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failedcsonce: Passed CS at second attempt
作者:USMedEdu
发表时间:2009-04-29
更新时间:2009-04-29
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发信人: failedcsonce (failedcsonce), 信区: MedicalCareer
标 题: Passed CS at second attempt
发信站: BBS 未名空间站 (Wed Apr 29 12:41:56 2009)

早上本来不敢自己看成绩,想把Score report 保存下来让老公帮着看,结果一进去
OASIS 就看到You ECFMG certificate will be sent to you within two weeks. 不容
易啊,终于考过了! 我知道版上不少人CS 准备了很短时间, 很轻松就通过了。不过我不
属于这种情况。从第一次CS 没有通过,把十个月大的孩子送回国,放弃CS 全力准备CK
,考过CK 再继续准备CS,中间花了差不多一年的时间。

废话少说,我觉得我第一次没过,不能抱怨运气不好,主要还是实力不行。我把我的经
验写一下吧,希望给后来的人一点借鉴。


Failed 过的人都知道,score report 会很详细地说明你在每个部分的表现。我第一次CIS 和SEP 都没过,只有Data gathering 这部分却非常好。但是恰恰是因为问了太多问题,做了太多查体,导致整个考试fail. 我有两个case 完全没有closure, 还有好几个case 我正counsel 到一半时间就到了。就算是勉强完成的case,因为太着急,估计说得也特别快,病人就很难听懂。痛定思痛,我第二次少问了很多问题,也少做了很多查体,这样除了一个下腹痛的病例是卡着点完成的,别的都提前至少二三十秒出来的。

病史这次我就是完全按照LIQOR AAA + PAMHUGS FOSS 问的,只有associated symptoms 需要展开。
下面是我总结的associated symtpoms,有不对的地方大家指正,以免贻误他人啊。


各系统相关问题,简化版本。如果想找完全版本,First Aid, UW 上面有。

消化系统
What type of food do you usually eat?
Did you eat anything unusual?
Do you have a fever?
Do you feel nauseous?
Did you throw up?
Any change in your bowel habits? (Be careful! Do not ask this question twice)

循环系统
Do you have a chest pain?
Do you feel that your heart is racing (or pounding)?
Do you have difficulty breathing?
Do you have difficulty breathing during the night?
How many pillows do you use?
Any swelling in your legs?

呼吸系统
Do you have a fever?
Do you have a runny nose?
Sore throat?
Coughing? Any thing comes up when you cough? Could you describe it?
Do you have a chest pain?
Any wheezing in your chest?
Any difficulty breathing?

感染系统
Have you ever come in contact with anyone who has similar symptoms?
Have you ever traveled recently?

各种出血
Do you feel dizzy now?

妇科
要问四方面内容:Menstrual history, sexual history, pregnancy, Pap smear
复杂版本First aid 写了,我写个简化版本吧:

When was your last period?
Is your period regular?

Now I need to ask you some questions about your sexual life. This may be embarrassing, but I want to assure you everything between you and me are confidential.
Are you sexually active?
How many sexually partners do you have in the past year?
Are they male, female or both?
Have you ever had sexually transmitted infection?
Have you ever had been tested for HIV?

Have you ever been pregnant?
How many times?
How many children do you have?
(You can calculate if the patient has ever had any miscarriage or abortion even without asking her).

Have you ever had Pap smear? What’s the result?
Any you ever had any abnormal Pap smear?

儿科
也要问四方面问题:Birth history, developmental history, immunization and check-up, social situation (daycare, school, home situation).
(注,如果不是和孩子母亲,而是和孩子的祖父母或其它亲戚谈话,注意人称变化)
Did you have prenatal care when you were pregnant with XXX?
Any complications during pregnancy?
Did you smoke when you were pregnant? (You can skip this question.)
Did you drink alcohol when you were pregnant? (You can skip this question.)
Was your pregnancy full-term?
Was it vaginal delivery or C-section?
Any complications when you gave birth?

Have your child ever had any medical problems after birth?
Is he/her developing normally?
When was his/her last check-up? Was everything OK?
What’s his/her height?
His/her weight?
When did he/her start to talk?
When did he/her start to walk?
Did your child get all the vaccinations?

Does your child go to daycare/school?
How is he/she doing at daycare/school?
Do you know if anyone from daycare/school who has any symptoms like this? (Do not need to ask in every case)
Any big changes at home recently? (Do not need to ask in every case)

精神系统
Depression
FACE SLIPS
F------Do you feel guilty, depressed, anxious, worthless (Ask one question at a time)
A------Any change in your appetite
C------Do you have any difficulty concentration?
S------ Do you have difficulty sleeping?
L------ Any change in your interest in sex? (Ask this question in sexual history)
I------ Do you have any hobbies? Do you still enjoying doing it?
P------Psychomotor symptoms (I never ask this question.)
S------ Have you every thought about hurting yourself? Do you have a plan? Have you ever tried to hurt yourself? (Suicidal thought/plan/attempt)

Abuse
SAFE GARDS

神经系统
Do you have a headache?
Any change of eyesight (vision)?
Any difficulty talking?
Walking?
Any weakness of your arms or legs?
Any numbness?
Any tingling?

如果是Dementia/confusion, 还要问DEATH SHAFT
如果是LOC, 要分别问之前,过程中,还有之后的情况,比如
晕倒之前发生了啥?
Did you feel dizzy (lightheaded) before you passed out? (Ask one question at a time)
Did you see (or smell) anything usual before you passed out?

晕倒过程中发生了啥?
How long did you pass out?
Did you bite your tongue?
Did you pass any urine? Any stool? (Pause between each question)
Did you fall?
Did you hurt your head?
Any shaking of your body?

晕倒之后发生了啥?
Did you feel confused after you gained consciousness?


Physical examination

我的教训就是不要做太多查体。比如右下腹痛,因为要涉及到三个系统,消化,泌尿,妇科,需要问的问题比较多,就只做腹部查体就够了。心肺可以省略。

关节痛,无外伤史,这个要问的问题也满多的。查完关节IP ROM MRS P 就差不多了,可以省略心肺查体。
I------Inspection 看所有关节
P------Palpitation 从上一个关节和下一个关节,往疼的关节触
ROM------Range of motion,先主动,后被动
MRS------Motor,sensory,reflex
P------Special 四个关节有特殊的检查,分别是肩(查肩部感觉),腕(Phalan or Tinel 中选一个查),膝关节(如果有外伤史,要查drawer’s test 等几个检查),back pain (要查下肢还有gait).

神经系统病例,这个是最容易做不完的,一定要省很多东西。比如心肺,还有gait 最好都省掉,以保证足够的时间closure.

我在Kaplan 的老师说, 就算有的case 完全不做查体, 只要别的方面不是太差, 一样可以通过。这个说法有点夸张,但是说明查体其实是最不重要的了。


Patient Note

这个可说的不多。我是支持打字的。看起来很清晰,给人第一印象比较好。真正考试的界面,和练习的界面查不多,就是多了个显示进度的东西,可以看到还剩余多少空间。还有就是字看起来都特别大,不知道是不是我的那个考场电脑设置的关系。

SEP
口语好的可以直接跳过。

我口语不要,所以找了tutor, 从这个网站找的:
www.wyzant.com/

如果没记错的话,是Claymore 告诉我的这个网站,谢谢你!

考试的时候关键要说得慢,宁可少问几个问题,也要把话说清楚。尽量说简短的句子,不要说很长很复杂的句子。同一个问题,可以试试不同的说法,看哪种病人更容易听懂。比如,问visual changes,如果vision 这个词发不标准的话,可以问 any change in your eyesight。还有我问aggravating factors 的时候,我说anything makes it worse 总有人听不懂,后来改成what makes your symptom worse 好多了。有的词总是惹麻烦,比如diet,后来干脆鸵鸟政策,饶开这些词,比如说what type of food do you eat?当然,这个因人而异,每个人的发音问题都不太一样。

容易听不懂的地方,可以配合手势。比如问palpitatin (heart racing),指着心脏问。当然这招也不是总灵验,有时候病人低着头,不看你。

问题安排的有条理一些,也可以让病人不感到很突兀,容易听懂。比如同一个系统,从上往下,从头到脚按个顺序问,问完一个系统再问另一个系统,好一些。比如,Loss of consciousness,问完headache,memory changes,numbness/weakness,接下来已经问到心血管系统 chest pain/heart racing,然后回头想起来,再转回去问any change in your vision,最后这个问题病人就容易听不懂,还不如不问呢。

练习的时候,把自己说的录下来,反复听,也很有用。


CIS

一直以为我第一次CIS 没过是就是因为有好几个病例没做完。上了Kaplan course 才发现,不是这样的。如果前面做得非常好(指问病史和查体),两三个病例没有完成,也一样有机会过。反之,如果前面毛病很多,再加上有做不完的,就通过不了了。我觉得上Kaplan 5-day course 对查体,还有CIS 的提高还是很有帮助的。这个等我以后有空,把Kaplan 上课教的,再好好写写。


考场的比较

我朋友在费城也一次就顺利通过了,再次说明考场不重要。不过,我估计是少数去过费城和芝加哥两个考场的人,还是说说吧。我第一次在费城,第二次在芝加哥考的。费城那次是上午,24 个人一起考。芝加哥那次是在下午,11 个人一起考,这11 个人中只有三四个白人 (可能是碰巧)。

在芝加哥我遇到过至少两个病人,我刚开始问他associated symptoms,我刚问他一条,他一口气回答三四条,语速还挺快的,好象背书一样,估计把他知道的阳性的一口气都告诉我了。好处是我接下来这些问题都不用问了,节省时间。坏处是,有时候来不及记下来,还要跟病人一一核实。我记得我在费城没遇到过这样的情况,都是我不问,病人就不主动说。不过总体来讲,我还是更喜欢芝加哥考场。


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※ 修改:·failedcsonce 於 Apr 29 13:13:16 2009 修改本文·[FROM: 76.24.]
※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 76.24.]

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共有2条评论
1   [USMedEdu 于 2009-04-30 07:14:28 提到] [FROM: 10.]
failedcsonce:顺便贴点可能有用的东西


Kaplan CIS checklist
#1 Examination knocked before entering
女生要注意不要敲得太轻了,当然也不能使劲砸。

#2 Appeared professional in dress/grooming hygiene
芝加哥考场还特意说了,可以带牙刷。

#3 Introduced self by name.
一定要把病人名字写在那张蓝色纸,以免叫错名字。

#4 Made comfortable eye contact.
如果病人坐着或平躺,可以选择站着或者坐下。如果病人侧卧,最好坐着。要在病人右侧,45 度角,离病人一个手臂的距离。但也不需要一只盯着病人。举个例子,你问 "when did your pain start? ", 对方回答"one week ago",这个过程中你要看着病人,然后你可以低下头在蓝纸上记录,同时复述病人说的"one week ago".

#5 Focused attention and concentration on patient
我正式考试中遇到过腹痛病人躺着,但是leg extension 并没有拉出来,这时候要在一开始就帮他拉leg extension. 还有比较容易忘记的就是re-tie gown.

#6 Respectful and nonjudgemental attitude
Kaplan 的观点是尽量不要说"good", "excellent" 这些词,可以多说"thank you". 理由一个是病人可能很痛苦,说这些词并不一定合适。另外如果你一直说"good", 病人告诉你他吸烟,你这时候沉默,会让人觉得你judgemental. 还有,我被批评最多的就是,每次接触病人,再着急也要先把话说完 (Ex., now I need to press on your stomache),然后再伸出手。

#7 Used appropriate draping technique
最好一进门就把病人盖上。病人坐着,可以对折之后盖在病人身上。

#8 Used transitional phrases
这个至少说三次,比如:
Now I need to ask you some questions about your health in general.
Now I need to ask you some questions about your sexual life. I want to assure you that everything betweeen you and me is confidential.
Now I need to ask you some questions about your social life.

#9 Expressed sympathy and made appropriate reassurances
这个也要至少三次
比如一开始,病人说完主述,可以说:
This must be a difficult situation. I want to assure you that I will try my best to help you. I need to ask you some questions first.
如果是个腹痛或其它急症,一开始可以说:
I can see you are in pain, but I need to ask you a few questions and do a quick physical exam, to find out what is causing your pain. I want to asssure you that I will be as quick as possible.
中间如果提到啥症状或者阳性家族史,可以再说一次:
This must be frightening.
I am sorry to hear that.
体检的时候,比如腹疼,关节疼,在触诊前先说:
Now I need to press on your stomache. This may cause some pain, but this is very important. I will be as gentle and quick as possible.
最后结尾的时候还要强调一下:
I want to assure you that I will try my best to help you.
I will find out what is causing your problem and give you the best treatment possible.
You are in good hands.

#10 Gave patient time to think and answer without interrupting
再着急也要每问一个问题都停顿一下,给病人时间回答。

#11 Asked open-ended questions
尽量多问几个
What caused you to come in today?
Could you tell me more about your pain?
Thank you for answering my questions. Is there anything else that you want to tell me? (洗手之前问一句,病人可能会告诉你没有问到的东西)

#12 Used non-leading questions
有时候一时大意,就问错了问题。比如,妇科病人,上来就问"How many times have you ever been pregnant", 实际病人根本没有怀孕过,或者not sexually active. 先问sexual history, 然后问"Have you ever been pregnant", 然后问"How many times",就能避免尴尬。再举个例子,还是妇科,病人说"I have been pregnant three times", 医生说"You have three children?", 病人回答"No, I have three miscarriages". 这个应该先问"How many children do you have?" 怀孕次数,减去子女数,就能知道有没有过miscarriage/abortion.

#13 Ask one question at a time
比如容易连在一起问题,有nausea/vomiting, 这是两个问题,要分两次问,中间停顿一下,给病人时间回答。类似的还有weakness/numbness.

#14 Used lay language
比如Diabetes 也最好不要说,"high blood sugar" 更好些。

#15 Listened and paraphrased information throughout the encounter
复述并不浪费时间,可以同时记笔记。只有复述的时候不需要看着病人。

# 16 Was connected and purposeful during the physical examination
如果万一想不起来下一步该干啥了,也不要慌,可以跟病人说"Now I need to check your pulse", 然后一边假装测脉搏,一边整理思绪。

#17 Summarized in closing and explained diagnostic plans
Kaplan 教的是先总结四点,可以是病史或者查体中的任意四点。接着,选一个你认为可能的的鉴别诊断,分别用 medical term 和 layman's term 解释。然后告诉病人需要做的两项检查。比如,

"Thank you for your cooperation. Now let me summarize...... I think you may have Alzheimer's disease, which is a brain condition that causes memory loss. However, I need to run some tests to make the final diagnosis. I need to take a sample of your blood, and take a picture of your brain. I know this must be a very difficult situation for you, but I want to assure you that I will try my best to help you. Do you have any questions?"

#18 Placed patient at ease and communicated information without alarming the patient.
我的理解在诊断里最好不要跟病人说肿瘤等特别严重的病,哪怕你认为那是最可能的诊断,这种情况可以告诉病人你认为的第二可能性的诊断。

#19 Asked if patient had questions and answered appropriately.
我的教训,先问病人有没有什么问题,最后counsel. 因为counsel patient 时间不太好控制,万一说太多,没时间问问题,就不合算了。





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※ 修改:·failedcsonce 於 Apr 29 22:04:46 2009 修改本文·[FROM: 76.24.]
 
2   [USMedEdu 于 2009-04-29 17:54:45 提到] [FROM: 10.]
发信人: failedcsonce (failedcsonce), 信区: MedicalCareer
标 题: Re: Passed CS at second attempt
发信站: BBS 未名空间站 (Wed Apr 29 16:34:04 2009)

我不清楚啊。按理说fatigue 应该问问是早上更严重,还是晚上更严重。我不问那么详
细的话,还是会问问aggravating/alleviating factors.

我以前很傻, 连sore throat 还要问LIQOR AAA, 后来才知道纯属浪费时间, sore
throat直接从associated symptoms 开始问就好了.

【 在 harrywfu (天南海北山东人) 的大作中提到: 】
感觉在fatigue病例中alleviating factor 和aggravating factor就不用问了。对吧。


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※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 76.24.]


发信人: failedcsonce (failedcsonce), 信区: MedicalCareer
标 题: Re: Passed CS at second attempt
发信站: BBS 未名空间站 (Wed Apr 29 17:14:06 2009)

顺便把我考前问Kaplan 老师 Konrad Gut 的一些问题贴一下。 他人还是很好的, 耐心回答了我不少问题。

1.Question (shoulder pain case): Should I untie the patient's gown to expose the shoulders, or ask him to pull up his sleeves?

Answer: Yes. You may want to since you are going to need to fully inspect,
palpate, and perform the sensation of the axilary nerve over the deltoid.
It will make things more easy. Just remember that you need to retire the
gown when you perform MRS so you don't lose a point for overexposure.



2. Question:How to ask "urinary urgency", "urge to urinate", "tenesmus", "
fatty stool"?
Answer:"Do you feel the urge to urinate"
"Do your stools float?" ------fatty stool
Tenesmus ------ you are reaching to far ... keep it SSS (simple short stupid)
我自己觉得tenesmus 还是挺重要的,就是话不太容易说清楚, 我后来的版本"Do you
feel that you cannot completely empty your bowel after passing stool?" 不是
考试的时候我还是忍住了没有问这个问题, 就怕病人听不懂啊.

3.Question: Could I skip "gait exam" if time is tight?
Answer: If you are pressed for time, yes skip gait. Unless it will tell you
something important (ex. Parkinson's).

4.Question: What should I say during Weber test?
Answer: "I'm going to put this on your forehead. Do you hear it? Is the
same in both ears?"

5. Question: What should I say when checking CN V (clench the jaw)?
Answer: Never ask permission to do anything. Explain what you will do and
do it!
"I need to check your jaw." place your hands on the pt. "Clench. Thank
you."

6. Question: What should I say before I untie the patient's gown?
Answer: Now I need to untie your gown. Explain what you need to do first ...
"I need to listen to your heart, I will untie your gown."

7. Question: How to explain disc herniation in layman's term?
Answer: "There is a disk between the bones of your back and it has moved out
of place, which is causing your symptoms."

8. Question: What should I say during finger-to-nose test?
Answer: "Please touch your nose. my finger. your nose, keep going." Repeat
on other side.

9. Question: Do I need to wash my hands after touching the patient's foot?
Answer: The only time you need to re-wash your hands is if you touch the
bottom (sole) of the foot and then attempt to do anything above the knee.
If you only touch the foot, but not the sole, such as in checking the pulses
, then you do not have to re-wash your hands.
结论,碰脚背没关系,但碰病人脚底就不能接触膝盖以上的地方,否则要再次洗手。例如ankle pain,先听心肺再查脚,或者干脆不听心肺,最后查脚。

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※ 修改:·failedcsonce 於 Apr 29 17:27:41 2009 修改本文·[FROM: 76.24.]



 
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