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failedcsonce: CS fail 掉的人来问几个问题/讨论
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发表时间:2008-09-26
更新时间:2008-09-26
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发信人: failedcsonce (failedcsonce), 信区: MedicalCareer
标 题: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 00:13:18 2008)

1. 大家都是怎么分配时间的?

我上次的时间分配:问病史9 分钟,查体3-4 分钟,closure 2-3 分钟。结果发现这样
时间还是太紧张。我想下次改成:问病史缩短到7 分钟之内,查体3-4 分钟,然后多留
出点时间closure, 不知道可行不?

2. 我上次有的case, closure 的时候吸烟喝酒safe sex 说了一堆,结果时间到之前
都没有来得及问 "do you have any questions". 这个不知道怎么改进。

3. History-taking steps
http://csprotocol.blogspot.com/2006/02/art-of-history-taking.html
我上次是按照这个问个,一共五步。现在觉得实在太花时间了。这里面的step 3-5 是不是要尽量精简啊?

4. SEP
这个怎么在短期内提高呢?我觉得我最大的毛病就是一着急就越说越快。下次一定要慢,不过这样就势必要少问几个问题。


接下来是几个具体的问题:
5. knee pain 的case
查体是不是只轻触膝盖,别的比如reflex 都不用查啊?我上次非常愚蠢地敲knee reflex, 结果病人大叫了一声。。。汗

6. 下肢感觉
这个大家怎么查的?我上次是问病人sharp/dull,怎么感觉有不止一个病人都是异常啊? 是不是我的手法有问题啊?

7. 洗手的时候
上次为了节省时间,留了几个问题洗手的时候问, 结果发现这时候病人容易听不清楚。我也不知道怎么办才好了。

8. Neuro
无论如何时间都不够用啊,怎么办?我上次头一个case 就是neuro, 很惨!

9. 产后抑郁/自杀
这样的case 怎么应对啊?

又想起来个问题:

10. mnemonics
除了LIQOR AAA, PAM HUGS FOSS, 大家是不是都不用别的mnemonics 啊?是不是pass 的人都不用mnemocis, 像我这样爱用mnemonics 的人都容易fail??
:-)

To be continued......


--
※ 修改:·failedcsonce 於 Sep 26 00:54:52 2008 修改本文·[FROM: 76.118.]



发信人: failedcsonce (failedcsonce), 信区: MedicalCareer
标 题: Re: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 00:41:53 2008)

对了,我上次是费城fail 的,下次要不要鼓起勇气还在费城考,还是换个地方?

费城离我们这里最近,而且考场周围已经比较熟悉了。不过我对那里多少有点心理障碍
;-)
--

※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 76.118.]



发信人: soaplover (Ha), 信区: MedicalCareer
标 题: Re: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 00:51:06 2008)

时间上普通的病人5分钟提示时开始查体完全来得及。neuro的,在doorway已经知道,
进门先siqoraaa,问完了赶紧查体,查完了再坐下来接着问PAMHUGSFOSS和补问HPI(如
果想起来的话)这个方法,12个病人全部能完成 closure. good luck~




--

※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 70.143.]



发信人: soaplover (Ha), 信区: MedicalCareer
标 题: Re: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 00:59:50 2008)

份特~~~你不是去考CS吗?
site
intensity
quality
origin
radiation
alleciation factors
agravation factors
associate syndrome
mostly used for pain, but can also use it to question all kinds of symdrome
ah~~~



--

※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 70.143.]


发信人: addictmed (addictmed), 信区: MedicalCareer
标 题: Re: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 09:26:54 2008)


【 在 failedcsonce (failedcsonce) 的大作中提到: 】
: 1. 大家都是怎么分配时间的?
: 我上次的时间分配:问病史9 分钟,查体3-4 分钟,closure 2-3 分钟。结果发现这样
: 时间还是太紧张。我想下次改成:问病史缩短到7 分钟之内,查体3-4 分钟,然后多留
: 出点时间closure, 不知道可行不?
when you practice, time your history taking within 8 minutes, time your
total encounter within 13 minutes. during the exam, if you're still in
history taking while "5 min warning announcement", cut your physical exam to
1 minute and jump to closure ASAP.

: 2. 我上次有的case, closure 的时候吸烟喝酒safe sex 说了一堆,结果时间到之前
: 都没有来得及问 "do you have any questions". 这个不知道怎么改进。
ask "do you have any questions?" before hand washing, actually, most of the
challenge questions were asked at that time.

: 3. History-taking steps
: http://csprotocol.blogspot.com/2006/02/art-of-history-taking.html
: 我上次是按照这个问个,一共五步。现在觉得实在太花时间了。这里面的step 3-5
是不是要尽量精简啊?
never visit this website. as I know PAMHUGSFOSS is enough.

4. SEP
这个怎么在短期内提高呢?我觉得我最大的毛病就是一着急就越说越快。下次一定要慢
,不过这样就势必要少问几个问题。
take some English classes in your local community college for one semester,
you'll get some sense of speaking English. Also try to speak all the CS
sentences in front of native speaker. let them polish your accent and speed.



接下来是几个具体的问题:
5. knee pain 的case
查体是不是只轻触膝盖,别的比如reflex 都不用查啊?我上次非常愚蠢地敲knee
reflex, 结果病人大叫了一声。。。汗
if light touch already cause pain, why bothering with reflex?

6. 下肢感觉
这个大家怎么查的?我上次是问病人sharp/dull,怎么感觉有不止一个病人都是异常啊
? 是不是我的手法有问题啊?
I did both sharp/dull, and I did have 不止一个病人都是异常.

7. 洗手的时候
上次为了节省时间,留了几个问题洗手的时候问, 结果发现这时候病人容易听不清楚。
我也不知道怎么办才好了。
don't ask questions during hand washing, it's not a polite way. you need to
show respect to your patients.

8. Neuro
无论如何时间都不够用啊,怎么办?我上次头一个case 就是neuro, 很惨!
my 1st case was Neuro too. it was intimidating!! I skipped lots of physical
examination and did a detail closure. after closure I still have 2-3 min
left, then I resume the physical examination until the last seconds.

9. 产后抑郁/自杀
这样的case 怎么应对啊?
I assume it's the same case as depression. closure will play a large part in
this case. make sure no thought of killing of baby, otherwise mention
immediate admission to the hospital.

又想起来个问题:

10. mnemonics
除了LIQOR AAA, PAM HUGS FOSS, 大家是不是都不用别的mnemonics 啊?是不是pass
的人都不用mnemocis, 像我这样爱用mnemonics 的人都容易fail??
I only used LIQORAAA plus PAMHUGSFOSS

--

※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 128.231.]


发信人: failedcsonce (failedcsonce), 信区: MedicalCareer
标 题: Re: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 09:43:27 2008)

谢谢addictmed 的详细解答。

我本来以为查体都不会有啥阳性体征。没想到感觉异常的还挺多的?

还想问问你,你洗手之前还总结一下病史吗,还是直接问any questions so far?

--
※ 修改:·failedcsonce 於 Sep 26 09:52:56 2008 修改本文·[FROM: 134.174.]



发信人: failedcsonce (failedcsonce), 信区: MedicalCareer
标 题: Re: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 10:11:14 2008)


又想起来几个问题,大家不要嫌我啰嗦啊。

1. Taking notes

大家在蓝纸片上都写些啥?

2. ROS
系统回顾大家问不问,是不是非常简单问一两个问题就算了?花在这方面的时间是不是
应该少于30 秒?

3.Physical Exam
查体大家都花几分钟啊?我觉得我查体速度太慢了,耽误时间。

4. Specific data-collection for the case
每个case 都有些特殊的问题,大家都是怎么记住的呢?我原来喜欢用mnemonics, 可是
我的mnemonics 太长,全问很耽误时间。大家有啥好办法?

5. Jugular venous pressure
这个大家都把床头抬高30 度吗?我上次有三个病人查了这个。有个病人很胖,我竟然
没搬动,太狼狈了。大家都差JVP 吗,让病人抬头呢,还是要抬床?


--
※ 修改:·failedcsonce 於 Sep 26 10:21:57 2008 修改本文·[FROM: 134.174.]



发信人: addictmed (addictmed), 信区: MedicalCareer
标 题: Re: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 10:48:40 2008)

usually before hand washing, I always say "before we move on to physical
examination, is there anything else that you want to let me know?" then most
patients will say no, half of them will ask challenge questions and I did
have one patients gave me more information.



1. Taking notes

大家在蓝纸片上都写些啥?

I put mnemonics down before entering room. during encounter, I put a click
after each question. I didn't write a lot on the paper. most of the cases
are simple and straightforward.

2. ROS
系统回顾大家问不问,是不是非常简单问一两个问题就算了?花在这方面的时间是不是
应该少于30 秒?
I'm not sure what your ROS mean, for me it is distributed during the whole
encounter. For example, a cough case, you'll definitely ask about "chest
pain? difficulty breathing? any sputum?" and plus "any similar symptoms
before", then the respiratory system is covered. PAMHUGSFOSS covered your
digestive system and urinary system. I think it's enough.

3.Physical Exam
查体大家都花几分钟啊?我觉得我查体速度太慢了,耽误时间。
It depends on each case. for example, neuro case, do neuro PE first, if you
have more time, do heart and lung, otherwise, go to closure. you should have
some sense how much time you need for different systems, like heart/lung
takes me 1 and half minute.

4. Specific data-collection for the case
每个case 都有些特殊的问题,大家都是怎么记住的呢?我原来喜欢用mnemonics, 可是
我的mnemonics 太长,全问很耽误时间。大家有啥好办法?
averagely, about 5 specific questions for each case, never more than 10
questions. if you have difficulty, ask the most important one. I doubt
though, since most CS cases are simple.

5. Jugular venous pressure
这个大家都把床头抬高30 度吗?我上次有三个病人查了这个。有个病人很胖,我竟然
没搬动,太狼狈了。大家都差JVP 吗,让病人抬头呢,还是要抬床?
I only do JVP in heart case. for me I only had one case and I forgot to do
JVP. if I remember correctly, all the bed are already at 30 degree.
--

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发信人: dreamcatchin (maydreamcometrue), 信区: MedicalCareer
标 题: Re: CS fail 掉的人来问几个问题
发信站: BBS 未名空间站 (Fri Sep 26 12:05:51 2008)

I passed CS at Philly.

产后抑郁/自杀
I had the same case. I managed to talk to her for 15 minutes. I am not sure
I did it 100% right but I will share with you about what I did.

After I introduced myself (no hands shake because she was weeping) I brought
a box of tissue and put it on the table right beside her chair. I sit right
in front of her. I did not take notes during all my CS exam encounters.

Then, I tried to find out what happened to her. What caused her suicidal
thoughts/attempts?
I asked her:
Is this her first baby? Is it a boy or girl?
Was it a planned pregnancy?
Were they (her husband and she) excited about the baby?
Were they expecting a boy rather than a girl (vice versa)?
Has her husband been helpful?
Does she have any others to ask for help?
Did she attend classes to learn how to deal with pregnancy and new born
child prior to giving birth?
Has she had some good rest after delivery?
Is she breast feeding?
Has she felt bounding between her baby and her?
I also asked questions about her pregnancy. Typical questions only such as
any drug use, any problems. I also asked questions about her previous
history: any mental health issue, any family history on depression/mental
problem, has she ever used drugs. …

After all these questions, I figured out that this was her first pregnancy.
Both her husband and she wanted to have a child so they tried to get
pregnant for a while. When it happened, they were very excited. They are
happy to get a child and does not care much about the sex/gender.

Everything went well. (She did have had depressions in college but she was
cured.) She gave birth about 3 weeks ago. At beginning, she breast feed her
baby but she gave it up lately because she was so tired. She has not had
good rest after giving birth. Although her husband is very supportive and
tried best to help, he is managing two jobs to bring enough money home or
something like that. So he is not around much. (when I figured out his
husband's absence, I asked her if she has others to help. I also asked
whether or not she has friends and family members in town, if any of her
friends have children.)She has nobody else to ask for help for baby sitting
or to ask for help when she does not know how to do something for the baby.
She does not have any relative or good friends in town (something like that)
. She talked to her mother and sister on the phone but has not been able to
do so because of all these going on in her house. None of her friends have
baby so when she has a problem, she has nobody to turn to.

She also said she felt very guilty because she did not bind with her baby.
She felt she was such a bad mother that's the reason she wanted to kill
herself.

So after all these, I started counsel her.
I told her:
1. It is far more common than she thought to feel depressed after giving
birth. There is nothing wrong with it. She should not feel bad/guilty about
it.

2. Based on what she told me, I felt she is going to be a fantastic mother.
I am sure she has everything she needed to be a good mother. She just needs
to get her chances to bring those out and I am going to help her to do so. I
spent quite sometime on this point but I did not remember the entire
conversation.

3. Then I told her that the hospital social worker can help her to get baby
sitters, so that she can have some rest at home. Once she felt better, I
asked her to consider resuming breast feed her baby again. I also encourage
her to join some new mommy gather together events which can be found through
our social workers (I pretend there is such a thing). I also encouraged her
to talk to her mother and sisters often. If she has questions regarding
baby care she can discuss it with her mom. She also can get some help
through a help phone number I am going to get it for her. So basically, I
told her everything I can think of as a way to help her.

Finally I told her I am going to give her all the info I promised and ask
her to come back to see me if she had any other problem…



I did only very simple physical exams for all my cases. I did not finish 3
of them.

For most of my cases, I finished history taken right around the 10 minutes
mark. So when the warning was on, I was about to finish history or washing
my hands.
Pretty stressful.
--

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