work, stool work, and some imaging
studies including an x-ray, which is just to take a picture of your chest.
As soon as we get the results back, I will come back to discuss the
diagnosis and treatment options with you. (Don’t tell pt at this point of
time any diseases like cancer or HIV when you have no clues for them. Tell
them the other possible benign disease.)
&#61656; One more thing, as your physician, I’d like to tell you alcohol
/smoking places you at a higher risk of high blood pressure, strokes, heart
diseases, even some kinds of cancer. I would recommend you to think about
stopping drinking/quitting smoking. If you decide to quit/stop, our
professional support group will help you, and I will be glad to provide you
all the necessary information.
&#61656; Other counseling includes instructions while waiting for the
results., such as drinking more water, taking a rest, pain medication, and
not eating or drinking in case of urgent ABD which might need emergent
surgery.
&#61656; Do you have any questions for me? (When answering the questions,
start with “I understand you concerns, xxxxxxxx. At the end, say “I want
to assure you that you are in good hands. We will take the best care of you
and make you feel better.”)
&#61656; Did I answer your questions? Any other questions?
&#61656; All right, I will meet you again when the results come out. It
is very nice meeting you. Take care!


Commercial names of drugs

Tylenol = Acetaminophen / Paracetamol
Advil = Ibuprofen
Allegra = Fenoxifenadine (allergy relief)
Maalox = Antacid (Aluminum Hydroxide and Magnesium Hydroxide)
Mylanta = Antacid (Mg. OH and Ca. Carbonate)
Nexium = Esmoprazole
Prilosec = Omeprazole
Zantac = Ranitidine
Lopressor = Metaprolol
Augmentin = Amoxcillin + Clavulanic Acid
Zyban = Bupripion (Antidepressant + smoking deaddiction )

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共有1条评论
1   [USMedEdu 于 2011-06-15 15:58:07 提到] [FROM: 142.]
发信人: julyer (julyer), 信区: MedicalCareer
标 题: CS passed
发信站: BBS 未名空间站 (Wed Jun 15 15:41:49 2011, 美东)

感觉考试的内容很基本。完全不用Kaplan哪本书。
考的过程不必面面俱到,把一个流程大概走下来就可以。我前面3-4个case完全忘了
summarize病情,中间有一个case没来得及做完closure,一个查体给病人造成了痛苦,
还有一个腹痛查体忘了查阑尾。这些都是想的起来的失误。但这些方面的评价还都不错
。让我惊讶的是自以为口语很好,但evaluation 不高。而且自以为比较擅长的data
gathering 的evaluation也不高。

感谢pony在我刚刚开始准备的时候给了一个talk,让我从一开始对考试就有了一个清楚
地认识。也感谢我的partner不厌其烦的让我练。

对于还没考的,最想说的就是不要把这个考试想想的太难。其实比起step 1,CK来讲,
CS应该是比较可以放松的。
--

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