SPOT2CS

การเตรียมตัวสู่ Fellow at US

2010-03-04T19:58:00.000+07:00

1 เรื่อง VISA
http://isso.ucsf.edu/scholars/new-scholars/j-1-visa-checklist

Mnemonic for history taking

2009-12-03T21:53:00.008+07:00

Some one said nmemonic is everything for step2CS exam.
In my opinion,it help to arrange lists of questions.
But we must judge to select focus question. Which come form "differential diagnosis".

Nmemonic for present illness:
Evaluation phase: OPD
O Onset of symptom ( When did it start)
Open ( Please tell me more about your symptom)
P Progression ( is it getting worse)
Precipitation ( Did anything happend before your symptom start
..Is it relate to any food/activity)
Previous (Have you ever had problem like this before)
D Duration ( Is it constant or does it come and go..How long does it last)

Pain: LIQRAAA
L Location of the symptom ( Can you show me exactly where is your pain)
Intensity of the symptom (On a scale from 1 to 10 with 10 being the worst pain,how would you
rate your pain)
Q Quality of the symptom ( Please tell me what the pain like...burning,clamping or pulsating?)
R Radiation of the symptom ( Does it move to anywhere on your body)
A Alleviating factors ( Does anything make it worse)
Aggravating factors ( Anything make it better?)
Associated symptoms ( Do you have any other symptoms such as.....)

Discharge: ABC
A Amount ( Do you have a lot of it)
B Blood ( Was there any blood)
C Color/Consistency ( Can you tell me what it like)

PMH (past medical history)
Search for: PAM HUG FOS SODA
P Past medical history ( Do you have any other medical problem )
A Allergies (Are you allergic to any drug...any else)
M Medicines (Are you taking any medication)

H Hospitalization ( Have you ever been hospitalized..Have you ever had surgery)
U Underweight Overweight ( Does any change in your weight)
G General daily activity (How about appetite / Sleep/Urine/ bowel movement)

F Family history ( How about your family, are you parents healthy
Are there any medical problem or cancer that run in your family)
O OB/GYN history (Excuse me but I need to ask..when did your last period.look more -> LMPV)
S Sexual habits ( I would like to ask you some personal question..do you use condom regualry. look more -> SACH)

S smoking ( Do you smoke..How much..How long)
O alcOhOl ( Do you drink : if more than 2 drink/day or 4 day/week -> CAGE)
D druge-recreation ( Do you use any recreational drug)
A activity ( Tell me about your diet/ exercise/travel)

I prefer asking Occupation while washing hand before physical exam.

adapted form:http://www.prep4usmle.com/forum/thread/1793/

Alcohol and smoking counselling

2009-12-01T07:06:00.001+07:00

It is important to counselling patient within 3 minutes for USMLE step 2 CS encounter
in health risk behaviors that detected by SODA question ( Smoke,Sex,Safety - alcOhOl -Drug-Appetite&diet) I prefer using " Ask, Address,Advise,Assist method in bief intervention.

Alcohol
Ask: Do you drink alcohol?
How much do you drink per week?
Address: As a concerned physician,Because ( eg.you have abdominal pain)
I worried about your drinking,Have you ever though cutting down alcohol?
then CAGE ( practice to finish it within 20 second!!)
Advise if patient say yes -> That is very good for your help....
if patient say no -> I understand your reason, however, cutting down alcohol will
improve your health in long run... when ever you ready please contact us...
Assist: We have a professional team to help you get through it.

amount of alcohol drinking that should start CAGE
if more than 4 units in man / 2 units in woman per day
or more than 14 units in man / 7 units in woman per week

2. CAGE Alcohol Screen
Cut down on drinking: Have tried repeatedly without success :
Have you ever tried to cut down?
Annoyed by criticism about drinking habits
Have you ever felt annoyed by criticism about your drinking?
Guilty feelings about drinking
Have you ever felt guilty about your drinking?
Eye-opener drink needed in the morning
Have you ever had a drink first thing in the morning to help you through the day?
If yes in 2 or more start Brief counselling

This is a good approach to alcohol example which take time only about 3 minutes. Adapted from http://www.hepatitis.va.gov/vahep?page=prtop03-alc-video

Smoking
Ask: Do you smoke
How many cigarettes do you smoke per day
How long have you been smoked
Address: As a concen physician.Because ( eg.you have coughing) I worries about your smoking habit.Have you ever though stopping cigarette?
Advise:
if patient say no: Mr XX, I understand your reasons, However stop smoking will improve your
health in the long run..when ever you are ready please contact us
Assist: we have a professional team to help get through it

Note: Recreation druge Slang: Pot = Malijuana, Joint = cigarette with Malijuana

1 page Summary

2009-04-25T21:33:00.000+07:00

flanker99 - 04/07/09 23:45

	small things which are easy to forget but can make a big difference if remembered during the encounter not necessary to ask all questions but even if we ask most, that can make a big difference the list is not complete, so feel free to add anything which is important 1. ASK ABOUT MEDICATIONS, MEDICATIONS CAN BE THE CAUSE OF THE CONDITION OR AN EFFECT ie SOMETHING THE PT TAKES TO GET RELIEF eg MULTIVITAMINS IN CASES OF FATIGUE 2. ASK ABOUT FAMILY HISTORY , ALWAYS 3. PMH ,ASK ABOUT SIMILAR COMLAINTS AND ALSO ABOUT RELATED COMPLAINTS eg HEARTBURN AND DYSPEPSIA ie INDIGESTION IN CASES OF ABDOMINAL AND CHEST PAIN 4. TREATMENT HISTORY OR DIAGNOSTIC PROCEDURES eg BLADDER CATHERTERIZATION IN INCONTINENCE AND BPH, IT CAN ALSO BE THE CAUSE OF A COMPLAINT eg INCONTINENCE SPECIFIC Qs FOR DIFFERENT Pt GROUPS 1. INFANTS & CHILDREN: ALWAYS ASK ABOUT THE THINGS WHICH CHILDREN LIKE DO ie EATING,PEEING,PASSING STOOLS,SLEEPING,PLAYING. REMEMBER TO ALWAYS ASK ABOUT CONTACT HISTORY(SIBLINGS OR DAYCARE), ABOUT ANY MOOD CHANGES SINCE ILLNESS BEGAN. ALWAYS ASK ABOUT DEVELOPMENTAL AND IMMUNIZATION HISTORY, REGULAR MEDICAL CHECKUPS. IN CASES OF ILLNESS ASK ABOUT DISCHARGE FROM EYES,EARS & NOSE, RASH ON SKIN, TUGGING OF EARS. 2. IN ADOLSCENTS ASK ABOUT BODY IMAGE PROBLEMS, EATING DISORDERS, STUDIES, EXTRACURRICULAR ACTIVITIES, SEX, DRUGS, ALCOHOL, MOOD CHANGES 3. IN FEMALES ASK ABOUT PAP SMEARS (WHEN DONE THE LAST TIME, ANY ABNORMAL SMEARS) , ABOUT PERIODS (IF EVER A MISSED OR DELAYED PERIOD), BREAST EXAMINATION ( ANY DISCHARGE NOTED), ANY HAIR CHANGES(FALL OR EXCESSIVE GROWTH), PILL USAGE 4. IN ELDERLY PEOPLE ALWAYS ASK ABOUT HEART PROBLEMS ie BP, ANGINA, DYSPNEA, CHOLESTEROL LEVELS. ASK ABOUT SUPPORT SYSTEMS ie FAMILY & FRIENDS. COUNSEL ABOUT ADVANCED DIRECTIVES, SENIOR HOUSING, HOSPICE(TERMINALLY ILL CASES) 5. IN CASES OF FATIGUE ASK ABOUT HAIR CHANGES, SKIN CHANGES, APPETITE, COLD INTOLERANCE, VOICE CHANGES, BOWEL MOVEMENTS, BLEEDING, DEPRESSIVE SYMPTOMS 6. IN CASES OF JOINT PAIN ASK ABOUT SKIN RASH, TRAVEL HISTORY AND INSECT BITES( LYME DISEASE), ORAL ULCERS, EYE PROBLEMS(REDNESS, PAIN). ASK ABOUT SEXUAL HISTORY, DISCHARGE, BURNING MICTURITION, ANY WEAKNESS AND NUMBNESS OF THE LIMB 7. IN ABDO PAIN ASK ABOUT JAUNDICE, COLOR CHANGES OF STOOL/URINE, BURNING MICTURITON, FEVER, FOOD PEFERENCES, SKIN COMLAINTS(ITCHING, DARKENING), DYSPEPSIA, HEART BURN 8. IN CHEST PAIN ASK ABOUT ANGINA, PAIN IN LEGS WHILE WALKING, PALPITATIONS, COUGH, DYSPNEA(POSTURAL/EXERTIONAL), FEVER, RELATION OF PAIN TO BREATHING, ANY LEG COMPLAINTS LIKE SWELLING/TRAUMA/PROLONGED IMMOBILIZATION , SEXUAL DYSFUNCTION SPECIFICALLY IMPOTENCE, CHOLESTEROL MEASUREMENTS. ALWAYS ASK ABOUT WEIGHT AND HEIGHT 9. IN HEADACHE ASK ABOUT AURA(REPEATED HEADACHES), NUMBNESS/WEAKNESS, PHOTOPHOBIA, NECK STIFFNESS, FEVER, VISION/HEARING PROBLEMS, SEIZURE EPISODES, ABDO PROBLEMS, IF Pt USES READING GLASSES AND LAST TIME VISION WAS CHECKED, ANY NASAL/EYE DISCHARGE. ASK ABOUT ANY Jt PAIN(POLYMYALGIA RHEUMATICA IN ELDERLY PTs), ASK ABOUT ANY PAIN IN JAW WHILE EATING. ALWAYS KEEP GLAUCOMA AS DD IN MIND INCASES OF UNILATERAL HEADACHES. ALWAYS RULE OUT DEPRESSION AS A CAUSE OF CHRONIC HEADCHES AND ALWAYS RULE OUT TRAUMA TO CERVICAL SPINE. 10. IN HIV/AIDS CASES ASK ABOUT MEDICATION COMPLAINCE, CD4 COUNTS, HEADACHE/WEAKNESS/MOOD CHANGES/FORGETFULLNESS, VISION PROBLEMS, CHEST PAIN/DYSPNEA/COUGH/FEVER, ABDO PAIN(PANCREATITIS)/DIET/APPETITE/WEIGHT, BLADDER COMPLAINTS, SKIN RASH(KAPOSI’S SARCOMA), PREVIOUS HISTORY OF STDs . ASK THEM IF THEIR PARTNER SHOWS ANY SIGNS OF AIDS. ADVICE THEM TO USE PROTECTION 11. IN STROKE CASES ALWAYS ASK ABOUT PREVIOUS EPISODES AND THE COMPLAINTS IN SUCH EPISODES LIKE VISION, SPEECH DIFFICULTIES, WEAKNESS(LIMBS/FACE), SENSORY PROBLEMS, HEART PROBLEMS, HYPERTENSION, DM, CHOLESTEROL LEVELS. ALWAYS ASK ABOUT WEIGHT AND HEIGHT 12. IN CHRONIC ILLNESS/MEDICATION REFILL ASK ABOUT THE COMPLAINTS OF THE ILLNESS, ANY MEDICATION SIDE EFFECTS ie BOTH CAUSE AND EFFECT, ANY CHANGES THE PT WAS TOLD TO MAKE IN DIET AND EXERCISE AND IF HE FOLLOWS THEM OR NOT. ASK ABOUT WEIGHT AND HEIGHT 13. IN ABUSE CASES ASK ABOUT GUILT, WEAPONS/POISONS. ASK IF THE PT IS BEING ILLTREATED AT HOME 14. IN STD CASES ASK IF THE Pt HAS PREVIOUS HISTORY OF STDs, IF HE/SHE KNOWS IF THE PARTNER HAS STDs. ALWAYS ADVICE THEM TO SEND THE PARTNER TO YOU TO GET TREATED. ALWAYS ASK THEM TO AVOID SEX UNTIL TREATED COMPLETELY AND THEN USE PROTECTION AND CONTRACEPTIVES 15. IN BACK PAIN ASK ABOUT RADITION OF PAIN TO LEGS, ANY WEAKNESS AND NUMBNESS IN LEGS, BOWEL/BLADDER INCONTINENCE, ANY CHANGE IN PAIN WHILE COUGHING/STRAINING(PROLAPSED DISK WITH NERVE ENTRAPMENT) 16. IN CASES OF DIARRHEA BESIDES ASKING ABOUT NATURE OF STOOLS ALSO ASK ABOUT THE THINGS WHICH ARE PASSED IN ADDITION TO STOOLS LIKE BLOOD, MUCUS AND ALSO ASK FOR TENESMUS 17. IN CASES OF LOSS OF CONSICIOUSNESS ASK IF THE Pt LOST CONSCIOUSNESS AND THEN FELL TO THE GROUND OR IF HE FELT DIZZY, FELT DIZZY, FELL TO THE GROUND AND THEN LOST CONSCIOUSNESS. ALSO ASK ABOUT THE SYMPTOMS HE FELT BEFORE LOSING CONSCIOUSNESS LIKE PALPITATIONS, CHEST PAIN, DIFFICULTY IN BREATHING 18. IN CASES OF EAR PAIN/HEARING LOSS/DIZZINESS ASK ABOUT FEVER, EAR DISCHARGE, FULLNESS IN EAR, ANY EAR COMPLAINTS AS A CHILD 19. ALWAYS COUNSEL Pts ABOUT PRECAUTIONS THEY HAVE TO TAKE UNTIL THEY COME AGAIN FOR THE REULTS OF THE LAB INVESTIGATIONS eg IN DIABETES/HT Pts COUNSEL ABOUT MEDICATION COMPLAINCE/REGULAR EYE CHECK UPS/DIET/SALT/SUGAR/EXERCISE/SMOKE/ALCOHOL , IN PEPTIC ULCER/GERD CASES COUNSEL ABOUT FREQUENT SMALL MEALS, AVOIDING SMOKE/ALCOHOL, AVOIDING GOING TO SLEEP FOR 2 HOURS AFTER MEALS, IN STDS COUNSEL ABOUT AVOIDING SEX, ALCOHOL(METRONIDAZOLE TREATMENT), CONTRACEPTIVES, REGULAR PAP SMEARS, IN CHILDREN COUNSEL ABOUT ORS, IN JOINT PAIN COUNSEL ABOUT MEDICATION COMPLAINCE/ REST/SOFT SOLE SHOES, IN DEPRESSED Pts COUNSEL ABOUT CALLING YOU ASAP IF THEY FEEL VERY SAD 20. IN CASES OF DIABETES, HYPERTENSION, OBSEITY ALWAYS ASK THE DIET IN DETAIL ie THE TYPE OF FOOD WHICH THE PT IS CONSUMING 21. IN ELDERLY CASES ALWAYS ASK THE SURROGATE IF HE NEEDS ANY HELP IN TAKING CARE OF THE Pt. IN ELDERLY AND CHILD CASES ALWAYS ASK WHO ELSE IS RESPONSIBLE FOR TAKING CARE OF THE Pt 22. IN FEMALES ALMOST EVERY CASE HAS PREGNANCY AS A DIFF DIAGNOSIS eg WEIGHT GAIN, INSOMNIA, UNCONTROLLED OR NEW ONSET HYPERTENSION, HEADACHE, FATIGUE 23. IN HEADACHE CASES IN FEMALES ALWAYS ASK FOR THE RELATION OF THE HEADACHE WITH THE PERIODS 24. IN CHRONIC JOINT PAINS ALWAYS KEEP HEPATITIS AND LYME DISEASE AS DDs IN MIND AND ASK Qs ABOUT TRAVEL HISTORY AND TICK BITE 25. IN ALCOHOLICS ASK ABOUT COUGH AND FEVER EVEN IF NO RESPIRATORY COMPLAINTS ARE PRESENT TO RULE OUT ASPIRATION 26. IN OLD PEOPLE COMING FOR ROUTINE CHECKUP ALWAYS ASK ABOUT HEART(HYPERTESION, CHOLESTEROL, DIABETES), LUNGS(DYSPNEA), CANCER(SORES ON SKIN, CHANGE IN BOWEL HABIT, DIFFICULTY IN SWALLOWING) 27. IN FATIGUE, HEADACHE CASES ALWAYS KEEP SLEEP APNEA IN MIND 28. IN TRAUMA AND DOMESTIC ABUSE CASES ALSO ASK ABOUT BLOOD IN URINE AND ALSO DO U/A FOR THE SAME, ALSO CHECK CVA TENDERNESS 29. IN CASE OF Pt TAKING DRUGS FOR SEIZURES, CHECK THE DRUG LEVEL. IN CASE Pt TAKING ANTICOAGULANTS CHECK PT/INR 30. CVS CASES- ALWAYS ASK ABOUT PAIN IN LEGS WHILE WALKING(PVD) ERECTILE DYSFUNCTION 31. IN CHRONIC CASES SUSPECTED TO BE COLLAGEN VASCULAR DISEASES ASK ABOUT EYE CHANGES, SORES IN MOUTH 32. IN JOINT PAIN CASES ASK ABOUT SORES IN MOUTH AND PRIVATE PARTS 33. DON’T EVER FORGET TO ADVICE/COUNSEL THE PATIENTS , IN ACUTE CASES TELL Pt TO WAIT UNTIL THE REPORTS ARRIVE. SOMETREATMENT LIKE ORS CAN BE GIVEN TO Pt. IN CHRONIC CASES COUNSEL HIM ABOUT DIET/EXERCISE/SMOKING/ALCOHOL/REGULAR FOLLOW Ups/CONTRACEPTIVES/ COMPLAINCE 34. DEMENTIA/CONFUSION/FORGETFULLNESS CASE- ASK ABOUT ONSET(SUDDEN/GRADUAL), DIURNAL VARIATION(SUN DOWNING), MEDICATIONS(PAIN KILLERS), GAIT, INSIGHT, MOOD CHANGES 35. HEADACHE CAUSES WORTH REMEMBERING- CAFFIENE/NSAID WITHDRAWAL, OBSTRUCTIVE SLEEP APNEA, PREGNANCY, PSEUDOTUMOUR CEREBRI 36. IN STD CASES ASK ABOUT GROIN SWELLINGS AND SWELLINGS IN ANY PART OF BODY LIKE NECK 37. IN INFECTIOUS MONONUCLEOSIS/ SORE THROAT CASES ASK ABOUT ANY RASH ON SKIN(PENICILLIN USE) 38. IN DYSPHAGIA CASES ASK IF THE Pt’s FINGERS AND TOES HAVE BECOME SENSITIVE TO COLD(RAYNAUD’S PHENOMENON) 39. IN TELEPHONE/SURROGATE CASES ALWAYS ASK THE Pt TO COME FOR A VISIT. IF NOT URGENT, THE Pt CAN ALSO COME ON A SATURDAY 40. IRREGULAR PERIODS IRRESPECTIVE OF AGE/SEXUAL ACTIVITY- ALWAYS SUSPECT PREGNANCY AND ORDER URINE PREGNANCY TEST 41. IF OBSTRUCTIVE SLEEP APNEA, ALWAYS DO ORAL AND NASAL EXAMINATION 42. IN CHILDREN ALWAYS ASK ABOUT STUDIES, HOBBIES, IMMUNIZATION IRRESPECTIVE OF THE CASE. IF PARENT NOT PRESENT, ASK ABOUT THE REASON 43. IN ANY CHRONIC RESPIRATORY PROBLEMS(NON INFECTIOUS) LIKE ALLERGY, ASTHMA, HYPERSENSITIVITY PNEUMONITIS, ASK ABOUT SNORING 44. IN LONG STANDING CHRONIC DISEASES WHICH ALWAYS PRESENT IN EPISODES, ALWAYS ASK HOW THE Pt IS BETWEEN EPISODES AND ALSO ASK HOW THE Pt’s LIFE HAS BEEN AFFECTED BY THE CONDITION 45. IN HIGLY SUSPECTED CASES OF DEPRESSION, GRIEF eg AFTER DEATH OF A RELATIVE, ASK IF COUNSELLING WAS GIVEN, IF NOT ,ADVICE ABOUT THE SAME 46. THYROID CASES- CHECK REFLEXES, LOOK AT EYES, SKIN AND IN HYPOTHYROID CASES, ASK ABOUT NECK SURGERY, MEDICATIONS, EXPOSURE TO RADIATION 47. IN ABDOMINAL PAIN AND HEAD ACHE, ASK ABOUT THE RELATION OF PAIN TO FOOD AND ALSO ABOUT PERIODS 48. IN MENOPAUSAL AGE GROUP FEMALES ,ALWAYS ASK ABOUT MENOPAUSAL SYMPTOMS 49. IN VAGINAL BLEEDING CASES ASK ABOUT THE RELATION OF VAGINAL BLEEDING TO SEXUAL INTERCOURSE 50. IN CASES OF PREGNANCY ,ALWAYS ASK IF THE PREGNANCY WAS PLANNED OR NOT AND IF CONTRACEPTIVES WERE BEING USED 51. IN MISSED PERIODS ASK ABOUT THE TELLTALE SIGNS OF PREGNANCY LIKE NAUSEA, VOMITTING, BREAST FULLNESS OR TENDERNESS AND ANY NIPPLE DISCHARGE 52. IN LONG STANDING AMENORRHEA AND IRREGULAR PERIODS ASK ABOUT ANY FACIAL HAIR 53. IN ERECTILE DYSFUNCTION CASES ALWAYS ASK ABOUT MORNING ERECTIONS 54. IN SUSPECTED BPH CASES ,IN ADDITION TO ASKING ABOUT URINARY SYMPTOMS , ALSO ASK ABOUT BACK PAIN, TRAUMA, LEG WEAKNESS AND NUMBNESS, WEIGHT LOSS AND FAMILY HISTORY OF PROSTATE CANCER. ALSO ASK ABOUT ANY EPISODE OF URINARY RETENTION AND SUBSEQUENT CATHETERIZATION 55. ALWAYS KEEP APA SYNDROME IN MIND AS A DD IN CASES OF DVT/PE 56. HEADACHE ---- CEREBRAL VENOUS THROMBOSIS ------ OCP USE 57. NAUSEA/ VOMITTING/ ABDO PAIN IN DIABETIC Pt ---- DIABETIC KETOACIDOSIS 58. ABDO PAIN / VOMITTING IN OBESE ----- HYPERTRIGLYCERIDEMIA / PANCREATITIS 59. IN ADDICTION CASES , ALWAYS ASK THE REASON FOR ADDICTION AND IF THE Pt HAS MADE ANY EFFORTS TO QUIT THEM 60. IN STD CASES ALWAYS ASK THE Pt IF SHE NOWS F THE PARTNER HAS ANY STD AND IF HE KNOWINLY TRANSMITTED THEM 61. IN DEPRESSION CASES DUE TO DEATH OF RELATIVE, ASK IF DEATH WAS SUDDEN AND UNEXPECTED 62. IN CHEST PAIN OF SUDDEN ONSET AND PROLONGED COUGH , ALSO ASK ABOUT ANY RASH ON SKIN, NIGH SWEATS, SWELLINGS IN NECK(LYMPHADENOPATHY) TO RULE OUT TB 63. ALWAYS ASK THE Pt IF HE WOULD LIKE TO TELL ANYTHING ELSE ABOUT HIS HEALTH. 64. ALWAYS THANK THE Pt IF HE VOLUNTEERS ANY USEFUL INFO BY HIMSELF. ALWAYS CONGRATULATE THE Pt IF HE HAS GIVEN UP ANY BAD HABIT RECENTLY 65. IN EVERY PERIOD RELATED CASE IN FEMALES, ASK THE FOLLOWING WITHOUT FAIL : PREVIOUS PREGNANCIES AND ABORTIONS, OCP USE, PREVIOUS STDs , PAP SMEAR, BREAST EXAMINATION, MENOPAUSAL SYMPTOMS, AGE OF MENOPAUSE IN MOTHER, VISION PROBLEMS, THYROID COMPLAINTS , EXCESSIVE FACIAL HAIR 66. BEFORE BEGINNING OCP, ALWAYS ASK ABOUT AN KIND OF CONTRAINDICATION THE Pt MIGHT BE HAVING , NAMELY : LEG PAIN, HEADACHE, ABDOMINAL PAIN/JAUNDICE, ANY ABNORMAL PAP SMEAR, ABNORMAL BREAST EXAMINATION, FAMILY HSTORY OF BREAST AND UTERINE CANCERS 67. TEENAGE PREGNANCIES, ALWAYS ASK: EDUCATION, GOALS FOR FUTURE, R/O ABUSIVE RELATIONSHIP, PLANNED PREGNANCY OR NOT, ANY CONTRACEPTIVE USE. ALSO ADVICE REGARDING PARENTING CLASSES AND ASK HER TO BRING PARTNER ALONG WITH HER DURING THE NEXT VISIT 68. IN CHEST PAIN WHICH IS HIGHLY SUSPICIOUS OF ANGINA , EXAMINE FOR COSTOCHONDRAL TENDERNESS JUST TO r/o COSTOCHONDRITIS AND ALSO COMMENT ON THIS IN THE PE 69. NEWLY DIAGNOSED AIDS CASE--- MOUTH, CERVICAL LYMPHADENOPATHY, SKIN, ABDO, CVS/RS(QUICK) 70. IN CHRONIC ACHES , ASK IF THE PT IS TAKING ANY MEDICATION AND IF IT HAS HELPED IMPORTANT THINGS FOR PE 1. ALWAYS LOOK AT THE FACE OF THE Pt TO SEE WHAT KIND OF EMOTIONS HE IS SHOWING , ESPECIALLY IN CASES OF PAIN 2. IN CASES OF FATIGUE, DEPRESSION, INSOMNIA/EXCESSIVE SLEEP ALWAYS KEEP THYROID CONDITIONS IN MIND AND SO WHILE WASHING HANDS ALWAYS FILL A CUP OF WATER. ALSO IN SUCH CASES MAKE A POINT TO CHECK REFLEXES 3. IN HEART AND RESPI CASES ALWAYS CHECK THE NAILS FOR CLUBBING 4. IN HEART CASES ALWAYS CHECK THE PMI 1ST AND THEN GO FOR AUSCULTATION 5. IN CVS CASES Pt SHOULD BE MADE TO LIE IN RECLINING POSITTION AND THEN EVERYTHING CAN BE CHECKED ie EYES, NAILS, PULSES, JVP, PMI, AUSCULTATION AT THE SAME TIME. THEN MAKE THE Pt TO SIT UP AND AUSCULTATE ONCE AGAIN, IF RUNNING SHORT OF TIME JUST AUSCULTATE IN 2 PLACES 6. KEEP IN MIND TO CHECK LIVER SPAN AND SHIFTING DULLNESS 7. IF Pt SHOWS PAIN WHILE LIGHT PALPATION, DON’T LET GO AT ONCE , INSTEAD PRESS A LITTLE MORE DEEPLY AND THEN LET GO WITH A FLOURISH TO ELICIT REBOUND TENDERNESS 8. IN HEADACHE CASES ALWAYS PALAPATE FOR TENDERNESS ESPECIALLY OVER SINUSES 9. SPECIAL TESTS IN HEADACHE: NECK STIFFNESS, KERNING’S SIGN, BRUDZINKI’S SIGN 10. SPECIAL TESTS IN CHEST PAIN: TENDERNESS OVER COSTOCHONDRAL JUNCTION AND OVER RIBS IN CASES OF TRAUMA 11. SPECIAL TESTS IN ABDOMINAL PAIN: MURPHY’S SIGN, ROVSINGS SIGN, PSOAS SIGN, OBTURATOR SIGN, CVA TENDERNESS 12. SPECIAL TESTS IN BACK PAIN: STRAIGHT LEG RAISING TEST AND CVA TENDERNESS 13. CHECK THE POSITION OF TRACHEA IN CASES OF SUDDEN ONSET CHEST PAIN IN WHICH PNEUMOTHORAX IS SUSPECTED 14. IN DIABETES CASES CHECK JOINT POSITION AND VIBRATION SENSATION 15. ALWAYS RUB HANDS AND THE DIAPHRAGM BEFORE PE 16. CN 7 CAN BE COMMENTED UPON IN THE PATIENT NOTES WITHOUT EVEN TESTING FOR IT ie WHETHER FACE IS SYMMETRICAL OR NOT 17. IF Pt DOES NOT HAVE COMPLAINT REGARDING A PARTICULAR SYSTEM, DO MINIMUM OR NO EXAMINATION OF THE SYSTEM eg IN A CAR ACCIDENT CASE IN WHICH Pt HAS HURT HIS HEAD BUT NOT HIS EXTREMITIES, JUST PALPATE THE EXTREMITIES FOR ANY TENDERNESS AND INSPECT THEM QUICKLY 18. IN SUSPECTED CYSYTIS/UTI/PID CASES ALWAYS PALPATE THE SUPRAPUBIC AREA FOR ANY TENDERNESS 19. CHECK HOMAN’s SIGN AND CALF TENDERNESS IN CHEST PAIN CASES WITH SUSPECTED PE 20. CHECK FOR SIGNS OF LIVER STIGMATA LIKE PALMAR ERYTHEMA, LIVER FLAP, PERI-UMBILICAL VEINS, ASCITES, GYNECOMASTIA 21. LOOK AT THE WAY THE Pt IS DRESSED, WHETHER HE IS MAINTAINING EYE CONTACT AND COMMENT UPON THIS IN THE PE NOTES 22. IN ACCIDENT CASES/ DOMESTIC ABUSE CASES ALSO LOOK INSIDE THE MOUTH TO SEE IF ANY TEETH ARE MISSING AND ALSO COMMENT ON THAT 23. CHECK POSITION OF TRACHEA IN CASES OF SUSPECTED PNEUMOTHORAX 24. IN HEADACHE CASES EXAMINE THE CERVICAL SPINE, TEST ROM ONLY IF NO HISTORY OF TRAUMA 25. IN HEADACHE CASES ALSO EXAMINE TM JOINT. ASK Pt TO OPEN AND CLOSE THE JOINT. COMMENT IF ROM IS FULL AND WITHOUT ANY CLICKS

US VISA for USMEL step2 CS in Chiang Mai

2009-02-09T12:04:00.013+07:00

I've just back from doing VISA at the Chiang Mai US consulate
Surprising in really friendly and easy process.
I appoint this day (9 th Feb) because this is a Buddish holiday for Thai offial place.
Fortunately, it is working day for US embassy.
After waiting about 30 minutes, I got interview only 2 minutes and finish!.
That is far different from experience of doctor in some country I read in website which seem so complicate.

These are steps for Thai doctor to apply US VISA for CS exam ( Type = B1 visitor visa)
1. Visit this website
https://thailand.us-visaservices.com/Forms/SelfServiceLogin.aspx
You will ask for choosing place to do VISA
If you have been working or studying in 15 nothern province for atleast 1 year, you can do VISA at the Chaing Mai consulate
Next, You will ask for create login name for making interview appointment.
To get date for appointment, you need to purchase " PIN" by internet (408 B) or phone (680 B).
To prepare application document, you need to fill from DS156 and DS 157 in website. And print
out them bringing in the interview date

2. Visiting the Post office.
There are two post office in Chiang Mai that specialized in process US VISA, Mae-Ping post
which locate near Warorod market , and Chiang Mai university campus post office. Anyway, only Mae Ping post still operate in Thai holiday. At the post office your task are
- Pay for VISA fee 4,454 B. ( only cash, no check, no credit card)
- Buy EMS letter 75 B
You must keep the bill both blue and whitish very well as evident of VISA fee payment.

This webblog is very useful for details ( Thai language)
http://www.bloggang.com/mainblog.php?id=lovergirl&month=06-10-2006&group=11&blog=5

Special for doctor who will take USMLE.
Interviewing question : What will you do after taking the exam?
I think the word need appear in answer "I will come back to my country for waiting the result" :>
Important document : CS letter and Salary certified from workplace
Well, I actually prepare many documents include book banks, Health insurances etc
I ask the interviewer wheter he would like to see these evidents
The answer is - No Thank, you will get the VISA within 4 business day :>
Nither booking hotel nor Air ticket itinery necessary.

Note
1. From DS156 there are three pages. The first and last one has a barcode number which
run each time of printing out. If you print out this form many times,please check that
barcode number in first and third page "Must" be the same.
2. Even you do visa at Chiang Mai consulate, place of issuance in DS156 is Bangkok

13th Feb 2009 ; I get my passport back with the 10 year type R (regular) B1/B2 visa :>

USMLE study report 5

2009-02-07T07:28:00.005+07:00

FA case 5, A 55 year-old man with complaining blood in his stool

Point 1: Hand checking
firmly check which express sincerely cooperation = feel firm at first hand webspace
( between thumb and index finger)

Point 2: Responding to " Could I have...."
I understand your concern, however there are many possibilities for - what is causing your problem. Unfortunately, one of that is colon cancer. Therefore we need to find out more information and some tests.

Point 3: Responding to "Can I tak a trip"
I think we should find out what is your problem first and then we can design.

Point 4: While taking examination
Please tell me if you feel any pain or discomfort.
I am going to press it deeply,is that OK with you?

Point 5: What is .....scopy
Colonoscopy = A procedure to look at your colon.We have a long thin tube with a camera
at the end. We put the tube into the rectum up to your colon.

Endoscopy = A procedure to look at your stomach. We have a long thin tube with a camera
at the end. We put the tube into the nose down to your stomach.

note : Procedure = Pro-see-jer

USMLE study report 4

2009-02-04T18:39:00.007+07:00

FA case 4; A 21 year old male with sore throat

Point 1:Pronounciation error
Swollen = swo-lin
Change in = chian-gin
Changes in = chain- jez-in
Kick in = Kic- kin
Kicked in = Kick -tin
Notice in any = Notis tin tiny.

Point 2: Asking about jaundice
Have you noticed yellow eyes or skin

Point 3: Everything is scaling system
On a scale from 1 to 10 with 10 being the...,can you rate your....?
eg.
On a scale from 1 to 10 with 10 being the worst, can you rate your pain?
On a scale from 1 to 10 with 10 being the most beautiful, can you rate your wife :>

Point 4 : Asking about contact person
Does anyone around you have a similar problem?

Point5 : Asking about fatigue
How is your energy level

Point 6: Recomend - need . must
Mr..., I strongly recomend you to have HIV test
If you do,you need to sign a conset from. Is that OK with you?

And Since your spleen could get injury easily.you must avoid any contact sport.

Peadiatric case Mnemonic

2009-02-01T07:41:00.009+07:00

RUSH : Real sick kids -> need urgency evaluate
Rash (Does he have any rash..tell me more about it)
Urine (Does he have normal amount of urine)
Seizure (Has he had a seizure or shaking)
Habit (How does he look... Is he playful/Can he sleep)
details: http://spot2cs.blogspot.com/2008/12/telephone-case.html

PAM 'Fam'-BINDER : Pediatric review ( instead of PAM HUG FOSS SODA in adult)
Past medical history (Does he have any other medical problem)
Allergy ( Is he allergic to any drug)
Medication ( beside tylenol..is he taking any medication)

* Family history Esp Child behavior
Can you tell me about your family - how many sibling does he have?
Does anyone in your family have the same problem?
Does any punishment

Birth history ( How about his birth history...Was he born full term...Was there any birth
problem..after birth)
Immunization (Are his immunizations up to date)
Nutrition ( Please tell me about his diet)
Development ( Tell me about his development..can he speak)
Exposure ( Has he contact any sick person..such as his peer in day care)
Recent check up ( When was his last check up..is everything OK)
l

USMLE study report 3

2009-01-29T13:43:00.008+07:00

Case FA number 3: a 74 year old male with Right arm pain.

Point 1: Loss of conciousness VS Pass out
Loose = (adj) not fit
Lost = (adj) unable to find
Loss = (N) the state of no longer having
Lose (ลูซซซ) = (V) to be lost
Did you pass out before your fall? = Did you get fainting that cause you fall?
Did you lose conciouse after your fall? = Did you get head injury from your falling?

Point2:
Systemic illness eg. fever, depress
Dose anything make you feel better/worse
Locallized illness eg. pain
Does anything make the pain better/worse

Point 3:
Anychange"in" your weight
not "with" your weight

Point 4: Exploring the details of fall
fall = (N) the acting of falling
fall - fell -fallen (V)
to break my fall = (idium) to protect my body from injury by fall
Doctor: Can you tell me more about the fall
Patient: I tripped over a toy on the ground and fell on my hand to break my fall.
Doctor: What were you doing when you fell.
Patient : I was playing with my grandchildren.
Doctor : Did you see a doctor at that time?
Patient: No
Doctor : Why not?

Point 5: Permission to do physical exam
I would like to feel your right arm, is that OK with you?
patient may refuse because it produce pain
I am going to check your neck
patient should be OK

Point 6: Closing case
Do you have any questions or concerns?
Allright, After we get the test results, I will meet you again.

Point 7: In case of suspected abused but patient don't tell the truth, may offer help like this
Is everything OK at home? ( S)
Do you have any emergency plan if you get accident again? (E)
Any friend or family member can help in that time? (F)
Excuse me, but I need to ask
Anyone in your family use alcohol or other recreational drug? (A)

We have social worker team who can advise you about safty plan.
And if you need emergency help please contact this number.

...There is some issue about refering to a social worker
not promise to patient that social worker will help in payment!

Depression

2009-01-27T15:09:00.004+07:00

The best screening question for psychiatric problem is " Sleeping"

Do you have problems sleeping?

Have you lose interest in things that used to interest you

Do you feel guilty

Do you lack your usual energy?

Has it been difficulty for you to concentrate?

Has your appetite changed?

Have you ever thought about suicide?

USMLE study report 2

2009-01-22T19:31:00.005+07:00

case 2 FA 21 year old female come to ER with abdominal pain

point1 : Counselling in ER situation
It's not appropriate to use ask,address,advise,assist bla bla.. in time that patient have severe pain. So just
I would like to talk to you later about sexual practice and smoking.

point 2: Tense & Sense
If patient say: I smoked last year = Last year she smoke only once
If patient say: I used to smoke last year = Last year she smoke regualry
If patient say: I have smoked since last year= She emphasize that today she still smoke.
note: ever only use in question sentence.Therefore patient will not say : I ever smoke
but...
If doctor ask: did you smoke = Please recall recently
If doctor ask: Have you smoked in past year = Please recall through last year
If doctor ask: Have you ever smoked = Please recall through life !!

point 3: To - For-On
check for
listen to
press on / thumb on

point4: Sensitive question
Excuse me, but I need to ask..
How many sexual partners have you had in past year

point 5: aware word " Quit it" - "Stop it" which are too command
prefer using "stop smoking" or "Stop smoking"

point6: Again! always asking permission for examination before washing hand
eg. Next,I would like to do a physical exam - is that OK with you....

point7: Precipitating factor
What were you doing when the pain starte - for physical symptom
Did anything change in your life before you have this problem - for psychological symptom

Safesex and HIV counselling

2009-01-18T17:56:00.013+07:00

Safesex

May I ask you some personal questions, is that OK with you

Ask: Are you sexually active?

With male, female or both
How many partners have you had in the past year?
Do you use condom regularly?
Do you use any contraceptive method?

Address. Excuse me, I know these following question is very sensitive but I always ask sexually active person. is that OK with you?
Have you ever got sexual transmitted disease?
Have you ever tested for HIV?

Advise: I strongly recommended you using condom during intercourse.
It will protect you and your partners from sexually transmitted disease and unwanted pregnancy.

Assist: Before doing the HIV test, we need you get information and sign some document (Pre test counseling and consent form) , is that all right? ..OK our team will come to talk with you later.
Please feel free to contact me anytime If you have any question.

Safe home environment
Ask Is there every thing all right at home
Address .As your safety is my primary concern,
Are you comfortable staying with your family ( the SAFE)
Advise. If patient not feel safe at home -> I understand your concern..
If patient feel safe -> I am happy to hear that
Assist We have social worker team to help you find the resource you need.
If you need any help please let us know

Abused case

2009-01-17T18:43:00.014+07:00

In my country-Thailand the abused problem cannot be accurate determine. However the prevalence seem less than US which one study reports that 29% of women and 22% of men report having experienced physical, sexual, or psychological intimate partner violence during their lifetime !!

Abused case

Ask: I see your bruise, can you tell me about it
or I normally ask my patients about being abused because the abuse of women
(elder/children) usually occurs in our society nowadays. Please feel free to tell me, I will
keep everything confidential.- Have you ever been abused by your spouse(child/parents)?
Address: with SAFE
Advise: You don’t deserve to be beaten, battering is against the law. And the onlyway to end abuse is to get away from batterer.
Assist: I care about your safety.
Would you like to speak with our counselor.
Here is a phone number of supported group

Suspected situation
1.Injury with delayed seeking treatment
2.Multiple uncovered bruise
3.Chronic vage symptom eg. Headache, fatigue without explanation
4.Sexual related complaint
5.Emotional problem eg. Depression, Anxiety
6 Over controled by caretaker(who is a batterer)

Main Idea of SAFE
It's important for physician are concerned of the patients safety and health and also
of her children if she has children.(Most of the time pts are in denial) Inform pt
the importance of having an emergency plan and informing family/freinds on her problem.
And you also inform patient of help via support groups and resources for ppl who suffered
from domestic abuse. And if there is abuse of children, tell the patient you have to inform
child protective services
original SAFE from http://emedicine.medscape.com/article/805546-overview
Stress/Safety: Do you feel safe in your relationships (marriage)?
Should I be concerned for you and your children safety?
Afraid/Abused: Do any situations exist in your relationships in which you have felt afraid?
Have you been physically hurt by your partner?
Friends/Family (assessing degree of social support):
If you have been hurt, are your friends or family aware of it?
Do you think you could tell them if it did happen?
Emergency plan: Do you have a safe place to go and the resources you (and your children) need
in an emergency?

Short version SAFE
from GATO (http://forums.studentdoctor.net/showthread.php?t=570107)
Safe: “Are you concerned about safety of you and your children?”
Afraid: “Do you feel afraid?”
Friends/Family: “Do you have friends and family support”
Emergency plan: “Do you have an emergency plan?” - If say no, give consult

Drug refill ( Follow up chronic disease)

2009-01-16T19:53:00.010+07:00

As a primary care doctor, I have a lot of chronic disease patients who just come for
refill their medication -- Before I attend family medicine training,I wondered how boring it is to face same disease, say same things many many times. Since I got the holistic view, I learn that there are vairety of human being in same disease.

OPD ONCALL for Drug refills case

Onset
When was it diagnosed?
Progression
How do you feel today?
Drug*
name - What medications are you taking?
compliant - Do you take them regulary?
Side effect -Do you get any problem from using medication?

Controle*
How is your blood sugar/blood pressure recently
Associate symptom
( asking about complication- pain / discharge?)
Do you have any numbness?
Do you have problem with your urination
Lethragic
Do you have any weight change?
Limit activity include Libido!
using open question " Do you have any concern that I don't address?"

Then follow by PAMHUGFOSS SODA

Diet counselling
( eg for DM)
Ask: How’s about your appetiteWhat do you usually have?
Address: Do you think that eating habit may cause problem?Most diabetes patient tired to controle their weight by eating less calories. Have youever thought doing that?
Advise: For better controled your blood sugar, You may considered increase vegetable anddecrease meat and fat.
Assist: We have a professional team to help you deal with it better. Such as giving diet instructions.Feel free to contact me anytime If you are interested to join us

USMLE study report I

2009-01-15T19:01:00.014+07:00

Today is the first day of David class. Practicing with my boyfriend and friends make me
have clear idea and focusing on my error easily . Therefore it is a good idea to informal practice with someone else before start with formal class. Mr.David is not only lively but also dedicate teacher. That's worth for 400 Baths per hour since he give me lot of effective way of communication.

FA case I : abdominal pain

Point1:
Can you " Tell" me more about your pain
; instead using "Describe" which difficult for Thai not to forget "b" end sound.
Does the pain "Move"to anywhere
; instead using "Travel"

Point 2:
Does anything make you feel better
..Anything make you fell worse
Do you have any nausea
...Any + N eg. Any vomiting ....Any rash

Point 3:
Use present simple if you need them recall things recently
= Is it constant or does it come and go
Do you have any allergies
Do you have any other health problems

Use present perfect if you need them recall back through life
= Have you ever been hospitalized
Have you ever had surgery

Point 4 :
Is "That"OK "with" you
not Is it OK to you

Point 5:
I would like to / I am going to / I need to...
not I will...
"I need to" is the most professional sense so it's suitable use in asking personal question
I need to ask you some personal questions
I need to do the rectal exam

Point 6:
May/Can I untie your gown
better than Let me untie your gown
I'd like to retie your gown

Point 7:
Can you turn this point ( indicate direction)
not turn your back esp when patient sit on the cough

Point 8:
Responding to worry question " Could I have pancreatic cancer?"
use "Yes But So" method
I understand your concern + but there are many possible causes for your pain + so we need to do some tests ( Tes's) that should help us have a conclusion.

Point 9:
Summary after history taking --make it easy
OK, you told me that you have..............for............and you also have............., is it correct?

Point 10:
Transition from Hx to PE
Thank you for your information Now, I would like to do a physical exam, is that OK with you?
All right ( next go to wash hand without asking permission!)

Point 11:
Transition from PE to closing
...Please sit up ( if patient lining down)
Thank you Mrxxx , From the information you gave me and the physical exam. It could be..............or....................or it could be something else. So we need to do some blood tests,
stool test, recal exam and ultrasound. Is that OK with you?

Point 12:
I am going to listen "to" your heart, please breath ( พลีสส - บรีทท) normaly
I am going to listen "to" your lungs, take a deep breath (ดีพ-เบร็ท)

Point 13
What do you do Mrxxx
Umm interesting -Do you enjoy your work?

Point 14
Touch (sensation) -> Feel (lymphnode) -> Press (Abdomen) ->Thump(Kidney)-> Pound (heart manual shock)
not use palpate

Point 15;
Rebound tenderness test;
Now, I am going to press and release
Please tell me - if it hurts more - when I press or when I release

Point 16;
Ultrasound explanation " It's like Xray but with sound wave"
not use word " imaging"

Point 17;
Do you have any questions or concerns ? --No
So we will talk again after the test results come back.

Demantia case

2009-01-13T11:05:00.013+07:00

Happy New Year 2009!

I found out from practice why practice is sooo..importance. Approach in such a time limit
need more than mnemonic, it also need to do it rattle as praying ( Suad-Montra). Therefore
I will start select some dialogs for praying. The first one is ..

Demantia case
Confusion or behavioral problem without focal neurological deficit

Ask: ask about ADL (DEATH) and IADL (SHAFT)
Address : MMSE
Advise: I concern that you may trouble with Alzheimer diseas
Assist: Would you like someone help you manage daily activity?

MMSE

" TimePlacePerson + RepeatReversRecall + Pen&Paper"

I will ask you some question to test your memory and thinking, is it OK ?

Can you tell me your name
Can you tell me state you are now?
Can you tell me what time it is now ?

I will name three objects for you,please repeat them to me immediatly : Pen Ball Tree
OK I will ask you after a few minuts.

I want you to count backward starting with 7

Now, can you tell me the three objects I mentioned before?

Do you know what this called (Pen)

I will give you a pice of paper. Take it in your right hand
,Fold in half and put it on the floor

Note: adaped from CSprotocal.blogspot --I think this approach method is practical to finish within 2-3 minutes. It's impossible to do real-full version of MMSE which take about 10 minutes! --It may help to support thinking about demantia but not help to detect case as original version do.

Mnemonic for fatigue and ED

2008-12-25T06:35:00.005+07:00

There are a lottt of mnemonic for making differential diagnosis for common symptom.
However, postgrad MD may not feel nessesary.
I choose only that seem frequent missed for me.

BATHE-SAD DATA for " fatigue or any strange presentation"

B: Backgroud :“What is going on in your life?”
A: Affect to life: “ How do you feel about it ?”
T: Troble : “What troubles you the most about this?”
H: Handling “How are you handling that?”
E : Empathy: “That must be very difficult for you.”

S: Sleepless/sleep apnea
A: Abdomen ( Pain?, Anorexia/Wt loss, Bowel hapit change)
D: Depression / Domestic violence

D: DM/DI (-> Blood glucose, UA, Electrolyte)
A: Anemia ( -> CBC, stool for occult blood,iron level, B12 level)
T: Thyroid ( -> TSH )
A: Autoimmune eg. Myasthenia gravis, Firbromyalgia ( ESR high- if low -> chronic fatigue syndrome)

STOP PENIS for Impotence
SSRI
Thioridazien
AlcOhOl
Propanolol

Psychogenic ( intact nocturnal or early morning erection)
Endocrine ( Testosterone def ; pituitary VS male menopause)
Neuropathic (DM)
Ischemic (Leriech syndrom-claudication)
Scar ( need genital exam..may be Prostate surgery,injury,idiopathic)

Overall protocal

2008-12-21T00:19:00.023+07:00

Finally, I try to summarized from many sources..First Aids book, Neeraj's note, Prep4USMLE
This exam seem to be test in major two aspects
1. To satisfy rater patient : Communication skill ...weighted 70%
2. To satisfy rater physician : Medical record ....weighted 30%

There are three parts for communication skill

1 Information taking skill
2 Information sharing skill
3. Nonverbal " Good bed side manner"

1. Information taking skill
Aim is effective interview.Able to encourage patient give information without embarrassing
- Open ended question
- Address patient idea
- Address patient sign
- Paraphrasing
- Use transition phrase
- Summarize

2. Information sharing skill
Aim is appropriate response to patient reaction. Diplomatic yet polite manner.

3. Nonverbal manner
- Smile
- Drape
- Empathy expression

From those three concepts let me make protocol as following

Opening encounter
Someone from prep4usmle suggest "The all 10 become by practice"
1 KNOCK KNOCK (Recall patient name before knocking) ---- Enter SMILING
2. Ms/Mr......... - I am Dr............ (first patient name then your name) .
3. Shake hands and Eye contact with patient (2 & 3 are done together)
4. SIT DOWN on the Stool (May I take a seat and take some note while we are talking)
DRAPE (as you say "I would like to make you more comfortable") -
5 Open question (How can I help you today) - Empathy expression ( eg.I see you are in pain)

Between encounter
Present illness

Next, I would like to ask about your general medical condition.( Transition )
Past history : PAM HUG

I'm going to ask you some personal question, is that OK for you? ( Transition )
FOS ( SODA )
" To make sure I've understand your problem correctly ; you have......................, is this correct
( Summarize)

OK - Next I would like to do some physical exam,is that OK with you.
...I want to wash my hand for a minute-
...." What type of work do you do..."
...." How is this problem affect your life?"

Physical exam:
First I would like to check your eyes....
I would like to check your heart and lungs..May I untie your gown...
---well done---I will retie the gown for you.
Focus system eg. JVC,Abdomen,Neuro

Close encounter
Thank you for your cooperation.Mr X.
From the information you gave me and the physical exams.
There are some possible cause of your problem.
You may have ( Impression).....or.........
So I would like to run some test,including rectal(Vg/breast) exam,blood test(urine test,pregnacy test0,and possibly CT scan(X-ray/ultrasound) of your abdomen (Investigation)
Is that OK with you?

OK,Mr. Smith,as a concerned physician, you need to quit smoking.
We have a smoking cessation clinic here at the hospital that can help you quit
smoking (Giving Counselling)

Do you have any question or concern?
..After all the lab results come, I will discuss with you more in details.

Throughout encounter
appropriate paraphrasing for important patient's answer *BUT Don't repeat question!!
approprate respons for challanging patient's question
.......

By the conclusion, there are 8 critical steps to do in every case
1. Introduction
2.Drape
3.History taking
4.Wash hand
5.Physical exam
6.Inform (Diagnosis+Investigation)
7.Counseling
8.Any question or concern

Pronouciation practice with usmlehelp

2008-12-18T07:20:00.006+07:00

Another thing I have to concern in the Spoken english proficiency is how to speak more clearly. Even I have conversation class with an English man who help me a lot in correcting my errors. In non-english speaking environment, it is not easy to practice myself.I found http://www.usmelhelp.com/ from google.

This website provides pronunciations practice by follow the master sound. It is interesting compare with pretty low cost ( 9.75 USD or about 360 Bath for 1 month subscription). The voice of a female physician is grateful. Most of the dialouges appear in First Aids book yet applied to be shorter, easier for IMG to speack.

There are two things disappointed me about this site

First, Sophisticate in a registration process. I understand that they intend to do the site in student-friendly rather than a real business way.Therefore, they have used pay-pal as a payment system that be quite tricky. Eg. after pay with credit card,it is necessary to click back to the merchant..Otherwise, you have to wait for password for a few days!- no other suggestion.
Actually,I think the customer can solve by themselves by access paypal website to get the invoice ID in first log in.

Second, It would be better if there were patient's respond sound as real exam.
And each dialouge should be organized in situation pattern eg. Opening encounter, Present illness, Past history taking, Counselling, Responding to the challange questions.

I plan to practice by speak out loundly..since Richard,my englishman teacher, said that speaking english need more widen mounth opening than Thai do. I have to exercise mouth muscles as much as I can.

Patient information sharing:Dx & Ix

2008-12-14T07:45:00.028+07:00

Standard pattern :

Thank you for your coorperation.
From the information you gave me and the physical exam.
There are several possible causes for your problem.
You may have A, B or C.
To make the diagnosis,I would like to do X,Y and possible Z.
About Z, it is a test that....
Is that OK with you?
Do you have any question or concern?

Example

Thank you for your coorperation.
From the information you gave me and the physical exam.
There are several possible causes for your problem.
You may have..Stomach ulcer. or Gall stone..or less likely but serious illness that we need to prove such as...tumor.
To make the diagnosis,
I would like to do..a rectal exam, blood tests and possible upper endoscopy.
About the endoscopy, it is a test to examine your stomach by a small video
with tube passed through your mouth.

Telephone case

2008-12-10T18:10:00.015+07:00

I have appointment to practice a case by webcam with my friend in tomorrow. We decided to start with a pediatric case which is phoning encounter because it shouldbe simplest since no need physical exam.

Door way note

White,7 mo,fever
DDx
1.URI
2.Pneumonia
3.Meningitis
4.Gastroenteritis
5.UTI

For fever in pediatric patient; I use ONCALL plus BINDERS...

(knocking the door)
(push the phone button only once)
D: Hello Ms.White, I am Dr.G. I am on call physician
How can I help you today?
M: My child has a fever
D: I am sorry to hear that, may I have his or her name ?
M: His name is Josh
D: When did the fever start?
M: Yesterday
D: Do you know how high the fever is?
M: Yes, I've just measured it, and it was 101.
D: Does anyone in your family have the same problem?
M: His three year old brother had an upper respiratory tract infection one week ago, and
he is fine now
D: Has Josh taken any medication?
M: I gave him tylenol syrupt every 6 hour but his fever still high.
D: Does Josh have ear discharge?
M: No
D: Does he have runny nose?
M: Yes
D: Does he have a cough?
M: No
D: Does he have shortness of breath?
M: No
D: Does he have a rash?
M: No
D: is he playful or tired?
M: He has looked tired and irritated since yesterday
D: Does he vomit?
M: Yes 3 times for today.
D: Is he making normal nuber of wet diaper?
M: Yes

D: OK, May I ask about his birth and development history.
M: Fine
D: Was your pregnancy full term?
M: Yes It was 40 weeks
D: Did you have any complications during your delivery?
M: No
D: What was his birth weight?
M: I cannot remember exactly but I think it was in normal range.
D: Are your child's immunization up to date?
M: Yes
D: Did your child have any medical problems after birth?
M: Jaundice in the first week of life
D: Has your child had any serious illnesses?
M: No
D: When was his last checkup ?
M: 2 weeks ago and everything perfect for him
D: How were the child development for example weight height language?
M: Yes there are normal
D: Did you brest-feed your child?
M: I am breast feeding him.
D: Are you giving your child pediatric multivitamin
M: Yes
D :How is his appetite now?
M: He has refuse my breast since yesterday
D: Does he have any allergy?
M: No
D: How is his sleeping ?
M: Last night he did not sleep well and cried when I laid him down.
D : Oh you must be tired.

M: Yes I really concern in his fever..Is my child going to be okey?
D: Well, from history you given. I think that he has viral infection which mostly be not serious illness.
M: Do you think I need to the hospital?
D: That's a good idea. I still need to examine your child to make in the diagnosis befor giving him an appropriate treatment.
M: The problem is my husband worked in other country and I cannot drive a car.
D: All right you can call 911 they will help transport you and your child here.
Is it OK for you.
M: OK

Physical exam

2008-12-07T13:58:00.029+07:00

I summarized from some guy post in prep4usmle http://www.prep4usmle.com/forum/thread/75653/ that The minimum PE would be

Specific examination + Auscultation Heart and Lung

This Step2CS is tend to emphasize in communication skill rather than physical exam skill.
It should be around 3- 5 min for PE and spare time at least 3 min for councelling and closing case. Heart and lung auscultation itself take atleast 40 sec.

The teaching video of The virginia university is really helpful for me in figure out American way of approach - because they record how doctor ask permission from patient . It includ Sexual issue interview.

These are special interested exam in some compliants.

HEENT
Normocephalic/atromatic (NC/AT)
- I am going to check your head and face..please turn left..turn right
Extraocular movement intact (EOMI)
-Follow my fingers with your eyes,please keep your head still.
Pupil eqaul,round,reactive to light,and accomodation (PERRLA)
-I’m going to shine this light in your eyes.And across your eyes
Opthalmoscope-> no papiledema
-I’m going to look in your eyes with this light,please look straight at the wall ,don’t look at the light
Whispering test-> no decrease hearling acuity

I am going to whisper on each of your ear . Please repeat the word what I say..OK?

Doctor..hospital..

Weber test -> no lateralization
-I’m going to take this tunning fork and put at your forehead,
I want you to tell me if it sond the same on the left and the right.
Rinne's test-> AC>BC both
- I’m going to take this tunning fork and touch it behind your
ears, I want you to tell me when you cannot hear it anymore.
First, your right ear…( now I cannot hear it)…and now?
Next, your left ear…( now I cannot hear it)…and now?
- Please open your mouth widely and say ahh…
Otoscope -> TMs normal
-I’m going to check your ears
First, your right ear OK now,your left ear

Neuro
CN II -XII grossly intact
- Now, I’d like to check your cranial nerve.
- Please raise your eye browns.
- Please close your eyes tightly and don’t let me open them.
- Can you show me your teeth
- Clench your jaw
- I’m going to touch your face lightly..please close your
eyes..could you feel this..can you feel this
- Can you stick out your tounge
- Please shrug your shoulder..please resist me.
- Turn your head to the left..resist me
Turn to the right..resist me
Finger to nose normal
I want you touch your nose with your finger and touch my finger and touch your nose again..again and again ..now the other hand
- Tendem:
Motor power: strenght 5/5 throughout
- Now, I’m going to test your motor power
Please do like this..resist me
And here..resist me.
- Raise your leg…resist me
- Extend your leg…resist me
- Pull it back…resist me
Sensory intact pain sensation
- This is sharp and this is dull
Please close your eyes and tell me wheter it is sharp or dull.
DTRs: 2+ symmetric
-I would like to check your refexes at your arms and legs
Just relax..and another your arm
Barbinski (-) bilaterally
- I am going to gently rub stroke your foot with this tool...it may be a little tingling.
Rhomberg test (-)
-Do you have any difficulty in balancing yourself when walking.
Please stand up on your feet and close your eye. I will stay beside to support you.
Gait normal
- Please walk to the door and return to here

1.Headache
- Cranial nerve
- EOM
2.Dizziness
- Finger to nose/Rhomberg
- Dix-hallpike (just write)
3.Hearling loss
- Weber and Rinne's test
4.Blurr vision and DM
- EOM
- Opthalmoscope
5.Demantia
- MMSE
- CN
6.Weakness
- Motor
- Barbinski

Respiratory tract and Cardiovascular
Throat
I'd like to check your throat, please open your mouth and say ahh...
Sinus tenderness
I am going to tap on your face. Please tell me if you feel pain.
Lympnode
I am going to feel your lymphnode at neck.
Jugular vein and Carotid artery
- I need to adjust the bed head up a little
Next, I would like to check your neck..all right
and listen.

...I would like to listen your heat and lungs..May I untie your gown..
Chest clear breath sound bilaterally
Please take a deep breath..good..again..
Heart RRR normal S1S2 no murmur
Now, you can breath normally , I am going to listen to your heart.
Chest palpation no tenderness
I am going to push on your ribs, please tell me if you have any pain.
Percussion : normal equal BL
I am going to tap on your chest
Tactile/Vocal fremitus : normal equal BL
Please say 99 repeatly untill I say enough ( if use palm = tactile, if listen by stethoscope = vocal)
Egophony absent ( no E -> A )
Please say EEE continuously

note: dullness percussion with abnormal tactile/vocal fremitus or present Egophony -> consolidation : dullness percussion without above -> pleural effusion.

Apical impulse not displaced
Please lie down on your left hand,I am going to feel your heart
Extremities no edema
I would like to check your legs
Peripheral pulse 2+ symetric
I would like to check your pulses at hands...and legs.

while checking this may asking more
- Have you ever woken up during the night with dyspnea
- Have you noticed any swelling at your legs.

Cough/Shortness of breath/ Chest pain
- Chest palpatiton, percussion
- Tactile fremitus or Vocal fremitus or Egophony
- Apical pulse
- Leg edema
- Peripheral pulse
- pulse oximeter (just write)

Abdomen
Next, I would like to check your abdomen.
To make you more comfortable, I would like to pull the leg extension
Now you please lie down on your back and raise up your gown
BS (+)
I'm going to listen first..normal bowel sound
Nondistended,nontender
I'm going to press on your abdomen..please tell me if you feel pain or any discomfort
* If there is pain any where DONT release and repeat
tell patient.I I'm sorry to hurt you. but it is nessesary to confirm diagnosis..at this time..
(do rebound or murphy)
Rebound tenderness (-)
I'm going to press a little deeper and then release.
Please tell me which one you feel more pain.
Murphy's sign (-)
..I an going to press while you take a deep breath..Does it hurt..
No hepatomegaly
I'm going to tap on your abdomen to estimate your liver size.

Psoas sign
Please flex your knee and raise your tight against my hand

Please lie on your left side I'll your right leg

( Psoas muscle is " Hip flexer" the irritation could be illicited by contract-resist flexion

or streth-passive extension)

Obturator sign
I'll move your hip and knee a little bit
( Internal rotation - wich opposit to sign of 4)

CVA no tenderness
I'm going to pound on your back, please tell me if you feel any pain

1.Epigastrium pain
- Murphy sign
- Tap for liver size

2.Lower abdominal pain
- Rebound tenderness
- Psoas sign
- CVA tenderness

Back
No deformity
I would like to check your back
No tenderness
I'm going to press on your back.does it hurt?
ROM: no restriction
could you bend forward..thank...and back ward
Straight leg raising (-) bilaterally

I am going to raise your leg up, is there any discomfort..do you the pain shooting down beyond the knee

Extremities
ROM
I am going check your left arm(normal side) first.
please raise up..extend
then right arm..sorry I don't want to hurt you. Please raise it up as you can.
Motor
I'd like to check your both arms.
Please do like this(Push out/Pull in) and resist me..good
sensation
I am going to check your sensation. Please close your eyes...do you feel this and this
are they the same?
reflex below the level of pain
I am going to check your reflexes, please relax.
check nerve
Can you move your wrist up and down
check pulse
I am going to check your puls both hands
Phalens test
Press backs of both hands together to form right angles

Explain workup

2008-12-06T10:30:00.013+07:00

Rectal exam = in order to check blood in your stool, it's a little uncomfortable but it's not painful
Blood test = in order to know what's going on about your liver...kidney...
HIV test = An HIV viral load that can help diagnose a new HIV infection
An HIV antibody that can look for a preexisting infection.

Colonoscopy = A test that look at your colon by a thin tube that contain camera passed
through your rectum.
( It may be a little uncomfortable but we will give you something to make you
feel better)
Endoscopy = A test that look at your stomach by a thin tube that contain camera passed
through your mouth
( It may be a little uncomfortable but we will give you something to make you
feel better)

Ultrasound = A test that give a picture of your abdomen by a computerized machine
using sound waves.( It doesn't hurt and only take a few minutes)
CT scan = A test that give a picture of your abdomen by a computerized machine using X-rays
MRI = A test that give a picture of your abdomen by a computerized machine using magnet.

ECG = A test that gives us a graphical recording how your heart is function
( It doesn’t hurt and only takes a few minutes)
EEG = A test that gives us a graphical recording how your brain is function.

These are medical term that OK for general
Abdomen
Uterus..most of organ
Infectious mononucleosis

I recognized a problem in using layman's langauge. Even don't know if that medical term is Jargon or not?. These are database for them http://www.usmletomd.com/layman.html

The Patient note

2008-12-06T10:25:00.012+07:00

History
30 yo F c/o Headache for 2 days.
PI: -The pain localized in forehead and both cheeks,severity 9/10,pulsating,aggravated by leaning forward,alleviated by sleeping and resting.
Positive for fever 3 days ago,sneezing nose.
Denies for nausea or vomiting,vision change,weakness/numbness.
ROS: negative exept as above
PH: sinusitis 2 yrs ago.
Allergy: peanut, NKDA
Medication: vitaminA supplement
FH: Noncontributary
OB/Gyn: LMP 6 weeks ago.Regular.G1P1 uncomplicated NSVD. DMPA, unsafesex
SH: work as a teacher,smoking 1/2 PPD,1-2 beers/week.no illicit drug

Physical exam:
Patient is in moderate headache
V/S fever 38.1 c no hypotension
HEENT: NC/AT, tender at forehead and both cheecks, PERRL,EOMI,no papilledema
nasal congestion +,mild injected pharynx.
Neuro : Alert , CN 2-12 grossly intact. stiff neck negative. Motor strength 5/5 throughout.
DTRs 2+ in upper and lower extremities.
Chest: clear breath sounds bilaterally
Heart: RRR,no murmur

Differential diagnosis
1. Acute sinusitis
2. Common cold
3. Aseptic meningitis
4. Pseudotumor celebri
5. Pregnancy
( This time think review : MED PATHO)

Diagnostic workup
1.Pneumatic otoscope*
2.CBC
3.CT sinus
4.LP

* Always think about Otoscope,Rectal exam,Vaginal exam,Brest exam first

>>>>>>>>>>
There are two choices for doing patient note-Typing and Writting. I choose to write because
1.The thing I can practice in everyday life is OPD card. Generally, I write physical examination and investigation in english. Since today I will try to write patient history in english too.
2. Even typing is good in correction and easy to read more than hand-writting. It also be problem
in exiting atmosphere if I unintened press delete button. Furthurmore I think my hand writting
is not bad by nature yet wrosen in busy work time.

There are two style of OPD card. Narative style given sample in FA book and bullet style.
I preferthe later one which using short appropriate phrase instead long complete sentence. Don't forget I got quite low score in TOEFL writting :-( Fortunately, USMLE does not care Grammar as long as it UNDERSTANDABLE :-)

mnemonic for special situiation

2008-12-05T16:05:00.045+07:00

These are special questions set for each special situation

CAGE for alcohol problem screening
Have you ever tried to cut down?
Have you ever felt annoyed by criticism about your drinking?
Have you ever felt guilty about your drinking?
Have you ever had a drink first thing in the morning to help you through the day?
details:http://spot2cs.blogspot.com/2008/12/brief-counselling-for-alcohol-misuse.html

LMPV for OB Gyn
L: Last menstrual period. (When was your last period?)
M:Menstrual detail ( Tell me about your period..is it regular?.. How many pads or tempon you use in the normal day)
P: Pregnant ( Have you ever been pregnant..Tell me more about your pregnant)
V: Vaginal discharge ( Do you have vaginal discharge/ vaginal spotting)

SCHAME for sexual practice
S: Secret- I would like to ask you about sexual practice, these information will be keep confidently.
C: Condom use/ Contraception ( Do you use condom regulary, what other form of contraception do you use)
H : HIV risk ( How many partners have you had in the past year -> Have you ever got STD?)

A : Are you sexually active

M : Male ,female or both

E : Evaluate and encourage to check ( Since your sexual habits put you at a high risk of HIV, Have you ever checked for HIV? I f you wish we can test you foIf you wish we can test it for you)
details:http://spot2cs.blogspot.com/2009/01/safesex-and-hiv-counselling.html

SAFE for domestic violence:
S= Safety inquiry (Do you feel safe at home?)
A= Afraid and alcohol (Do you feel afraid ? does your spouse abuses alcohol?)
F= Friends/Family who are aware/Fractures ( Dose anyone for example friend or family know
that you was abuse ever resulted in fractures?
E=Emergency plan (do u have an emergency plan?/Ever tried to leave/divorce? why not?
details:http://spot2cs.blogspot.com/20(09/01/abused-case.html

SIG-ECAT for depression
Suicidal idea ( Have you ever thought about suicide/hurt yourself)
Interest ( Can you tell me about your interest)
Guilty ( Do you feel guilty)
Energy ( How is your energy level)
Concentration ( Do you have any difficulty concentrating)
Appetite ( Any change in your appetite)
Thyroid low ( Any change in your weight/hair/skin + Do you feel oversensitive to cold)

details: http://spot2cs.blogspot.com/2009/01/depression.html

DEATH for Activity of daily living (ADL):
How is this problem affect your daily life activity?...for example
Dressing
Eating
Ambulating
Toileting
BaThing

SHAFT for Instrumental ADL (IADL):
Shoping
Housekeeping
Accounting
Food preparing
Transportation/Driving

MMSE: TimePlacePerson- RepeatReverseRecall-Pen&Paper
ORIENTATION:
Time - Which state or city are u in ?
Person- What's your name OR Do you know who I am ?
Place - Can you guess what time it is now ?

REGISTRATION + ATTENTION+RECALL
Repeat follow the three words
Reverse the "7 to 1"
Recall those three words again

LANGUAGES+ COMMAND FOLLOWING
show Pen and ask what is this
give Paper -> hold in right hand, fold to half , put to the floor.

details:http://spot2cs.blogspot.com/2009/01/spot2cs.html

ABCDEF: Medication refill
Ask ( How long have you been diagnosed with diabetes..how do you feel today?)
BP/BS ( When was your last BP reading)
Compliance ( what is your treatment...Do you complied with your medication)
Druge reaction ( Have you noticed any side effect of medication)
Eye exam ( When was your last time eyecheck)
Foot exam ( Is there infection with your foot)

AMPLE: Accident case
Accident event ( Can you remember what happened in the accident)
Medication (Are you taking any medication,when was your last dose)
Past surgery
Last meal ( When was your last meal or drink)
EtOH ( Did you drink alcohol before driving)

Challange question

2008-12-05T15:59:00.029+07:00

Response to patient question within 10 second!!

Typical format..
= I understand....(Empathy)
It is.. (Opinion/Informatation)
More investigation/management

NEVER EVER say DONT WORRY!

There are about 7 catergories of challanging question
1.Ask for diagnosis
2.Ask for prognosis
3.Ask for reasoning
4.Ask for treatment
5.Ask for not wait
6.Ask form home (pediatric)
7 Others

1.Asking for diagnosis

If it possible = My father had colon cancer,could I have too
I understand your concern Mr..., You have higher risk of XXX
because of...your family history(or some thing else)
However, to make a certanin diagnosis
we need more information from physical exam and some tests.
After they are done, we will discuss this again.

If it unlikely = My father had pancreatic cancer,could I have too.
I understand your concern Mr..., it is unlikely
However, to make a certain diagnosis,
we need more information from physical exam and some tests.
After they are done, we will discuss in more details.

Need reassure. Is it heart attack, am I going to die
I understand your concen Mr..., there are many possibilities causing your chest pain
We need more information from ECG and chest X-ray
My team and I will do our best to help you

Need explore. Do you think I have AIDs.
Well,It is a difficult question Mr.., First, May you tell me why you so concern about it.
( patient will tell some risk)
I understand your concern Mr..., You have increase risk to get HIV because of your
lifestyle,however, we need to confirm diagnosis from HIV test, Are you willing to do this test?

2.Asking for prognosis

Ask if it worse Will I lose my feet,doctor?
I understand your concern Mr..., I hope you will not.
For your benefit, we need to keep monitor your bood sugar and your feet.
We will discuss how to do that later in the visit

Ask if it better Doctor,do you think I will be able to move my arm again?
I understand your concern, I hope you will
However to make a certain prognosis,
We need more information from physical exam and X-ray
After the they are done, we will discuss in more details.

3. Asking for reasoning
Not true They told me this(hematuria) is because of my old age.Is that true
Well, Aging could not play role in bloody urin. It is rarly normal.
we need more information from physical exam and some tests.
After they are done, we will discuss in more details.

Prtial true They told me this (Impotent) is because of my old age.Is that true.
Well. Aging could play partial role in decrease sex hormone.
However,there are certain reversible cause of your problem.
we need more information from physical exam and some tests.
After they are done, we will discuss in more details.

true They told me this (memory loss) is because of my old age.Is that true.
Well, Aging could play an important role in decrease memory ability.
However,there are certain reversible causes of your problem.
we need more information from physical exam and some tests.
After they are done, we will discuss in more details.

4. Asking for treatment

Antibiotic Do you think I need Antibiotic ,doctor
Well,it is a good question, in case of bacterial infection it help, however
viral infection it does not.
so we need to make a certain diagnosis form physical exam and sometest.

Week off. I need a week off from work, my back pain is terrible
I understand your concern Mr..., it is true that hard working wrosen your back pain
however light movement is no problem.
I will ask your boss to reassign you to light duty for a while

5.Ask for not wait.

Pain I am in pain, can I have something now?
I understand that you are in pain,
For your benefit,
I need to ask you a few questions and give you physical examination.
I will be as quick and gentle as possible.
After they are done, I will give you appropriate pain killer.Is that okay with you”

Concren about family My child is in the house alone,I must leave now.
I understand your concern Mr....
For your benefit,
It's better to wait for the test result in order to get appropriate treatment and
make sure that you are feeling well enouth to take care your child.

...Our social worker can help you deal with this problem...

6.Ask form home (pediatric)
Is my child going to be OK?
I understand your concern Mrs...,
To make sure it is nothing serious with your child.
I need more information form doing physical exam and some tests.
Is it possible for you to bring him to see me today?

7. Others

Where have you been, doctor? I have been waiting here for the whole day
I’m so sorry you had to wait so long.
I’m so sorry you had to wait so long.
There were too many appointments prior to you.
However, I am here now and I’ll do my best.

I am afraid of surgery
I understand your feelings.
It’s very common to have these feeling before surgery.
You can ask a question if you have any special concern.

what kind of test is it? Will it hurt? ( Opthalmoscope)
I understand your feeling.
It is simple examination of your eye.
It may cause some discomfort but it is very important exam to reach diagnosis.
I will be as gentle as possible. Is it okay with you

……………….(sitent)
You look sad…do you know the reason.

I think life is full of misery. Why do we have to live?
MrsXX.I know this is a difficult situation for you.
Is there anything bothering you?
....Have you thought of ending your life?

I feel sad…(cry)
…..(sitent , may touch hand)…( give tissue)
Do you need cup of water….I know you feel sad, would you like to tell me about it

One of my boyfriend’s friend,he use illegal druge…etc…..
Mrs.XX, I am sorry to interrupt you.
I know that these thing is important.
but my number one priority is your specific problem.

Why I get gonorrheaI have sex only with my husband , is it possible that he could be cheating on me?
I know that it’s difficult MrsXX.
You most likely get infection from your partners.
It would be best to talk to him regarding this matter.
If you wish I will arrange meeting with the counselor who can discuss this issue with both of you. I would also advise you to bring him to be test and treat.

Do I have to tell my wife about my HIV result.
Yes, You have to.
I know that it’s difficult MrXX,
But doing so will allow you and your wife to take the appropriate precautions and treatment.

I think I need Antibiotic ,doctor
Mr.XX, as a concerned physician I should be very cautious using antibiotics. If I will give it to you right now it may not benefit you. Instead it may cause some side effects. I will ask you a few questions and give you physical examinations to identify exact cause of your infection. I will be as quick as possible

I read from internet that there are research about treatment of this disease by herbalCompounds. What do you think of that?
I’m not familiar with that study. Let me research it for you, and when we meet again I will explain my thoughts on it more details.Please doctor,

D: I see you have many bruises on your leg. It look like somene hurt you.
so Can you tell me about this....
P: Why are you asking me these question?
Since there are some patient come with this problem are dealing with abusive relationship,
I ask about it routinely.
Your information will keep in confidence.
Please don’t hesitate to tell me.
.

Suggestion from success friend

2008-12-01T21:46:00.004+07:00

I feel glad to have many very nice person help me in preparing. Dr. Quan is one of success
step2 CS examinee. She is not only wonderful physician but also thoughtful person. This is
her useful sharing for me.

.....
What you need to perform in every patients are as following

1. Read a doorway information carefully
- Take note of Pt lastname (You have to greet pt by their name!)
- Take note of age & abnormal V/S (You have to write it down on your pt note)
- Write down 5 possible diagnosis from given chief compliant (+age+sex)
This will remind you to ask important questions, so you won't loss your point.
- Write down an nmenomic of questions that you "must" ask in every patients.
PAM HUGS FOS SODA WET

P = Past medical history
Have you ever had any medical problems?
Have you ever had any surgeries before?

A = Allergy
Are you allergy to anything? (Ex. Any Medications?, Pollen?, Cats?)

M = Medication
Are you taking any medications? Herbs? Over counter drugs?

H = Hospital Hx
Have you ever been hospitalized before?

U = Urinary problems
Have you ever had problems about urination? Any Urgency?

G = GI problems
Do you have any problem with your bowel movement?

S = Sleep
Do you have any problem sleeping?

F = Family History
Are there any genetic diseases or cancers that run in your family?
How about your parents? Are they in good health?
What did they die of?

O = OB/Gyn
When was your last menstrual period?
How long did it last?
Are your periods regular?
How many pads/tampons did you use per day?

S = Sexual History
Do you use any contraceptives?
How many sexual partners have you had last year?

S = Social History à SODA WET
S = Smoking
Do you smoke? Or Did you smoke in the past?
How many cigarettes do you smoke per day?
How long ago did you stop smoking?

O = Occupation
What kind of work do you do?

D = Drug
Have you ever used any illegal drugs/street drugs/illicit drugs?

A = Alcohol
Do you drink? How much?
CAGE
C = Cut down
Have you ever thought about cutting down on your drink?
A = Annoy
Have you ever felt annoyed by the other’s criticism?
G = Guilty
Have you ever felt guilty about your drinking habits?
E = Eye opener
Have you ever drink alcohol first thing in the morning?

W = Work
What kind of work do you do?

E = Eat
How is your appetite?

T = Travel
Have you traveled recently?

2. Entering the roomSmile ! (Important!)
Greet the patient by his/her nameShake hands firmly
Introduce your self ex. Hello (Good Morning) Ms.Smith. Nice to meet you. My name is Dr. XXX. I'll be your doctor today.
I am going to ask you some questions and do the physical examination on you. OK?How may I help you today?
When you enter the room, there is a cloth on a chair.Don't forget to drape this cloth on your patient.
I did it every time before I sat and talked to patient. ex. Please let me make you feel more comfortable (drape the cloth).

3. Talk to a patient- Try to use "some" open-ended questions.
After a patient talk about his/her CC.
I would ask "Could you tell me more about that?"and then ask specific questions about that topic.
- If it's a yes/no question, a patient will answer very quickly.
Be ready to ask other questions(Try to practice a lot, it will help you to continue asking questions spontaneously)
- KEEP EYE CONTACT!This is very important. You might nod your head or say something to make them know you're interesting.
- Write some important note for your PN.
- Sometime before starting to ask about sensitive topics such as their sexual life, you should say some "transition"."I am going to ask you some personal questions because they might be some hidden clues which help me to diagnose your problem. Please feel free to tell me anything. Whatever you tell me will be kept confidential"
- Before starting PE, ask "Is there anything you want to tell me more about this?"This will help you to get some more details. However, most of them answered "no". 555
- Show your sympathyex. If pt cough, give him/her a drink. (It'll be a plastic cup in the exam room.)

4. PE- WASH YOUR HANDS!!!"
I am going to do a physical examination. Please give me a second to wash my hands."
- You may talk to the patient during washing your hands, but I didn't talk much. I tried to think about what I wanted to do next.
- Ask pt permission before perform PE" I'm going to do physical examination on you. Everything I am going to do, I will keep you inform. Is that OK with you?"" I am going to listen to your heart and lung. I need to untie your gown. Is that OK with you?"If your hands are cold you might have to tell them" My hands are a little bit cold, I hope you won't mind about this"(I washed my hands with warm water and tried to keep them warm.) " Please open your mouth and say "Ahhh" for me"" I'm going to exam your tummy. I will press around. If you feel pain anywhere, please let me know"
- Avoid to repeat a painful exam" I'm sorry to hurt you. Do you feel pain anywhere else?"
- Don't forget to perform some specific examex. if pt has HTN, perform fundoscopic examination.

5. Conclusion
Give pt some information about what are possible diagnosis and what are you going to do." From the information you gave me and physical examination, there are some possibilities that might be the cause of your problem such as ....... . To make a specific diagnosis, I suggest to run some more tests such as ...... "" Do you have any questions for me?"" Thank you for your co-operation. I will come back as soon as I get the lab result"" Goodbye"

6. Be prepare for the challenging questions
......

Such an honest note !!
I really appreciate her.

Study plan

2008-11-30T17:21:00.006+07:00

First thing I did was download video orientation from
to figure out how the exam is.

Then I read very nice preparation guidance from
http://csprotocol.blogspot.com/2007/12/usmle-step-2-cs-study-plan-for.html
Even the authors suggest 15 days is enough for prepartion, in case of non-native
speaker like me,actually,need more time.
I complied stratergies for myself as following

Within First month
1. Research what are the best study materials. Many people suggest FirstAids for step2CS and
USMLEworld. I already have FA book but I need more information in considered subscrbe
UW.It cost $50 for 30 days,$60 for 45 days and $70 for 60 days. http://www.usmleworld.com/csapricing.asp . Another website that less popular,however look good, is http://www.usmlesource.com with little cheaper $40 for 21 days, $ 45 for 30 days.
Anyway, I notice that all of these three resources,there are real practice cases about 30s cases -that mean pay attention deeply in FA itself may be enough.
2. Know the common cases that would appear in the exam and mastering in
Differential diagnosis. I can read from FirstAids book by myself
3. Practice pronounciation common question in early part of FirstAids book. I will practice with
my english teacher.

Next
1 Practice with my Thai friend as study partners by online and webcamera
2.Finding some special step2CS class with experienced foreign teacher.I know one stay near
my workplace but he cost is not cheap ( about 400 baths/hour). So it should use in highly
concentrate period.

Free time
I will try to expose english as much as I can.
1. Watching the ER series and listen english news online in VOAnews should be OK.
2. Phone with my boyfriend in english.He speack very well espacially "streat language" :>

Process in application to CS

2008-11-26T20:33:00.002+07:00

1. I apply by online IWA https://iwa2.ecfmg.org/ in Friday 21st Nov 2008.
The application fee 1200 USD ( about 42,000 B) paid immediatly by credit card.
Afterthat It will appear "in process" in Oasis application information. While this
period the CS application did not registered yet.

2. In Monday 24th Nov 2008. I recieved the schedule permission by email.
That mean my application was registered and I abled to choose The test center
and test date at http://www.usmle.org/Examinations/step2/step2cs_registration.html.

This is example of The schedule permit that include of my 1 year available period and suggestions in step2Cs exam.

IMPORTANT DOCUMENT - TAKE TO TEST CENTER
UNITED STATES MEDICAL LICENSING EXAMINATION™ (USMLE™)STEP 2 CS (Clinical Skills) SCHEDULING PERMIT

November 28, 2008
Name:
Pxxxx xxxxxxx
Address:
1xx/x xxxxxx. Muang Chiangmai THAILAND
USMLE/ECFMG ID:
0-xxx-xxx-9
Eligibility Period:
November 24, 2008 - November 24, 2009

1.This Scheduling Permit authorizes you to sit for this examination during the period noted

above unless there is a change in your eligibility status. In the event of such a change, you must

contact ECFMG immediately.
2.To schedule an appointment, you can access Step 2 CS Calendar and Scheduling on the ECFMG

website at www.ecfmg.org. You will be required to login using your USMLE/ECFMG

Identification Number and on-line services password. On-line scheduling is generally available

24 hours a day, 7 days a week. You will be prompted to print out your Confirmation Notice

after scheduling.
3.If you are unable to schedule on-line, you can call (215) 966-3574 (9:00 AM to 5:00 PM,

Eastern Time in the United States, Monday through Friday) and a representative will

schedule for you. There is no advantage to scheduling by telephone because the

representative will use the same on-line system.
4. If you have a scheduled testing appointment and are unable to take the exam on your

scheduled test date or at your scheduled test center, you can cancel your scheduled testing

appointment and reschedule for a different date and/or center, subject to availability. A fee

may be charged for this service depending on how much notice you provide when canceling

your appointment. Refer to the ECFMG Information Booklet, USMLE Bulletin of Information

and the Step 2 CS Calendar and Scheduling website for specific fee information.
5. Before taking the examination, review the applicable editions of the ECFMG Information

Booklet and USMLE Bulletin of Information, and the ECFMG and USMLE websites for Step 2

CS updates.
6. For admission to the test center, you must provide an unexpired, government-issued form of

identification (such as a current driver's license or passport) that includes both your recent

photograph and signature. You will not be admitted without this form of identification. Your

name as it appears on the form of identification you present must match exactly (not case

sensitive) the name in your ECFMG record. If the names on your identification and in your

ECFMG record do not match exactly, you will not be allowed to take the exam. The only

acceptable difference would be the presence of a middle name, middle initial, or suffix (Jr, Sr,

III) on one document and its absence on the other. You can check the name in your ECFMG

record by accessing OASIS on the ECFMG website at www.ecfmg.org. To change the name in

your ECFMG record, use the Request to Change Applicant Biographic Information (Form 182)

on the ECFMG website. Name changes or corrections cannot be made within seven business

days of your scheduled test date.
7.Bring this Scheduling Permit, your Confirmation Notice, a white laboratory coat, stethoscope,

and only necessary personal items with you to the test center. A small open storage cubical in a

locked area and coat rack are available. Luggage may not be stored at the center.
8.The time you should arrive at the test center will be noted on the Confirmation Notice you will

print after scheduling. Please note that if you arrive late, you may not be allowed to test.
9.You may not possess cellular telephones, pagers, personal digital assistants (PDAs), or two-

way communication devices during the examination, including during breaks. You must store

these devices in the cubicle provided and turn them off before storing them.
10.At the end of your test day, the test center staff will provide you with a letter that certifies
you appeared at the center to take the examination.

Time to apply for step 2 CS

2008-11-25T19:50:00.009+07:00

.....Suggestions from many people include CSprotocal blog that should to apply step2CS can be summarized"As soon as possible"
However in there are some factors to make decision when to apply that
....1.Timeline:
for example-I plan to attend matching in september 2009 and the rank list order date
is about Febuary 2010 that mean I "should" to get step2CS result within August (because I can apply for interview without CS result but this may decrese my chance to get interview)
And "must" to get it within January 2010 ( I have to pass all the steps to get ECFMG certificate at that time)
Able to check result at http://www.usmle.org/Examinations/step2/step2cs_reporting.html
....2. Observationship available
Even if observationship is not compulsary things,it would helps IMG to familiar with
"American way" approach. Furthurmore, It also increase interesting of CV.
I connect one of university in California to observe their palliative care in June-July 2009.
It would be nice if I observe them at least a couple of weeks before taking exam.
....3. Permission from workplace
This may not be problem for whom work part-time. But I work as full time staff of university.
I concern this point too. So I choose time that "Gap" for Resident rotation.
....4. My confidence..I know myself is not very good in english..espacially in speacking. I ever took the TOEFL IBT last year and the speacking skill is my weaknest. TOEFL somehow useful in
self english proficiency evaluation even its score not be require in USMLE . ofcourse,I need
time atleast 3 months for prepare it.

...Eventually, I choose to apply in 22th June. It is about 3 weeks after expected observationship schedule. It fall in "May 24 through Jul 18" period wich result will report in Aug 19-Sep 16. In case of I fail..I still have a chance to retake exam to get certificate.

Start here

2008-11-23T15:02:00.005+07:00

.......While I stayed at Siriraj hospital in November 2008, I liked to spend my free time in travelling Chao-Pra-Ya river by boat. Looking for some good books at Tha-Pra-Chan ( Thummasad university). Two books aspirate me to create a blog related to Clinical skill .There are “ English Handbook for Doctor” by Dr.Kittiphon Nagaviroj and “Conduct your dream” by Bandit Ungrangsi.
........I interested in the first one because Dr.Kittiphon is a famous family medicine lecturer of Ramathibodi university.His book is thin yet effective. Cover in communication with difficult patient as well as language function.So I get a lot of idea from this useful book.
........The other book is really important part of my inspiration. It is not only “How to” style but also make reader being cheerful. Everything big thing comes form collecting of small parts. I will go to my dream to study aboard in clinical field by stepping each small steps everyday. In this time, I am preparing for OSCE part to take ECFMG certificate ( known as USMLE step2CS) . Beside finding practice partners, I will practice by myself with blogging, watching ER seiries. Not serious.As if have hobby. Find a learining way that is satisfied.
.........I belive as Sayadaw Jotica write in “ Snow in the summer” that “Life is a series of experiments”.Even if I able to get knowledges from many sources, only way to get wisdom is practice practice and… practice.