paasu
Forum Newbie
Topics: 8
Posts: 33
| | 12/28/07 - 12:45 AM
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| #1 |
I find it hard how to start the preparation. I was alone and new to this place. I was always finding myself difficult to speak up with the so called fluency with the people around me. As the days were near I panicked and thought that passing CS will be like a dream.
I looked in this forum and found the link to CS audio Kaplan courses. I suck it out and tried to listen to it. I started but left before it's all over.
For beginners like me, those audio holds good.
Meanwhile I started some pages from Usmleworld Books, but never finished more than 10 days. First aid was always my back up but I never used them. I tried www.csprotocol.blogspot.com and wrote the format of questions to be asked in my notebook but never reused it again.
Until late I joined some of the friends who have already grabbed the matter and knew the strategies to crack the exam. The first time I started the virtual case encounter, it was really discouraging for me .I was pathetic, but my friends consoled me that I will be in a good shape once I start practicing cases and utter relevant questions.
Then was the time that hit me that I lay in a verge of failing exam if I don't improve then. Next day in the practice, I asked all the history in the way I like and what I thought at the same time. Again I was told that I am not improving. I could figure out that I was not sincere enough to start the preparation.
Next day I took a day off from the practice and tried to go through the usual questions.
Then when I practiced in front of the mirror, I find out how difficult it is to ask the questions to patients being real calm and with empathy and important of all, on time.
The next day I went to practice, it was not that good but better than earlier.
2 cases and rest - never tried to write a patient note till then.
During our case practice we used to see both UW and FA cases and find out which one is missing what, after making an amalgam, we practice one by one the same case and comment upon one other's encounter.
Materials required –
Plain sheet of paper (in real exam of no importance because it is not evaluated)
Any ball point pen (Papermate brand black thick tipped-- in the real exam -2 in number)
Ideally should use a clip board (they use it in the real exam)
Timer/Stopwatch
Person who can simulate a patient (may not be a medical one, but should be a critic).
Has to cough if case is of cough, has to feel low if he has Depression, Has to itch if he has obstructive jaundice. Try this in every 1 in 5 encounter you do so that you won't miss out any.
Checklist and marking by the patient once the practice is going good.
Proper doorway information-Age, Sex, +/-Caucasian or white, complaints in patient's language (h/o passing out for unconsciousness, Pain in right side for Pyelonephritis) or ideal one (h/o cough, chest pain etc)
A table with length less than the usual bed to simulate patient's examination bed, as there is foot extensor in real patient's bed. Also know the real bed has drawer like area in the foot end of the bed to act as a step if patient has to step down to show you their gait. Use wood planks to simulate foot rest and foot extensor.
DO NOT TRY USING THE GLOVE EVEN IF YOU KNOW OR USED TO IT.Practice hand washing with proper technique—turn the water on and keep it on .Use the soap every time (push for it in the liquid soap case). Make sure you take your time cleaning nail area palm and dorsum. Now after you wash. Try to soak by 3-4 papers as one won't be enough, I know that. Then only with the wet paper on your hand you turn off the faucet/tap. Some faucet is left turn right turn separate type and some both in one type. I may sound silly explaining this minor stuffs but it will help you for sure ,so better learn earlier or else it will lower your confidence in your exam if you don't know how to close a tap.
And of all, DO LOOK AT THE PATIENT even if you have to twist yourself. Ask some question like-How have your mood been so far? Have you done your pap smear? Have you undergone colonoscopy? depending upon the patient. Make an ideal question the every time you wash your hands.
Alcoholic wipe, not mandatory but if time permits it can make patient happy as doctor is caring for their skin health.
A thin towel big size,folded simulating a drape and a chair should be present in every encounter.
A small room 7ft* 5ft with the bed near and facing parallel to the door entrance either to the left or right of the door.
Doorway information pasted on the door which can be flipped to view as the time starts for the encounter.
Objects simulating knee hammer, Tuning fork, otoscope, ophthalmoscope, switch nearby the patient's bed
Stethoscope
Lab coat worn opposite way to simulate a gown of the patient
Starting encounter with standard 'Examinee you may begin the encounter',
Sincerity not to look at the case unless the time starts, Giving a little time to stay out from the door to read patient information and to write Differential Diagnosis & PAMHUGSFOSS .In special condition which says-patient as diabetic write in the note DTR n fundus as you tend to forget to do in examination, MMSE if h/o feeling low.
DEATH n SHAFT if the patient has difficulty in remembering.
Starting an encounter:
'SP(standardized patients) be ready'—after 30 secs 'Examinee you may begin the encounter'
Go through the doorway information. Give some time to think –write age, sex, Last name of patient and remember that(you have to talk with them telling their name-practice with harder names e.g. Slaine, Brococh, Aubhaum)
Knock on the door 2-3 times and a pause, then get inside the room facing towards patient—be sure to tell morning / afternoon correctly. Good morning Mr. Slaine. I am doctor XYZ or Resident A and I will be seeing you today. Are you comfortable with the settings of the room? Let me make you make you more comfortable with this drape. (Sometimes patients get draped themselves, you just talk about the drape that's it)
(Simulate your feeling with the patient-eg Say you seem to be in great pain .I will be real quick and gentle with the examination. As soon as I get to know the cause, I will have my nurse give you the medication. Shall I proceed?) Next time they act to have pain, say the same with gentle touch over their shoulder or upper arm -never hands or back.
You will be surprised to see how they get well soon.
Donot shake the hand with the patient with shoulder pain.
Ask the pertinent history: Make sure you never miss OPD-Onset,Progression and Duration.
If complaint is pain –Ask all LIQOR AAA (location, quality, onset, and radiation,Aggravating,Alleviating factors,Associated factors)
Do not go on asking negative history eg: chest pain, cough, etc in a diabetic—even if the case is linked, ask quick questions.
Then ask about PAMHUGSFOSS—you should try to finish these questions in around 3 minutes maximum. So practice it harder. This roughly assess whether you will finish the conversation on time or not.
Focus on CIS (greeting patients,sorry to hear that,May I Is that ok with you n stuffs like that) and SEP (mainly effective counseling-try to utter few words but meaningful, you donot have to include everything so never be enthusiastic in that ,just attempt to give some most imp ones)
ICE consists of history taking and patient note –so if you missed out something also you can write that in patient’s note.
NEVER SAY I AM DONE ASKING-coz u might have missed something which you can ask later while u examine also.
Physical Examination:
Ask him/her that you are going to wash your hands.
Make sure you rub it to make it warm.
Begin with May I proceed?
Each time you donot have to say-there is no pallor,icterus etc. Just say that after you are done with it.
Neck-I cant see any visible veins or abnormal pulsation.
I want to take BP in both sitting n standing position, which I will do later.
Check pulses if case allows you.
Now I wud (no typos like that in exam) like to check your heart and lungs. For that I need to untie your gown, is that ok with you? Finish exam and tell let me ie back your gown.
Can you take a deep breath for me ?
Can you hold your breath for me –carotid bruit
Never be blank, do everything and let patient feel that you are doing something.
Shoulder pain/ leg pain –always say looks normal/abnormal when I compare.
No swelling, redness etc. Check the pulses, range of motion and sensation
Here US patients say pain and tender as somewhat same so you can ask for tenderness but when in doubt ask if it pains.
Abdomen-
I need to check your belly—do not say abdomen, they act like they don’t know or some even don’t know.
Can you please lie down for me? I will help you. Help them with the extension at the foot end to stretch their foot.
I need to adjust your gown to see your belly,
Is that ok with you?
Adjust it carefully.This is really difficult ,try a partner with only an underwear on and you will know how difficult will it be.
DO EVERYTHING SILLY BEFORE THE EXAM BUT NOT IN THE EXAM- any way some silliness happens but that should not feel you bad during whole of the exam.COZ 50% is what you need to pass-no one is excellent for 100%
Inspect-I can’t see any mass, redness or scars.
Auscultate- always the second step in abdomen ,no second thought ok.
Let me hear the bowel sounds.
Then palpate-do not just start.
Now I am going to feel your belly first gently then deeply-please let me know if you feel hurt or uncomfortable ok
Quickly touch all quadrants. Then deeply( not that deep-patients do not want you to poke him,the more gentle u r the less they are pissed off)
Now I am going to tap on your belly.Do single percussion on all quadrants.
Then say that you will do rectal/genital exam afterwards. BUT DO NOT DO just say only,you will get points for that.
CNS-start with MMSE if needed (in dementia,depression pts)
Then do cranial nerves- know 1 q for each cranial nerves.
Place the 5 fingers 1 feet in front-Can u count this? U will know if vision is normal or not.CN 2
Please move your eyes to follow my fingers,do not use your head for CN 3,4,6
CN5-clench your teeth.close ur eyes and tell me whether you feel something on your face.
CN 7-smile for me. Frown for me.
CN 8- rub your thumb over index finger infront of both ears,Ask if they hear it equally.
CN 12-wiggle your tongue
CN 9 n 10 –say “ahh”
CN 11-Shrug your shoulder when I resist.
Power same way—first explain I will try to resist your movement..Then say kick outkick in
Push out /pull in
Check vibration in a diabetic.
Do the senses.
Do not ask I will do the jerk—say reflex—jerk means stupid in slang
Fundus-
I will dim the light and will shine a light in your eyes to see the back of your eyes-might be little uncomfortable but please bear with me .I will be quick.
Babinski-FIRST ASSURE. this might tingle you /make you uncomfortable .please bear with me for a while.I will be real quick
Otoscope—I am going to look in your ear.
After you are done with the examination let them sit.
From whatever you told me and the examination I did, I have certain probabilities in my mind (NEVER SAY YOU HAVE Pancreatitis/ Depression directly) You might be suffering from a condition in which your pancreas get inflammed-which is called pancreatitis….other possibilities may be ( state max. 2 possibilities)
In order to make it sure I need to run some blood tests-cholesterol,glucose,routine test etc, a graphical recording of your heart which is called EKG, picture of your heart which is called Echo—Do not let patient ask what is ECG or Echo.
Even if they ask be prepared to speak less and mean more.
IF A PATIENT SAYS I CANT UNDERSTAND-NEVER say those words again ,think of some other words to describe it.
After you told the diagnosis n say that will do some tests.
If he is a smoker/ /alcoholic– counsel for stop smoking ,support groups available, let me know if you want to quit,
Depressed- want counselor to talk to? Support available for your care.
diabetic/hypertensive- be regular on your medications,exercise n life style modification, eye check up annually,check glucose n BP regularly.
Then:
I am happy that I was able to work with you .We will meet after the test results and will discuss on the treatment options ok. Shake hands and say bye.
GET OUT AS SOON AS YOUR TIME ENDS: Will c u later.shake hands n bye
Use stopwatch and set exact 10 mins or you can continue early if you finish encounter early. Print the sample patient note on usmle CD or you can use the First aid patient note section and the sample patient note there.
Use the paper with same width and length, in fact I practice with lining the paper first over the sample given in FA and print the same letters in same manner – eg 10 line below .
History ten line gap then-- Physical examination---- D/D -----Investigations
Practice to write patient after every practice encounters –You will know how difficult will it be finish in 10 mins. So you will have to work on that how to finish in time.
Try the basic abbreviation only. You will get that in USMLE cd or in usmle.org
TRY N DO 2-3 encounters with patient note writing every day.
THIS MIGHT SEEM TO BE A MORE BOTTLE-FEEDING TYPE APPROACH but this is what the exam is all about—little clinical knowledge,be prepared for the worst condition,Tackle them with conscience and have patience---12 encounters to go.
Have a good food in between the break. Talk to other examinees in the starting before the exam, during the break—this will give you confidence to speak and you will never feel that you are doing bad.
Deal each encounter with the same happy mood.
Do not think over the bad encounters.
Positive vibes and confidence will only help you conquer this exam.
Hope this will help .
There may be typos but ignore them ok.
Any question you have ,I will try to clear it out.
Good Luck to all the CS givers..
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| ShweHope99.9998
Forum Fanatic
Topics: 12
Posts: 2,573
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Hi , thought there is the rule, u should not discuss cases with any one especially on exm day in the exm center .
Also u better not to or r not allow to speak to each other in exm center even in wash room in case u might run into talking about the cases , that is 100% possible & run into own country man ends up at one point or all the time , speaking in ur own language other than English that seems suspicious in ECFMG point of view though they might even know the language we speak [ chances r they will ] .
Though just happy to speak in plain conversion, nothing to do with any cases, exm or pts , u will still in trouble , since ur speaking in non-English language .
Since u have already lay out in step by step , could u also please , do same for all mneumonic with what each letter stands for or mean in long form including those you've just mentioned above such as .........
PAMHUGSFOSS , if Diabetic case .. DTR n & fundus , MMSE if h/o feeling low , DEATH n SHAFT if the patient has difficulty in remembering & etc including
LIQOR AAA [ although this one already have each letter in long form u alraedy did , just want to have all mneumonics in one post by u again , thanks mate] here ... that will be great , so we can use this page a sole final , daily summary notes for the CS cases like bible  .
Thanks for detail info . Hat's off to ur time to write all out in here in detail .
GL 
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| arlete
Intern in 2009!!!!!
Topics: 30
Posts: 2,234
|
Thanks for sharing, good luck!
I thought we could not talk to the other examinees, was I wrong, then?
___________________
When men make the rules, God decides the exceptions.
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| paasu
Forum Newbie
Topics: 8
Posts: 33
|
Talking to other examinees I mean is before you are guided in the real exam room with 12 cabins.
You can speak with them when you line up and when the first 5 and second 4 encounters are over--I did that just to boost my confidence.
I agree on your part that you can not speak in any language other than English.Also the speaking part holds good for the anxious ones only .
Will post the mnemonics soon.
Thanks arlete n ShweHope99.9998
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| ShweHope99.9998
Forum Fanatic
Topics: 12
Posts: 2,573
|
ur welcome & thanks to you too .
Happy New Year
GL
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| alexaE
Forum Elite
Topics: 23
Posts: 334
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you can speak, in each break, to anyone about anything But the clinical encounters.
___________________
veni vidi...vincam
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| paasu
Forum Newbie
Topics: 8
Posts: 33
|
Ya that's true alexaE but when in doubt keep your mouth shut---There is a proverb "Its better to move kilogram of head than to move ounce of tongue"
Speak only in break and not about any of the encounters.
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| paasu
Forum Newbie
Topics: 8
Posts: 33
|
Here is the mnemonics for most of the cases.
http://www.prep4usmle.com/forum/thread/1793/
I will try to get some more for this forum.
Hope it helps
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| arlete
Intern in 2009!!!!!
Topics: 30
Posts: 2,234
|
Thanks, guys!
___________________
When men make the rules, God decides the exceptions.
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