1. A 64-year-old man is admitted to the intensive care unit with pneumonia and septic shock. Over the past 4 days, he has had increasing shortness of breath and fever. He has hypertension. Surgical history is significant for a previous cholecystectomy. Medications are amlodipine and hydrochlorothiazide.
On physical examination, temperature is 38.8 °C (98.8 °F), pulse rate is 110/min, respiratory rate is 22/min, and blood pressure is 85/50 mm Hg. Cardiac examination reveals a grade 2/6 systolic murmur. On pulmonary examination, there are crackles over the entire right lung field. There is trace pedal edema.
Laboratory studies on admission:
Laboratory StudiesGlucose 115 mg/dL (6.38 mmol/L)Blood urea nitrogen 22 mg/dL (7.86 mmol/L)Creatinine 1.4 mg/dL (123.79 μmol/L)Sodium 135 meq/L (135 mmol/L)Potassium 4.8 meq/L (4.8 mmol/L)Chloride 103 meq/L (103 mmol/L)Bicarbonate 10 meq/L (10 mmol/L)Albumin 3.8 g/dL (38 g/L)
Arterial blood gas studies (with the patient breathing room air):
pH 6.94PCO2 48 mm HgPO2 51 mm Hg
Which of the following conditions is most likely present in this patient?A Anion gap metabolic acidosisB Mixed non–anion gap metabolic acidosis and respiratory acidosisC Mixed anion gap metabolic acidosis and respiratory alkalosisD Mixed anion gap metabolic acidosis and respiratory acidosisE Mixed non–anion gap metabolic acidosis and respiratory alkalosis
2.A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of 290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril for hypertension and glyburide for type 2 diabetes mellitus. She also has intermittent episodes of gout.
Fasting serum studies show:
Total cholesterol 252 mg/dL HDL-cholesterol 80 mg/dL Triglycerides 300 mg/dL Glucose 118 mg/dL Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step in management?
A) Alcohol cessation B) Better control of diabetes C) Switch from captopril to calcium-channel blocking agent therapy D) Gemfibrozil therapy E) Thyroid replacement therapy
3. A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of 290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril for hypertension and glyburide for type 2 diabetes mellitus. She also has intermittent episodes of gout.
Fasting serum studies show:
Total cholesterol 252 mg/dL HDL-cholesterol 80 mg/dL Triglycerides 300 mg/dL Glucose 118 mg/dL Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step in management?
A) Alcohol cessation B) Better control of diabetes C) Switch from captopril to calcium-channel blocking agent therapy D) Gemfibrozil therapy E) Thyroid replacement therapy
4.A 23-year-old man comes to the physician because of a 1-month history of intermittent right-sided abdominal pain, nausea, and vomiting. He has sickle cell disease and has been treated severaltimes for painful crises. Examination of the abdomen shows tenderness to palpation of the light upper quadrant on inspiration.
Laboratorystudies show:
Hematocrit 25%Leukocyte count 11,000/mm3Serum Bilirubin Total 3.2 mg/dLDirect 0.3 mg/dLAlkaline phosphatase 56 U/L
Ultrasonography of the gallbladder shows a fillingdefect. Which of the following is the most likely cause of this patient's hyperbilirubinemia?
A) Aggregation of cholesterol in the gallbladder
B) Inhibition of glucuronosyltransferase
C) Lysis of erythrocytes
D) Malnutrition-induced cirrhosis
E) Neoplastic growth in the gallbladder
16. A 58-year-old white store manager comes to the office for a periodic health evaluation. You have been treating both the patient and his wife for the past 15 years. Today the patient is tearful and agitated. He says that he is having difficulty with his son, who is age 32 years and has schizophrenia. The son has been living intermittently in a group home or on the streets. The patient says that his son is noncompliant with his antipsychotic medications. Recently, the son has been calling the patient's house asking for money, which the patient suspects his son uses to buy alcohol and illicit drugs. It is most appropriate to advise the patient to do which of the following?
A
) Arrange an involuntary commitment to a psychiatric hospital for his son
B
) Ask his son's psychiatrist to adjust his medication
C
) Change his phone number
D
) Contact the local chapter of the National Alliance for the Mentally Ill for support and advice
E
) Obtain a restraining order against his son
17. A 20-year-old man comes to the health center because of ankle pain. Two days ago he sustained an inversion injury of his left ankle in a basketball game. He has been able to walk unassisted since the injury. Today he has pain and moderate swelling and discoloration over the lateral malleolus. Physical examination shows tenderness on palpation over the anterolateral corner of the ankle joint. He has had two similar injuries in the past. Which of the following is the most appropriate initial management?
A
) An ankle-strengthening exercise program
B
) Application of a long-leg cast for 3 weeks
C
) Application of a short-leg cast for 3 weeks
D
) Protected weight bearing
E
) Surgical repair of the ankle ligaments
18. A 52-year-old woman comes to the office because of a 4-day history of increasing pain of the right hip and thigh. The pain is exacerbated by lying on her right side while sleeping. She says the pain often awakens her and is accompanied by a burning sensation along the right side of her posterior thigh that radiates to her knee. She usually has stiffness and pain in the hip during the following morning that gradually diminishes as she walks around her house and does house chores. She says the pain is also triggered by sitting with her right leg crossed over the left leg. The patient is otherwise healthy and takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Vital signs are normal. Physical examination discloses tenderness on deep palpation of the right trochanter. Which of the following is the most likely diagnosis?
A
) Arthritis of the hip
B
) Aseptic necrosis of the femoral head
C
) Bursitis
D
) Gout
E
) Osteosarcoma of the femoral head
8. An 18-year-old man comes to the health center because he has had pain in his right leg for the past 5 days. He says that he recently added jogging to his weight-lifting workouts, and he started running 5 miles per day 2 weeks ago. He is 180 cm (5 ft 11 in) tall and weighs 83 kg (185 lb). On physical examination he has moderate tenderness over the midtibia. X-ray of the leg will most likely show which of the following?
A
) A bone cyst
B
) Displaced fracture
C
) Metastatic disease
D
) Soft-tissue calcification
E
) Normal findings
9. A 47-year-old woman returns to the office because of gastrointestinal symptoms. She says, "I still have burning pain in my stomach that travels up my chest to my neck after I eat." During the past 5 years she has been treated with antacids, H2-blocking medications, proton pump inhibitors and motility agents, with only mild relief. She smokes one pack of cigarettes per day and drinks one cup of coffee in the morning. There is no family history of peptic ulcer disease. Previous endoscopies, the last of which was 6 months ago, have shown lower esophagitis secondary to reflux with healing ulcers and scarring. Gastric and duodenal cultures for Helicobacter pylori have been negative. Vital signs today are normal. Physical examination, including rectal examination, is normal. Which of the following is the most appropriate next step?
A) Consider an alternative pharmacotherapeutic regimen
B) Continue current treatment
C) Do esophageal pH monitoring
D) Obtain surgical consultation
E) Repeat endoscopy 10.A 19-year-old college student comes to the student health center because of palpitations, shortness of breath and a runny nose. He has asthma that he has treated with an over-the-counter cold preparation and an epinephrine metered-dose inhaler every 2 to 3 hours at night. He just used the bronchodilator in the waiting room. Vital signs are: temperature 38.2°C (100.8°F), pulse 82/min and respirations 18/min. He appears to be somewhat anxious and his breathing is labored. Auscultation discloses mildly diminished breath sounds in all lung fields accompanied by scattered wheezing. Which of the following is the most appropriate management?
A
) Add oral aminophylline therapy
B
) Admit him to the hospital for respiratory therapy
C
) Prescribe decongestant/antihistamine therapy
D
) Prescribe antihistamine therapy
E
) Substitute an albuterol nebulizer for the epinephrine
11. A 25-year-old man develops fever, muscle pain, and headache 1 week after being bitten by several ticks while camping near the Grand Canyon. The fever remits and he feels better in 7 days. Two to four days later, his symptoms recur. A Giemsa stain of a peripheral blood stain shows intracellular bacterium. Which of the following is the most likely explanation of the reoccurrence of symptoms?
A) Expression of endotoxin-like structures on the surface of the organism B) Migration of the organism from a tissue site to the blood stream C) Production of a toxin that had become suppressed during the infection D) Secondary infection by a different organism of the same species E) Variation of a major surface protein antigen of the organism
12> A 4-year-old girl is brought to the emergency department by her mother because of severe wrist pain. The girl was playing with her friends in her backyard and fell, breaking the fall with her outstretched hand. On physical examination there is slight swelling over the dorsal aspect of the wrist. X-ray films of the wrist are shown.
The findings are most consistent with which of the following?
A) Carpal navicular fracture
B) Cortical fracture of the radius
C) Fracture of the distal radius and ulnar growth plates
D) Fracture of the distal radius growth plate
E) Perilunate dislocation of the wrist
13> Which of the following is the most appropriate management?
A) Apply an elastic bandage and apply ice packs to the wrist
B) Do closed reduction of the fracture
C) Do closed reduction of the fracture and report the case to child protective services
D) Immobilize the forearm and hand in situ in a cast
E) Prepare for open reduction and internal fixation
14.A 10-year-old boy is brought to the emergency department because he developed hives and shortness of breath 10 minutes after being stung by an insect. His father tells you that he had a similar episode of dyspnea and urticaria 2 years ago. Physical examination now shows a frightened child who appears out of breath, has generalized urticaria and asks for help in a hoarse voice. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 36/min and blood pressure 70/40 mm Hg.
Which of the following is the most important first step in managing this patient?
A) Administer diphenhydramine, orally
B) Administer epinephrine, subcutaneously
C) Administer oxygen via face mask
D) Establish intravenous access
E) Obtain arterial blood gas values
15> After 10 minutes there is no change in his condition.
At this time, the most appropriate next step is to administer which of the following?
A) Diphenhydramine, orally
B) Dopamine, intravenously
C) Epinephrine, subcutaneously
D) Prednisone, orally
E) Ranitidine, orally
16.> A 56-year-old white executive is admitted to the hospital from the emergency department following a severe nosebleed. One month ago he had a brief viral illness after being exposed to an exanthem eruption of one of his grandchildren. At that time the patient was also referred to a urologist because of fatigue, low back pain, and urinary frequency. He was diagnosed with prostatitis, for which he has been taking sulfamethoxazole-trimethoprim for the past 12 days. He does not take any other medications. On arrival in the emergency department vital signs were: temperature 36.8°C (98.2°F), pulse 100/min, respirations 16/min, and blood pressure 120/66 mm Hg. The patient appeared pale with scattered areas of bruising on his limbs and body and a few petechiae. No lymphadenopathy or organomegaly was found. Results of laboratory studies obtained in the emergency department are shown:BloodUrineHematocrit 21%WBC 0/hpfHemoglobin 5.6 g/dLRBC 10–20/hpfWBC 2000/mm3MCV 102 ìm3Partial thromboplastin time 26 secPlatelet count 20,000/mm3Prothrombin time 12.8 secINR 1.3
Bone marrow biopsy shows marked hypocellularity.Which of the following is the most appropriate management?
A) Administer granulocyte colony-stimulating factor
B) Administer high-dose short-term corticosteroids
C) Administer parenteral broad-spectrum antibiotics
D) Begin transfusion with whole blood
E) Discontinue sulfamethoxazole-trimethoprim
17> Supportive measures are provided for the patient.
Which of the following is the most appropriate treatment recommendation for this patient at this time?
A) Chemotherapy
B) Follow-up evaluation in 1 week
C) Glucocorticoid therapy
D) Hematopoietic growth factor therapy
E) Stem cell transplant
18.Healthy 23 yr old comes to the office for health maintenance exam. She has no complaints, does not smoke or take alcohol. No signifincant family history. Vitals are within normal limits, PE is also normal. PAP shows ASCUS. What is the most appropriate next step?
1) Refer for colposcopy2) Set up repeat pap in 3 months3) Treat with Doxy and repeat pap in 3 weeks4) Reassure and repeat Pap in one yr5) Obtain HPV testing on sample
19.29 yr old F comes to your office for routine health maintenance exam. She has H/O migriane headache, smokes 1 pk of cigarettes every 3 days, drinks alocohol on weekends. Dad died of colon ca at 50, mom is diabetic. She is taking no meds, Vitals are within normal limits and physical exam is normal. PAP smear + for HSIL and satisfactory colposcopy + for CIN-2. What is the next step?
1) LEEP2) Cryosurgery3) Laser therapy4) Expectant management5) Cold Knife conization
1.2.A3.D4.C5.e6.c7.c8.e9.d10.B11.E121314 B15 C16 D17 C 18.5 19.1
Wednesday, January 28, 2009
Tuesday, January 27, 2009
Important website for USMLE preparartion
I would like to introduce to you an excellent study resource for USMLE. I was amazed at the variety of resources offered by this website. It has tons of e-books (In my opinion all you need to clear the exams), Video lectures, Animations, lecture notes and live USMLE type online test. The amazing thing is that everything is FREE.
The Kaplan Qbooks for all the steps, online tests , videos and lecture notes and tons and tons of stuff are worth it. It was my friend who recomended the site to me. And boy, I was amazed. I cursed myself in not knowing about the website earlier.
And they have opened a forum, it seems, with live case file discussions by Dr.Cynthia, who is a well known USMLE trainer. The case files are of top quality and will surely help in exam preparation.
Visit this website and experience it. I assure you that it will a wonderful one. Visit it at:
http://www.learnerstv.com/
All the very best
The Kaplan Qbooks for all the steps, online tests , videos and lecture notes and tons and tons of stuff are worth it. It was my friend who recomended the site to me. And boy, I was amazed. I cursed myself in not knowing about the website earlier.
And they have opened a forum, it seems, with live case file discussions by Dr.Cynthia, who is a well known USMLE trainer. The case files are of top quality and will surely help in exam preparation.
Visit this website and experience it. I assure you that it will a wonderful one. Visit it at:
http://www.learnerstv.com/
All the very best
Friday, November 14, 2008
RECENT STEP 2CK QUESTIONS!!!!!!!
QS BY AN EXAMINEE
GI questions:
- pt c hematemesis, not actively bleeding -> sclerotherapy
- pt had hematochezia and bluish dicoloration of the cecum -> I don’t know I put angiodysplasia
- toxic megacolon, NPO/IVF/NGT wasn’t enough, then more pain and more fever c free air in abdomen ->laparotomy
- kid swallowed some acid, what to do in ER -> esophagoduodenoscopy
- no questions on h.pylori
- easy question to diagnose achalasia
- question on sjogrens what is next step -> SSA/SSB Ab or parotid biopsy
- guy had halitosis -> zenkers
- several questions on gout -> trial of PPIs
- question on esophageal scleroderma -> trial of PPIs
- guy has heartburn well controlled with antacids, used to have trouble swallowing only steaks, now cannot swallow many solids but liquids is ok -> PPIs or EGD
- diagnose esophageal cancer
- diverticulitis -> ct scan
- woman with jaundice, only + result was HAV IgG, what is she at risk for in the future? HAV, HBV, Hemachromatosis, Hepatocellular Ca, etc.
- pt with hepatic encephalopathy and high Cr -> dialysis
- question was very long, said pt had epigastric pain radiating to upper quadrants, fever, no jaundice, labs weren’t that bad (mildy elevated alk phos) what does she have -> cholecystitis, choledochilithiasis, pancreatitis, bla bla bla…
- Cholecystitis -> abdm U/S
- Older woman with h/o CABG and history of A.fib gets diffuse abdm pain after eating, and has abdm bruit, what does she have? Embolis in SMA, abdm aortic aneurysm, polycystic kidney disease?
- Acute pancreatitis question
- Question on malabsorption, pt had steatorrhea… lol I don’t remember the rest
- Guy had bloody stools and passed out on the floor, recent history of aortofemoral bypass -> I put fistula
- Dx pyloric stenosis
- What is the cause of intussuseption of small bowel in a 65yo? Idiopathic, tumor, cancer of small bowel, lymphadenitis?
- Dx meckels
CARDIO
- Question said positional chest pain, showed EKG of diffuse ST elevation -> pericarditis
- Had two heart murmur audio questions
- IVDA and vegetations on the heart -> tricuspid regurge
- Guy with angina and a.fib -> I put ECG stress test
- Which is the greatest risk factor for CAD? LDL-chol ration, HDL chol ratio, triglycerides, lipids
- Murmur got worse with standing and valsalva -> HOCM
- Kid with cyanosis in the 1st 24hrs of life -> transposition
- Diagnose tamponade
- Kid with holosytolic murmur -> left to right shunt (it’s a vsd)
- Diagnose MVP (said mid-systolic click)
- Diagnose ASD (said wide, fixed S2)
- Endocarditis prophylaxis for dental procedure in a kid with h/o reaction to ampicillin -> clinda
- Teenager with cramps in the legs, muscles on top are bulky, weak on the bottom, bad LE pulses -> coarctation
- Hyperaldosteronism -> PRA ratio
- 3 questions on temporal arteritis (2 dx 1tx)
- woman with renal artery stenosis what is elevated? Rennin
- diagnose dissecting aortic aneurysm -> TEE
- pt had low Na, low K, high Cl on thiazides and ACEI what is the reason for the labs? I put thiazide and ACEI reaction, other choices were hyperaldosteronism, hypoaldosteronism, other stuff
SKIN
- picture of some bad bad acne -> proprionobacterium
- HSV
- How do you treat ringworm > clotrimazole, permethrin, hydrocortisone?
- Pt had dermatitis herpetiformis -> gluten free diet
- Pt had optic glioma what will you find on skin -> café au lait
- Guys nose had a pearly looking thing on it -> basal cell
- Mentally retarted kid with seizures and a skin disorder -> tuberous sclerosis
- Acathosis nigrans -> check glucose
- Kid with DIC
- Picture of a hand with DIP inflammation and said his ankle was very tender -> gout
- Kid went into the woods now has itchyness and rash in a linear pattern -> contact dermatitis
- Mom wants to prevent daughter from getting sunburns ->advise not to go out before 2pm
- Contact dermatitis question -> cell-mediated hypersensitivity
ENDOCRINE
- Guy is depressed after his wife died and labs show high tsh, low t4 -> depression due to medical conidition, other choices were MDD, Adjustment disorder
- Graves disease what Abs are after -> TSH receptor
- Guy with A.fib what must you rule out -> hyperthyroid
- SOOO many questions on diabetes I and II soooooo many. Guy with DKA (give fluids and what type of insulin), guy with DM and foot ulcer (angiography or foot amputation), soooo many know your DM inside out
- Health care worker comes in after fainting has sugar of 40, normal c-peptide -> took insulin
- Guy with low insulin and high c-peptide -> insulinoma
- Guy with rash and high sugar -> glucagonoma
- Dx hyperparathyroidism
- Guy on lithium -> nephrogenic DI
- Dx SIADH
- Guy with loss of facial hair, small testes and is infertile -> check pituitary
- Pt cannot lactate after birth, had postpartum hemorrhage, what is deficient? GnRH, inhibin, progesterone?
- Dx PCOS
Hematology
- 3-4 questions on B12 deficiency
- 3-4 questions on folate deficiency
- what is low in goats milk? folate
- What is low in breast milk? Vit D
- Guy from
- Sickle cell crisis, after analgesia what do you give? Fluids or transfuse?
- 4-5 questions on iron deficiency
- kid eats anything now has low MCV -> lead poisoning
- I had like 4 questions that starts with a pt who had recurrent nosebleeds.
- One said pt c recurrent nosebleeds on lithium, bupropion and valproic acid, lithium levels are too high what to do next? D/c lithium, d/c valproic acid, d/c buproprion, check platelet level, check AST levels?
- Dx Hemophilia A (question said effusion of blood in the knee)
- Dx von Willebrands
- Question said besides the stockings how else can you prevent DVT? LMW heparin, warfarin, aspirin, tPA.
- Question on HUS (said history of recent infection)
- Dx Henosh-schonlein (said palpable purpura)
ID
- Dx otitis media
- Hard question on sinusitis, know how to differentiate chronic s/s from acute.
- Kid with barking cough -> laryngotrachietis
- A lot of wheezing questions in children
- CSF has RBCs -> HSV
- Pt exposed to so many things, one of them was unpasteurized milk, CSF was normal -> listeria
- Ring-enhanced lesion in the brain in an aids pt prophylaxis -> TMP-SMX
- Kid with h/o meningitis what is the diagnosis to the most common sequela -> confused between tympanometry or air-conduction hearing studies (I know the answer was hearing loss)
- Encephalitis question -> HSV
- Kid c wheezing and has tonsillar inflammation and had trouble opening his mouth but uvula was not displaced and it showed a picture of the lateral neck and asked what it was-> peritonsillar abscess or retropharyngeal abscess im not to sure, know the pix
- Dx pharyngitis
- Nurse with pernichila (the finger infection) that gets it drained, warm compress and Abx, what is next? Keep her away from pts, prophylax all pts, treat all the pateints she was exposed to, etc.
- 2 questions on mycoplasma dx (college students)
- 2 questions on aspiration pneumona
- PPD positive next step -> cxr
- Guy with white fluffy things that don’t scrap off, what is next test? HIV
- 3 questions on Lyme disease
- MANY MANY STD questions, all of them like syphilis, chancroid, gonorrhea, chlamydia, trichomonas (like 4), candida (2)…at least 2 on each one
- Guy with everything that seemed like gout, what is next step? Aspirate fluid from joint (treatment wasn’t an option)
- Had maybe 9-10 questions on the immunodefiencies, know them real well.
- Guy with indurated 5cm mass on thigh and fever, what do you do next? Surgical debridement or I&D?
- Pt has on several meds gets hearing loss, what is the cause?
-
Rhematology
- How do you treat pseudogout? Indomethacin, hyaluronidase injections, aspirin?
- 3-4 questions on RA
- 2-3 questions on Gout
- 1-2 questions on OA
- pt c psoriasis what else should you find? Clubbing of the finger
- 3 questions on Kawakaki’s disease (2 to dx, 1 to tx)
- dx polymalgia rheumatic
- tx SLE (prednisone)
- how do you treat fibromyalgia
- dx polymyositis
- dx DMD
- kid with recurrent fractures and blue sclera -> collagen 1 deficiency
- Showed picture of carpal tunnels -> median nerve at wrist
- Dx slipped capitus femoral (fat kid with a limp)
- Dx Osgood shlatter (showed picture of tibial tuberosity)
- Dx developmental hip displasia (said mom heard popping when changing diapers)
- Picture of chondrocalcinosis -> pseudogout
OBGYN
- Almost every other question started with G-P- (my test was A LOT of obgyn)
- Dx and tx ectopic
- 4 questions on mole (2 dx like HTN in 1st TM and enlarged uterus 2 tx)
- pt is 31weeks and gets in a car accident now has vaginal bleeding and uterine tenderness -> abruptio placenta
- pt is 11 weeks and has passage of fetal contents but no fetal parts noted, very high hCG -> 46XX
- Pt with TOA keeps getting worse and fever getting higher -> surgery
- Pt c cyst on labia majora, nowhere else, only on the majora -> labial abcess, bartholins abscess, bartholin cyst
- HSV at 39 weeks c 4min contractions c no breakouts while pregnant but she feels weird and said that usually when she feels weird she breaks out, what do you do? C-section, augmentation of labor, tocolysis
- 10cm dilation and after 10 minutes all you get is a “palpable minimal caput†what do you do next? Vacuum, continue contractions, c-section
- 37yo c breast mass and gets lumpectomy and after it showed noninvasive intraductal cancer without margins, what is next step? Tamoxifen, radiation, chemo, observe, or sentinel node bx
- Woman at 28wks had an amnio before and got RhoGAm what do you do now? Administer rhogam again
- Woman has baby that’s too small for gestation age, stress test shows late decelerations what is the cause of the IUGR? Uteroplacental insufficiency
- Mom is smoker while pregnant? IUGR
- What is high in a pt with gestational DM? HPL
- Mom is 34wks and gets severe preeclampsia what will the child suffer from? Sepsis, pulmonary insufficiency (that’s what I put).
- High AFP on triple screen? Anencephaly (other choices were trisomy 21, 13, 18)
- Tx gbs
- Pt with vaginal discharge, turns out fern+ what is the d/c? PROM
- Pt with postpartum hemorrhage, what do you do? Give oxytocin, give prostaglandin, surgery, artery ligation (massage was not an answer)
- Macrosomic kid whose mom had gestation DM gets seizures -> hypoglycemia, hyperglycemia, hypo or hypercalcemia, kalemia, natremia, etc.
- 3 questions on cervical dysplasia
- woman with PCOS is at risk for -> endometrial cancer
- woman who has BMI 33 is at risk for ->endometrial cancer
- woman with menopause and fracture -> dexa
- 2-3 questions on endometriosis
- 2 questions on fibroids
- 57yo with vaginal pruritis -> vulvar cancer
- 14yo girl has not had menses, all her friends make fun of her, physical exam is completely normal, what is the dx?
- post menopausal bleeding -> endometrial cancer
- obese F with menstrual cycle problems that when you take pap smear what else should you do? Endometrial biopsy
- woman feels bulging from her vagina, she had a total hysterectomy in the past, she has absolutely no other s/s besides the bulging which gets worse when she stands up -> cystole, rectocele, uterine prolapse?
- Guy who gets urge to pee but pisses on himself before he makes it to the bathroom -> detrusor hyperactivity.
- Know how to treat your STDs!!
- Bloody discharge -> intraductal papilloma
- 37yo woman with breast mass -> mammo, FNA, biopsy, sonogram?
- Menopause lady wants to prevent bone fractures that she seen in her sister, takes no HRT, what should she do? Calcium supplements, estrogen replacement, etc.
SURGERY
- Bleeding from urethral meatus ->retrograde urethrogram
- Dx tension ptx
- Stab wound to stomach -> ex lap
- Guy was on motorcycle crashed into truck and now feels abdm pain, VS are stable, what do you do next? DPL, CT, ex-lap
- Picture of a severely displaced radial bone and pt had no pulses, loss of sensation, and pallor. They said the feeling of the forearm was still very soft, what do you do next? ORIF, fasciotomy, angiography, cast.
- Not too much surgery
Growth development/preventative medicine
- 3yo rides a tricycle, still pees in his bed, can say two worded sentences, is he normal delayed (in each field like social, developmental, motor)
- dx separation anxiety
- kid wants to get circumcised, want should you tell him? Need parents consent
- no formula questions (sensitivity, specificity, odds ratio, bla bla bla)
- dx t-test
- what is the best test to measure incidence? Cohort study
- no bias questions
- if an HIV ELISA test is 99% sensitive and 95% specific, what happens to the sensitivity and specifity if you do “another test†(I don’t know if that meant another ELISA test or a western-blot, so I assumed another elisa and put stays the same)
NEURO
- carotid stenosis of 90% in an asymptomatic pt -> CEA
- how to treat cluster headache? Oxygen
- 3 questions on temporal arteritis
- a question about tremor at rest, not with motion or walking, the answer was related to parkinsons
- Showed a picture of the brain and said the pt had no memory problems but had personality changes, frontal area and temporal area looked atrophied -> Picks
- Guy is taking care of his wife (both really old) and she is getting worse, he promised he wont send her to a nursing facility. He cant afford a nursing aid anymore. Now his wife is making sexual advances and hes disgusted by it. What do you do? Put his wife in assisted living, give him sexual therapy, give him SSRI, give her diazepam.
- Woman with alzheimers is getting more crazy (screaming at her son for stupid reasons), what do you do? Tell her son its normal
- A LOT of dementia questions (not that hard)
- Wet wacky wobbly -> normal pressure hydrocephalus
- Woman who is one week ok and one week very bad (demented c loss of motor function), has history of CABG and her BP is still high -> multi-infarct dementia
- Dx MS
- 2 questions on Guillian barre (both diagnosis, one was hard)
- One question was on ALS, where is the problem -> motor neuron
- Dx subarachnoid
- One question asked what is the fastest way to treat high intracranial pressure? Intubation and hyperventilation, manitol, trendelenburg, head elevation
- Dx Narcolepsy
- Construction worker in the sun all day gets an episode of confusion (just confusion), he is otherwise healthy and on no medications, what is the dx? Heat stroke, malignant hyperthermia, some other dumb answers.
- Old pt with long history of DM and HTN gets progressive loss of vision, on physical exam the eye has no hemorrhages, no cotton wool spots, no neovascularization, what is the dx? Glaucoma, DM retinopathy, HTN retinopathy, cataracts
PULM
- Acute asthma attack tx
- Pt with situs inverses, recurrent pneumonia and bronchiectasis (so your thinking CF) but it says sweat-chloride was negative -> nasal scrapings
- Many questions on pneumonia
- No questions on pulmonary effusions
- 2 questions on sarcoidosis
- Dx asbestosis
- Dx chronic bronchitis (really easy)
- One question said what is the pathyphysiology of chronic bronchitis (what happens to the vessel walls, something about elasticity)
- 13month old kid with sudden inspiratory wheezing, CXR shows hyperinflation of just the right lung but no foreign object what is next step? Scope
- Dx Aspiration pneumonia. One question said what is the pneumonia consisting of? Gram + only, gram – only, both, gram + and anaerobes, gram – and anaerobes, etc.
- Dx TB (question even said positive PPD)
- Dx atelectasis (fever a few hours after surgery)
- 2-3 questions on ARDS
- One on neonatal ARDS, what to tx with? Surfactant
- Women suspected of having PE, the V/Q scan was negative what do you do next?
- Pt with PE what do you give? Heparin
RENAL
- I had about 10-15 renal questions, some really hard. 6 of them were in that category where you have a million answers and they give you 2 or 3 questions on the same answers. What else can I say but know your renal!!
- Guy had testicular mass, ultrasound confirms that it is a solid mass, what is the next step? Excisional biopsy or orchiectomy?
- 2 questions on BPH (dx)
- Pathophysiology of post-strep GN? I put destruction of foot processes (they didn’t have fusion)
- Muddy casts -> ATN
- Pt in car accident, CK level is off the roof, what is he at risk of? ATN
PSYCH
- Pt with depression and starts hearing voices for ONE week -> MDD, schizoaffective, schizophrenia, bipolar.
- Guy with narcolepsy, how to treat? I put methylphenidate
- Dx ADHD
- Dx anorexia
- Dx delerium
- Kid wondering the street at 2am, high BP, dilated pupils, combative and paranoid, what drug did he abuse
- Girl is found unconscious, high BP, dilated pupils, what drug?
- Woman is found wondering the streets, not oriented, dilated pupils, question said what should you give her, I put thiamine (other choices were naloxone, flumazenil, etc)
- Guy feels spiders on hit feet when hes trying to fall asleep, and he cant fall asleep because of it, what is the dx? Restless leg syndrome
- Another question on restless leg syndrome, the drug is aimed at what? Dopamine, serotinin, NE, Ach, etc.
- Girl is in love with the TV anchorman, keeps writing him letters, waits at his job, believes they will marry, what is the dx? Delusional
- 2 questions on the adverse effects of phenytoin, one was rash
- dx adjustment disorder
- dx normal bereavement
- Professor gets sweating and nervous when he gets on stage in any other place but his own university – panic disorder
- Dx social phobia
- Person feels like theyre in another place (sounds like depersonalization), but it happened after they were put at gunpoint and robbed. Now she has nightmares and can never go to the same place again, but denies having flashbacks -> PTSD, depersonalization, and other stupid answers
- Dx primary insomnia
- Woman has twins that are 2yo and now she feels loss of interest, cant sleep, hates doing anything, what is the next step? Assess suicide.
Saturday, October 4, 2008
CS Mnemonics and Other imp material
Psychiatry Patient :
Mental status exam: Patient well groomed or not Eye contact, flight of ideas Speech pressured/not Mood/Affect Hostile or not to examiner Co-operative or not Inattentive/atten. 3/3 for registration,3/3 recall,3/3 orientation, long term memory, concentration,judgement,comprehension
Paeds Patient: the primary informant is the mother(1st sentence) Birth Hx,G& D, Immunization HX, SocialHx-smokers at home, sick contacts,day care, siblings going to the day care OB/GYN: Sexual HX:STDs, vaccination against Rubella,Hep B, Smoking(increases risk of CA), Blood transfusions in the past
i divide the exam in 5 catogeries: opening,CC+HOPI,GE+SE,Summary+councelling, Close. once you enter CS center: see the the usmle video..it helps u to the feel of the actual exam which cannot be replaced by anything.. 2) when u r standing at the door and the announcement is made for u...the first thing u write is the patients name...belive me 8 out of 12 times at the end of the case i forgot abt the name...write as big as u can and when u come in room plz keep the pad upside down...so that the SP may not see what u have written...just my personal advice..then u write the
PAMHUGSFOSSOSDA
LIQORAAA
FCCNDTCHMMSR ..( REMEMBER THE DD )
3) the moment u come in after knocking the door..smile...greet the patient..shake hand...i m dr.mmm a physician here to help you....( a advice.... if the SP is not able to talk or in pain...u can directly start with like...mr.SP the nurse told me that you have pain in abd..how may help you with that..or can u tell me more abt it....
U can use the mnemonic - FCC NDTV HSSR for that..
F-FEVER
C-COUGH
C-COLD
N-NAUSAEA,NUMBNESS
D-DIZZINESS
T-TINGLING
V-VOMITTINGS
H-HEADCAHE
S-SORETHROAT
S-SHORTNESS OF BREATH
R-RIGORS,
RASH
4) there are 10 transitions sentences u have to use and 4 informative one...u cannot miss them in any case...make it like a routine when ur practising these cases..
5) u can talk while washing hands....dont have slience any time in the room unless u ascultating...
6) Ok now the big thing..examination...its so time consuming and u tend to forgot all the things.. 7) for general exam..follow the PICKLE and added O of opthalmoscope to it...check pedal edema now...and ask fr it also...check pulses...take BP
8) now for,, systemic exam... --start with sp sitting , untie the gown with
back chest insep/percussion/tactile fremituis/ascultation....check for spinous tenderness and CVA tenderness at the same time.. ---
SP still sitting..come front take the gown down ..sternal tenderness/ supraclavicular nodes axillary nodes...
PMI...all 4 heart sounds and ascultate the lungs.. --
tell the SP to lie down....look for JVP..carotid pulse...
go for abdomen...IAPP..
9)...summary...the most imp part...what u told me..what i found out...it might be (DD)..what we are going to do (investigations).. ---counselling..the most imp part of the closing....u have to do ....what precuations the SP has to take based on the CC..
10) closing....ok this is what i did.. a) i m going to tell the nurse to send the investigatiosns quickly b) the investigations might take 8-12 hours to come..till the time if there is any problems or worsing the CC plz give me a call ..i m goin to keep my contact info with the nurse.. c) and once the investigations comes we will meet again and dicuss abt the problem and management..i would like to again remind you abt i am alwayz here to hep you Mr.SP ..have a great day.!!!! Phew finish..come outside and start writing the PN.. writing PN is easy...so i guess i m not going to write abt it... .
1)Knock 3 times with confidence , a smile , walk in and say, "hello Mr. SP, I am Dr. XYZ and am here to see you today as your physician." Shake hands with the patient, look around the room and say "Is everything in the room alright for you ?" - SP says yes - Then you say "Let me make you a little more comfortable".....and while saying so, drape the patients legs up to his belly (applies to a sitting or a reclining SP) . Then, "So Mr. Smith, how may I help you today?" After the patient tells you the chief complaints and stops, first express sympathy - say, "Oh I am sorry to hear that, I shall try my best to help you. Hope you dont mind if I make a few notes as you speak" This makes you free to write or pretend to write as you try to recall what to ask without showing ur nervousness - actually a good time to write ur mnemonics !! now ask LIQORAAA + FCCNDTVHMSSR --2) hello Mr.SP now i need to ask you more Q regarding ur health..which will help me nderstand ur health better....NOW ASK FOR START WITH off with data collection, i.e. "PAM HUGS", before you move on to "FOSS", it is good to say, "Mr. SP, the way clinical medicine works, there could be some clues hidden in a few personal questions I need to ask you - is that OK with you ? " and then move on to FO ---4) now tell the SP that anything u going to tell is going to be confidential....ask the sexsual and social SODA. --- Transitioning to a hand wash: There have been quite a few concerns about how to handle a change from history mode to a hand wash mode ...A sample transcript : You = "I shall now need to perform a quick general examination and then look at your heart - is that fine ?" (No need to say Head, Neck, Eyes, Feet, etc and waste seconds ! - you're gonna be graded for doing it , not for u saying it in detail !) SP = "Sure, doctor" You = "Arrite ! Before we begin Mr. Smith , excuse me for a moment here to wash my hands" (smile) I had reserved the time to wash my hands to enquire about occupation and say "thats interesting, my uncle used to do something similar" or something like that. Transitioning to a Physical exam: Before you begin physical examination say "I will now need to perform a quick general examination and then we shall have a look at your chest [or abdomen - wutever the chief complaint is]" and do keep talking during each thing your examine - like "lets start with your eyes, could you look up for me" while examining pallor. By the way , a good mnemonic of quickly completing general examination is "PICKLE" - Pallor, icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy and Edema Feet" along with Jugular veins, carotid bruit if a CVS case. At the end of the entire general + systemic examination, summarise : "Based on what you told me and your physical exam, there are certain diagnostic possibilities like 1._____, 2. ________ or 3. _______ and others. But to be more certain, let us order a few tests - like blood tests, chest x-ray , an EKG , and then discuss further management. " The last minutes... While concluding, keep this 4-stage pattern in mind to cover everything and to be courteous: a. First, Counsel !!! For example - for a case of diabetes, it is good to say a few words on foot care ! if the patient smokes or drinks alcohol - say "are you aware of the harmful effects of smoking / alcohol ? Have you ever considered quitting - if you wish to , we have a good support team that is willing to help you quit the habit" thats it - dont get personal about it . b. Then say " Have you understood everything we have discussed today ?" c. Then "Are there any special concerns you have ?" d. Finally " Thankyou very much Mr. SP . I shall leave my contact information with my nurse - feel free to contact me anytime if you have any questions"Last day practice;general case 2) pedis case 3) pyshicatry case 4) absue case 5) telephone case.. take some sweet and start walking to the center ( i ate gulab jamun) yes the center is on the 5th floor....once ur out of lift take left and u r in the exam place.... talk to everyone u meet ...i had a girl from cincinnati next to me..we were talking abt the seinfeild episode in which kramer and his brother are SP's and were laughing abt it...its very relaxing.. but remember one thing dont talk abt the cases to anyone anywhere...period.. plz dont eat onions in the lunch..and bring some those breath dissolving things with u..plz plz bring those.. plz bring hankercheif...u get so sweaty...u need it before u knock on the door.. i just did the kaplan book and u have plenty of time buddy..10th june to 27th july...wow..i wish i could have that time VASES: In domestic abuse. Violence, Afraid, Safe, Emergency plan, Support system DEATH & SHAFT: Activities of daily living. Dressing, Eating, Ambulating, Toiletting, Hygeine. Shopping, Housekeeping, Accounting, Food preparation, Transportation. FROM HIS JFK CASE: Mental state exam (overlaps with SIG E CAPS actually) Funtionality Reasoning Orientation/ Outlook Memory/ Mood Hallucinations/ delusions Insight Speech/ Sleep Judgement Feelings Knowledge Concentration Attention/ appearance Suicidality Energy for depression - FACE SIPS F - feeling - shame guilt, sadness, anger A - appetite C - concentration, memory E - eneregy level S - sleep pattern I - interest in normal activites , hobbies P - pscyhomotor retardation S - sucidial ideation/intentWeight, Appetite, Diet, Stress, Exercise and Travel (WAD SET) only in GI, depression or possible endocrine (Thyroid, Cushings, PCOS) cases.I would the following questions in personal history after appropriate transition sentence- "Are you sexually active". If yes, I would ask "How many sexual partners have you had in the past six months". This I used instead of asking "Do you have multiple sexual partners" which I was not comfortable asking. Also, I found the question "are your sexual partners male or female or both" a little offensive though we may be required to elicit such information. So, I decided to reserve that question only in someone for whom I had high suspicion of STD along with "Have you ever been tested for STD". If the SP gives history of multiple sexual partners, then I would ask "Do you use condoms". If yes, I decided to leave it at that, especially if the history was that of a stable relationship. If I had to counsel specifically for STD, "There is a risk of infection with sexually transmitted diseases in anyone that is sexually active. The risk is increased when there are multiple sexual partners. Abstinence from sex is the best method to prevent infection with and spreading of sexually transmitted diseases. When this is not possible, the risk is reduced by limiting the number of sexual partners and using condoms which are also a reliable method of contraception." For psych cases, the counselling would ofcourse depend on the diagnosis which will be quite different for Alzheimers, depression, schizophrenia etc. Hope that helped. All the best for your exam.For PR u can tell - 'we will be examining ur back passage with one finger, its not painful but may cause bit discomfort'.When i explained about pr the SP asked the q ,whether it hurts doctor?. Counselling of lab result - My opinion is u should tell all the cases what investigation u are going to do in layman's term. There will be atleast one ER setting, just let the patient know that u care for their pain and will sort the pain as soon as the PE is over. The center will open at 7.30, they will def start the orientation at 8.00 am.Exam will be over by 3.30.U will get a 30 mt break after 5 cases, then 15 mt break after 4 and then 3 cases [ 12 cases ] .I hope that covers everything.I will be ready to help , in case u have anymore doudt.Mnemonics for psychiatrics SP. 3 mnemonics goes for it. 1. O.P.C. Onset: when did your fatigue start? there can b 2 kinds of answers to this Qs. group A: "2 months ago" for SP with PTSD, adjustment dis, malingering, cancer or other illness, etc. group B: I've been tired all my life or it comes and goes for SP with major depressive dis, cyclotimia, etc. Previous: have you ever had it b4? this Qs applies only to group A bcos group B already answers to it. Most of the answer group A will give will b a NO Cause: it is now the case, to ask to both groups a nice open ended Qs: what do you think is the cause of your problem? group A would give the important clue. MVA in case of PTSD, separation in case of adjustment dis, abdominal pain in case of possible pancreatic cancer. etc. if group A does not give the answer SPECIFICALLY ASK what happened 2 months ago? most of group B SP will say I don't know doc. cos they have felt like this all life. (but even group A SP could answer that)). NOW WE GO TO THE 2 MNEMONICS 2. FACE SLIPS 3. then I finish with PAM HUGS FOSSODA If SP has any other complaint, like pain, I have to investigate it through LIQORAAA and introduce it in my D/Ds and work up. I tried this system with all the psychiatrics chief complaints and it works.In case of fatigue, I have to ask: do you feel it all day long or you feel better in some particular moments? if yes, I investigate which moments. I put this Qs at O (onset), after asking when the fatigue started. In case of depression or feeling low, I have to ask if he generally looks at things in a positive or a negative frame of mind. I put this Qs in F (feelings), after asking If he has feelings of worthlessness. In case of PTSD, I have to ask about nightmare related to traumatic event. Even in this case I put the Qs in feelings, after asking about feelings of guiltinessI must always consider hypothyroidism as a D/Ds. also, I must always ask about delusion and hallucinations. But where to insert these Qs? maybe I should modify the Mnemonic from FACE SLIPS to FACE SLIPSO, with O being Others (actually 2 Qs: do you feel cold when other don't? do you hear or see what other people don't?) For the chief complaints which are neither Psychiatrics nor pain, I will use the following 2 Mnemonics. OAAA, where O is the onset the same from psychiatric history and AAA is (associated, aggravating and alleviating factors) taken for pain history. then I will continue with PAM HUGS FOSSODA. As a general rule, I will use this for all symptoms which are not psy (fatigue, depression, feeling low) or pain related (cefalea, sore throat, knee pain, etc. where LIQORAAA will be fine) The problem of these mnemonics is that if I want to make the history as much complete as possible, I often need to apply more than one Qs to some letters. Let's consider a chief complaint of knee pain for exemple. To perform a proper interview I have to apply more than one Qs to the letter O. Location: Could u plz tell me exactl where you feel the pain? Intensity: on a scale... howould u rate? Quality: how would u describe the pain? (important open ended Qs) Onset: here, I have verified that asking only when the pain starts makes the interview incomplete. So the Qs will b: 1. when did it first start? point X 2. have you ever had it before? before X 3. do have everyday? and all day long? if it is not all day long ask how long it lasts. after X 4. Is it worsening days after day or it is the same? progression Applying this Qs to Onset makes the History more complete. Radiation: does the pain move? Associated Symptoms: Do you have other problem other than this, for exemple fever, nausea, vomiting, diarrhea (it is important to give exemples and went the SP is done I ask anything else?) Aggravating factors: Do you know something that makes is worsen? Alleviating factors: ... that makes you feel better? Let's then return to the top. For all complaints that will not be psy or pain, I will use OAAA and then PAM HUGS FOSSODA. But in this case, I would apply to O the same 4 questions as above.According to many sources I have to make a transition sentence before starting with LIQUORAA or OAAA, and then between PAM and HUGS, between HUGS and F, between F and O, between O and S, etc, etc. For one who have been practising medecine like me this sounds really weird. Even my personal SP (which happens to be from the US) told me that all that transition sentences make the interview weird. keeping saying always "Now I need to ask some Qs about past medical history, is it ok? now I need to ask you about your family is it fine? I need to know more about your personal life is it okay with you? now I need to know about you social life is it fine? now I need to examine your chest? now it is the turn of your head, I need to palpate your belly. I need to check your pulse is it fine? is it fine? is it fine? is it fine? is it okay? is it ok? ok?ok?ok?ok?ok?ok?ok? COMEON!!!!!!!!!!! Maybe I do not do my transitions properly. But according to usmleworld I have to do these transitions. Now here is the deal: I know they want me to show professionality, compassion and respect. I do have a great deal of it. But I know I will not feel comfortable during the exam if I say it as it is described in usmleworld. So the deal is ask permission and describe what you are going to do in the same sentence. before going through the LIQORAAA I will say: I have been informed that you came in today because of abdominal pain. Could you pls tell me more about it? (I will not say what brings you in today? because I have read of one who recieved in response by the bus. In the same way, I will not ask why are you here today? because we are in a hospital and when we visit a patient we are supposed to know the chief complaint. In order to avoid any pb at the beginning of the interview, I think it would be better to start with a "closed ended Qs" I know that you are here because of abdominal pain, could you please tell me more about it? I think this gives an idea of professionality because it means that you get informations about the patient before seeing him. After the patient answer, I will say: I'm sorry to here that (only if it is the case). I need to ask you some questions about your problem, just to have a good view of it. Is it ok with you miss jones? yes. thank you very much. Then I will procede with the LIQORAAA then before going to PAM HUGS FOSSODA I'll say Now miss Jones, I will ask you some few Qs about your personal health, your personal life and your family. ok? okay! pls don't be embarrassed by my Qs because everything we'll talk about in this conversation will remain absolutely confidential. Then I'll go on. Let's then summarize the history taking. 1. In case of pain: LIQORAAA where O is related to 4 Qs and then PAM HUGS FOSSODA 2. In case of psy complaint OC (P is inside O) FACE SLIPSO PAM HUGS FOSSODA 3. In case of a complaint that is neither psy nor painful OAAA Cs advice ;;;Mr.Jones,....i want to tell u abt a few lifestyle changesU need to make at this point..----Monitor ur bp/sugarregularly, & don't miss u'r drug doses, eat healthy(low carb/low fat diet/low salt diet) & take extracare of ur feet, wear soft footwear & make sure u dontget hurt.As far as smoking and alcohol r concerned, uneed to seriously think abt quitting, it's never too lateto quit, espy if u r a dm'tic/htn'sive.. u need to be aware of their direct illeffects on the heart, brain & lungs..onlong term basis...I know it can be very tough to quit, buti cud introduce u to our peer support groups here, for goodphysical and emotional encouragement....let me know if u rinterested...& feel free to ask me any of ur concerns, my contact numbers r with my nurse...Is there anything u wantto ask me....Shall i see u then...good seeing u mr.jones.....
For the Phone Encounter-
"ON CALL IDIOT"
['On Call'since this is a phone encounter] - please dont think about "idiot" being offnesive - it is just a mnemonic people !O - Onset ?N - Number of Times a Day?C - Consistency ? / Color? / Content ? [Blood, Fat, Mucous ?] + Crying ? Cramps Suggestive ?A - Associated Symptoms [Fever, Runny Nose, Rash, Cough, Ear Discharge, Vomitting, Rash ?]L - Listless baby ? Lethargic, not Sleeping ?L - Liquids not passing ? [i.e. not urinating ?]I - Immunization up to date ?D - Diet Change ? Dehydration signs ? Day Care Center ? Developmental MilestonesI - Infections in family ? Immunicompromised mom ? [HIV ?]O - ORS counseling (Oral Rehydration Solution - see below)T - Travel history recently ?
Mental status exam: Patient well groomed or not Eye contact, flight of ideas Speech pressured/not Mood/Affect Hostile or not to examiner Co-operative or not Inattentive/atten. 3/3 for registration,3/3 recall,3/3 orientation, long term memory, concentration,judgement,comprehension
Paeds Patient: the primary informant is the mother(1st sentence) Birth Hx,G& D, Immunization HX, SocialHx-smokers at home, sick contacts,day care, siblings going to the day care OB/GYN: Sexual HX:STDs, vaccination against Rubella,Hep B, Smoking(increases risk of CA), Blood transfusions in the past
i divide the exam in 5 catogeries: opening,CC+HOPI,GE+SE,Summary+councelling, Close. once you enter CS center: see the the usmle video..it helps u to the feel of the actual exam which cannot be replaced by anything.. 2) when u r standing at the door and the announcement is made for u...the first thing u write is the patients name...belive me 8 out of 12 times at the end of the case i forgot abt the name...write as big as u can and when u come in room plz keep the pad upside down...so that the SP may not see what u have written...just my personal advice..then u write the
PAMHUGSFOSSOSDA
LIQORAAA
FCCNDTCHMMSR ..( REMEMBER THE DD )
3) the moment u come in after knocking the door..smile...greet the patient..shake hand...i m dr.mmm a physician here to help you....( a advice.... if the SP is not able to talk or in pain...u can directly start with like...mr.SP the nurse told me that you have pain in abd..how may help you with that..or can u tell me more abt it....
U can use the mnemonic - FCC NDTV HSSR for that..
F-FEVER
C-COUGH
C-COLD
N-NAUSAEA,NUMBNESS
D-DIZZINESS
T-TINGLING
V-VOMITTINGS
H-HEADCAHE
S-SORETHROAT
S-SHORTNESS OF BREATH
R-RIGORS,
RASH
4) there are 10 transitions sentences u have to use and 4 informative one...u cannot miss them in any case...make it like a routine when ur practising these cases..
5) u can talk while washing hands....dont have slience any time in the room unless u ascultating...
6) Ok now the big thing..examination...its so time consuming and u tend to forgot all the things.. 7) for general exam..follow the PICKLE and added O of opthalmoscope to it...check pedal edema now...and ask fr it also...check pulses...take BP
8) now for,, systemic exam... --start with sp sitting , untie the gown with
back chest insep/percussion/tactile fremituis/ascultation....check for spinous tenderness and CVA tenderness at the same time.. ---
SP still sitting..come front take the gown down ..sternal tenderness/ supraclavicular nodes axillary nodes...
PMI...all 4 heart sounds and ascultate the lungs.. --
tell the SP to lie down....look for JVP..carotid pulse...
go for abdomen...IAPP..
9)...summary...the most imp part...what u told me..what i found out...it might be (DD)..what we are going to do (investigations).. ---counselling..the most imp part of the closing....u have to do ....what precuations the SP has to take based on the CC..
10) closing....ok this is what i did.. a) i m going to tell the nurse to send the investigatiosns quickly b) the investigations might take 8-12 hours to come..till the time if there is any problems or worsing the CC plz give me a call ..i m goin to keep my contact info with the nurse.. c) and once the investigations comes we will meet again and dicuss abt the problem and management..i would like to again remind you abt i am alwayz here to hep you Mr.SP ..have a great day.!!!! Phew finish..come outside and start writing the PN.. writing PN is easy...so i guess i m not going to write abt it... .
1)Knock 3 times with confidence , a smile , walk in and say, "hello Mr. SP, I am Dr. XYZ and am here to see you today as your physician." Shake hands with the patient, look around the room and say "Is everything in the room alright for you ?" - SP says yes - Then you say "Let me make you a little more comfortable".....and while saying so, drape the patients legs up to his belly (applies to a sitting or a reclining SP) . Then, "So Mr. Smith, how may I help you today?" After the patient tells you the chief complaints and stops, first express sympathy - say, "Oh I am sorry to hear that, I shall try my best to help you. Hope you dont mind if I make a few notes as you speak" This makes you free to write or pretend to write as you try to recall what to ask without showing ur nervousness - actually a good time to write ur mnemonics !! now ask LIQORAAA + FCCNDTVHMSSR --2) hello Mr.SP now i need to ask you more Q regarding ur health..which will help me nderstand ur health better....NOW ASK FOR START WITH off with data collection, i.e. "PAM HUGS", before you move on to "FOSS", it is good to say, "Mr. SP, the way clinical medicine works, there could be some clues hidden in a few personal questions I need to ask you - is that OK with you ? " and then move on to FO ---4) now tell the SP that anything u going to tell is going to be confidential....ask the sexsual and social SODA. --- Transitioning to a hand wash: There have been quite a few concerns about how to handle a change from history mode to a hand wash mode ...A sample transcript : You = "I shall now need to perform a quick general examination and then look at your heart - is that fine ?" (No need to say Head, Neck, Eyes, Feet, etc and waste seconds ! - you're gonna be graded for doing it , not for u saying it in detail !) SP = "Sure, doctor" You = "Arrite ! Before we begin Mr. Smith , excuse me for a moment here to wash my hands" (smile) I had reserved the time to wash my hands to enquire about occupation and say "thats interesting, my uncle used to do something similar" or something like that. Transitioning to a Physical exam: Before you begin physical examination say "I will now need to perform a quick general examination and then we shall have a look at your chest [or abdomen - wutever the chief complaint is]" and do keep talking during each thing your examine - like "lets start with your eyes, could you look up for me" while examining pallor. By the way , a good mnemonic of quickly completing general examination is "PICKLE" - Pallor, icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy and Edema Feet" along with Jugular veins, carotid bruit if a CVS case. At the end of the entire general + systemic examination, summarise : "Based on what you told me and your physical exam, there are certain diagnostic possibilities like 1._____, 2. ________ or 3. _______ and others. But to be more certain, let us order a few tests - like blood tests, chest x-ray , an EKG , and then discuss further management. " The last minutes... While concluding, keep this 4-stage pattern in mind to cover everything and to be courteous: a. First, Counsel !!! For example - for a case of diabetes, it is good to say a few words on foot care ! if the patient smokes or drinks alcohol - say "are you aware of the harmful effects of smoking / alcohol ? Have you ever considered quitting - if you wish to , we have a good support team that is willing to help you quit the habit" thats it - dont get personal about it . b. Then say " Have you understood everything we have discussed today ?" c. Then "Are there any special concerns you have ?" d. Finally " Thankyou very much Mr. SP . I shall leave my contact information with my nurse - feel free to contact me anytime if you have any questions"Last day practice;general case 2) pedis case 3) pyshicatry case 4) absue case 5) telephone case.. take some sweet and start walking to the center ( i ate gulab jamun) yes the center is on the 5th floor....once ur out of lift take left and u r in the exam place.... talk to everyone u meet ...i had a girl from cincinnati next to me..we were talking abt the seinfeild episode in which kramer and his brother are SP's and were laughing abt it...its very relaxing.. but remember one thing dont talk abt the cases to anyone anywhere...period.. plz dont eat onions in the lunch..and bring some those breath dissolving things with u..plz plz bring those.. plz bring hankercheif...u get so sweaty...u need it before u knock on the door.. i just did the kaplan book and u have plenty of time buddy..10th june to 27th july...wow..i wish i could have that time VASES: In domestic abuse. Violence, Afraid, Safe, Emergency plan, Support system DEATH & SHAFT: Activities of daily living. Dressing, Eating, Ambulating, Toiletting, Hygeine. Shopping, Housekeeping, Accounting, Food preparation, Transportation. FROM HIS JFK CASE: Mental state exam (overlaps with SIG E CAPS actually) Funtionality Reasoning Orientation/ Outlook Memory/ Mood Hallucinations/ delusions Insight Speech/ Sleep Judgement Feelings Knowledge Concentration Attention/ appearance Suicidality Energy for depression - FACE SIPS F - feeling - shame guilt, sadness, anger A - appetite C - concentration, memory E - eneregy level S - sleep pattern I - interest in normal activites , hobbies P - pscyhomotor retardation S - sucidial ideation/intentWeight, Appetite, Diet, Stress, Exercise and Travel (WAD SET) only in GI, depression or possible endocrine (Thyroid, Cushings, PCOS) cases.I would the following questions in personal history after appropriate transition sentence- "Are you sexually active". If yes, I would ask "How many sexual partners have you had in the past six months". This I used instead of asking "Do you have multiple sexual partners" which I was not comfortable asking. Also, I found the question "are your sexual partners male or female or both" a little offensive though we may be required to elicit such information. So, I decided to reserve that question only in someone for whom I had high suspicion of STD along with "Have you ever been tested for STD". If the SP gives history of multiple sexual partners, then I would ask "Do you use condoms". If yes, I decided to leave it at that, especially if the history was that of a stable relationship. If I had to counsel specifically for STD, "There is a risk of infection with sexually transmitted diseases in anyone that is sexually active. The risk is increased when there are multiple sexual partners. Abstinence from sex is the best method to prevent infection with and spreading of sexually transmitted diseases. When this is not possible, the risk is reduced by limiting the number of sexual partners and using condoms which are also a reliable method of contraception." For psych cases, the counselling would ofcourse depend on the diagnosis which will be quite different for Alzheimers, depression, schizophrenia etc. Hope that helped. All the best for your exam.For PR u can tell - 'we will be examining ur back passage with one finger, its not painful but may cause bit discomfort'.When i explained about pr the SP asked the q ,whether it hurts doctor?. Counselling of lab result - My opinion is u should tell all the cases what investigation u are going to do in layman's term. There will be atleast one ER setting, just let the patient know that u care for their pain and will sort the pain as soon as the PE is over. The center will open at 7.30, they will def start the orientation at 8.00 am.Exam will be over by 3.30.U will get a 30 mt break after 5 cases, then 15 mt break after 4 and then 3 cases [ 12 cases ] .I hope that covers everything.I will be ready to help , in case u have anymore doudt.Mnemonics for psychiatrics SP. 3 mnemonics goes for it. 1. O.P.C. Onset: when did your fatigue start? there can b 2 kinds of answers to this Qs. group A: "2 months ago" for SP with PTSD, adjustment dis, malingering, cancer or other illness, etc. group B: I've been tired all my life or it comes and goes for SP with major depressive dis, cyclotimia, etc. Previous: have you ever had it b4? this Qs applies only to group A bcos group B already answers to it. Most of the answer group A will give will b a NO Cause: it is now the case, to ask to both groups a nice open ended Qs: what do you think is the cause of your problem? group A would give the important clue. MVA in case of PTSD, separation in case of adjustment dis, abdominal pain in case of possible pancreatic cancer. etc. if group A does not give the answer SPECIFICALLY ASK what happened 2 months ago? most of group B SP will say I don't know doc. cos they have felt like this all life. (but even group A SP could answer that)). NOW WE GO TO THE 2 MNEMONICS 2. FACE SLIPS 3. then I finish with PAM HUGS FOSSODA If SP has any other complaint, like pain, I have to investigate it through LIQORAAA and introduce it in my D/Ds and work up. I tried this system with all the psychiatrics chief complaints and it works.In case of fatigue, I have to ask: do you feel it all day long or you feel better in some particular moments? if yes, I investigate which moments. I put this Qs at O (onset), after asking when the fatigue started. In case of depression or feeling low, I have to ask if he generally looks at things in a positive or a negative frame of mind. I put this Qs in F (feelings), after asking If he has feelings of worthlessness. In case of PTSD, I have to ask about nightmare related to traumatic event. Even in this case I put the Qs in feelings, after asking about feelings of guiltinessI must always consider hypothyroidism as a D/Ds. also, I must always ask about delusion and hallucinations. But where to insert these Qs? maybe I should modify the Mnemonic from FACE SLIPS to FACE SLIPSO, with O being Others (actually 2 Qs: do you feel cold when other don't? do you hear or see what other people don't?) For the chief complaints which are neither Psychiatrics nor pain, I will use the following 2 Mnemonics. OAAA, where O is the onset the same from psychiatric history and AAA is (associated, aggravating and alleviating factors) taken for pain history. then I will continue with PAM HUGS FOSSODA. As a general rule, I will use this for all symptoms which are not psy (fatigue, depression, feeling low) or pain related (cefalea, sore throat, knee pain, etc. where LIQORAAA will be fine) The problem of these mnemonics is that if I want to make the history as much complete as possible, I often need to apply more than one Qs to some letters. Let's consider a chief complaint of knee pain for exemple. To perform a proper interview I have to apply more than one Qs to the letter O. Location: Could u plz tell me exactl where you feel the pain? Intensity: on a scale... howould u rate? Quality: how would u describe the pain? (important open ended Qs) Onset: here, I have verified that asking only when the pain starts makes the interview incomplete. So the Qs will b: 1. when did it first start? point X 2. have you ever had it before? before X 3. do have everyday? and all day long? if it is not all day long ask how long it lasts. after X 4. Is it worsening days after day or it is the same? progression Applying this Qs to Onset makes the History more complete. Radiation: does the pain move? Associated Symptoms: Do you have other problem other than this, for exemple fever, nausea, vomiting, diarrhea (it is important to give exemples and went the SP is done I ask anything else?) Aggravating factors: Do you know something that makes is worsen? Alleviating factors: ... that makes you feel better? Let's then return to the top. For all complaints that will not be psy or pain, I will use OAAA and then PAM HUGS FOSSODA. But in this case, I would apply to O the same 4 questions as above.According to many sources I have to make a transition sentence before starting with LIQUORAA or OAAA, and then between PAM and HUGS, between HUGS and F, between F and O, between O and S, etc, etc. For one who have been practising medecine like me this sounds really weird. Even my personal SP (which happens to be from the US) told me that all that transition sentences make the interview weird. keeping saying always "Now I need to ask some Qs about past medical history, is it ok? now I need to ask you about your family is it fine? I need to know more about your personal life is it okay with you? now I need to know about you social life is it fine? now I need to examine your chest? now it is the turn of your head, I need to palpate your belly. I need to check your pulse is it fine? is it fine? is it fine? is it fine? is it okay? is it ok? ok?ok?ok?ok?ok?ok?ok? COMEON!!!!!!!!!!! Maybe I do not do my transitions properly. But according to usmleworld I have to do these transitions. Now here is the deal: I know they want me to show professionality, compassion and respect. I do have a great deal of it. But I know I will not feel comfortable during the exam if I say it as it is described in usmleworld. So the deal is ask permission and describe what you are going to do in the same sentence. before going through the LIQORAAA I will say: I have been informed that you came in today because of abdominal pain. Could you pls tell me more about it? (I will not say what brings you in today? because I have read of one who recieved in response by the bus. In the same way, I will not ask why are you here today? because we are in a hospital and when we visit a patient we are supposed to know the chief complaint. In order to avoid any pb at the beginning of the interview, I think it would be better to start with a "closed ended Qs" I know that you are here because of abdominal pain, could you please tell me more about it? I think this gives an idea of professionality because it means that you get informations about the patient before seeing him. After the patient answer, I will say: I'm sorry to here that (only if it is the case). I need to ask you some questions about your problem, just to have a good view of it. Is it ok with you miss jones? yes. thank you very much. Then I will procede with the LIQORAAA then before going to PAM HUGS FOSSODA I'll say Now miss Jones, I will ask you some few Qs about your personal health, your personal life and your family. ok? okay! pls don't be embarrassed by my Qs because everything we'll talk about in this conversation will remain absolutely confidential. Then I'll go on. Let's then summarize the history taking. 1. In case of pain: LIQORAAA where O is related to 4 Qs and then PAM HUGS FOSSODA 2. In case of psy complaint OC (P is inside O) FACE SLIPSO PAM HUGS FOSSODA 3. In case of a complaint that is neither psy nor painful OAAA Cs advice ;;;Mr.Jones,....i want to tell u abt a few lifestyle changesU need to make at this point..----Monitor ur bp/sugarregularly, & don't miss u'r drug doses, eat healthy(low carb/low fat diet/low salt diet) & take extracare of ur feet, wear soft footwear & make sure u dontget hurt.As far as smoking and alcohol r concerned, uneed to seriously think abt quitting, it's never too lateto quit, espy if u r a dm'tic/htn'sive.. u need to be aware of their direct illeffects on the heart, brain & lungs..onlong term basis...I know it can be very tough to quit, buti cud introduce u to our peer support groups here, for goodphysical and emotional encouragement....let me know if u rinterested...& feel free to ask me any of ur concerns, my contact numbers r with my nurse...Is there anything u wantto ask me....Shall i see u then...good seeing u mr.jones.....
For the Phone Encounter-
"ON CALL IDIOT"
['On Call'since this is a phone encounter] - please dont think about "idiot" being offnesive - it is just a mnemonic people !O - Onset ?N - Number of Times a Day?C - Consistency ? / Color? / Content ? [Blood, Fat, Mucous ?] + Crying ? Cramps Suggestive ?A - Associated Symptoms [Fever, Runny Nose, Rash, Cough, Ear Discharge, Vomitting, Rash ?]L - Listless baby ? Lethargic, not Sleeping ?L - Liquids not passing ? [i.e. not urinating ?]I - Immunization up to date ?D - Diet Change ? Dehydration signs ? Day Care Center ? Developmental MilestonesI - Infections in family ? Immunicompromised mom ? [HIV ?]O - ORS counseling (Oral Rehydration Solution - see below)T - Travel history recently ?
Tuesday, September 23, 2008
Step 3 Important Links
The links below are to aid students their in STEP 3 STUDY:
1) http://rapidshare.com/files/145667642/UW_S3_QB-_Part_1.zip (USMLEWORLD STEP 3 QBANK- Part 1)
2) http://rapidshare.com/files/145668738/UW_S3_QB-_Part_2.zip (USMLEWORLD STEP 3 QBANK- Part 2)
3) http://rapidshare.com/files/145670044/UW_S3-_CCS.zip (USMLEWORLD STEP 3 CCS)
4) http://rapidshare.com/files/146062590/First_Aid_for_the_USMLE_Step_3.pdf (First Aid for Step 3)
5) http://rapidshare.com/files/146062591/Qbook-step3-PART1__2004_.pdf (Kaplan Qbook for Step 3-Part 1)
6) http://rapidshare.com/files/146062592/Qbook-step3-PART2__2004_.pdf (Kaplan Qbook for Step 3- Part2)
7) http://rapidshare.com/files/146062593/Qbook-step3-PART3__2005_.pdf (Kaplan Qbook for Step 3- Part3)
8) http://rapidshare.com/files/146062594/Vol.1_Internal_Medicine_Part1...__2004_.pdf (Kaplan Step 3Internal Medicine Notes- Part 1)
9) http://rapidshare.com/files/146062595/Vol.1_Internal_Medicine_Part2...__2004_.pdf (Kaplan Step 3 IMNotes- Part 2)
10)http://rapidshare.com/files/146062597/Vol.2_ObGyn__Pediatrics__Surgery__Psych...__2004_.pdf (Kaplan Step 3 OBGYN, SURGERY, PEDIATRICS, PSYCH and ETHICS NOTES)
1) http://rapidshare.com/files/145667642/UW_S3_QB-_Part_1.zip (USMLEWORLD STEP 3 QBANK- Part 1)
2) http://rapidshare.com/files/145668738/UW_S3_QB-_Part_2.zip (USMLEWORLD STEP 3 QBANK- Part 2)
3) http://rapidshare.com/files/145670044/UW_S3-_CCS.zip (USMLEWORLD STEP 3 CCS)
4) http://rapidshare.com/files/146062590/First_Aid_for_the_USMLE_Step_3.pdf (First Aid for Step 3)
5) http://rapidshare.com/files/146062591/Qbook-step3-PART1__2004_.pdf (Kaplan Qbook for Step 3-Part 1)
6) http://rapidshare.com/files/146062592/Qbook-step3-PART2__2004_.pdf (Kaplan Qbook for Step 3- Part2)
7) http://rapidshare.com/files/146062593/Qbook-step3-PART3__2005_.pdf (Kaplan Qbook for Step 3- Part3)
8) http://rapidshare.com/files/146062594/Vol.1_Internal_Medicine_Part1...__2004_.pdf (Kaplan Step 3Internal Medicine Notes- Part 1)
9) http://rapidshare.com/files/146062595/Vol.1_Internal_Medicine_Part2...__2004_.pdf (Kaplan Step 3 IMNotes- Part 2)
10)http://rapidshare.com/files/146062597/Vol.2_ObGyn__Pediatrics__Surgery__Psych...__2004_.pdf (Kaplan Step 3 OBGYN, SURGERY, PEDIATRICS, PSYCH and ETHICS NOTES)
Wednesday, August 20, 2008
STEP 2 CS CASES......MUST READ
LATEST CASES
1. Enuresis
History:
When did it start?
How frequently does he wet the bed? How many times per week?
When does this happen? Only at night or at daytime too?
Have you tried any interventions or drugs before?
Does he drink or eat much late-night?
Do you know the volume of the urine?
What is the color of his urine?
Do you notice any blood in the urine?
Does he have any urgency for urination?
Does he have any other urination problem?
Does he snore?
Does he wake up during the night?
Is there any major stress for him?
How does he behave in school?
Is there any environmental changes related to wetting?
Ask HLHUGS
Is there anybody on your family has the same problem?
Ask PHSAM
Birth history, regular check up, immunization.
Counseling and Closure
Bed-wetting is much more common than most people believe, so there is no reason for you or your child to feel embarrassed or guilty. (Enuresis often runs in families.)
Bedwetting usually goes away on its own. Almost all kids who wet the bed eventually stop. But until it does, it can be embarrassing and uncomfortable for your child. So it's important to provide emotional support and reassurance during this process.
There are something may help: Reassure your child that bedwetting is a normal part of growing up and that it's not going to last forever.
It may comfort your child to hear about other family members who also struggled with it when they were young.
Tell your kid not to drink anything after dinner
Remind your child to go to the bathroom before bedtime.
When your child wakes with wet sheets, have your child help you change the sheets. Explain that this isn't punishment, but it is a part of the process. It may even help your child feel better knowing that he or she helped out.
There could be other possibilities causing bedwetting, like an infection of urinary system. Would you please bring your child here? So I can give him a complete physical exam and order urine test.
DD Work-ups
Monosymptomatic primary nocturnal enuresis Genital exam
Secondary enuresis UA
UTI Urine culture
Constipation First-morning urine specific gravity
Sleep apnea U/S- renal
Functional bladder disorder
2. Picky eater case
History taking:
1. How old is your son?
2. How long has he been a picky eater?
3. Why do you think you son is a picky eater?
4. Is his picky eating habit getting worse or getting better ?
5. Has he ever eaten well when he got really hungry?
6. Does he watch TV before dinner?
7. Does he have any pain in his belly?
8. Does he have any problems with his bowel movement?
9. How many times a week does he have bowel movements?
10. How many children do you have?
11. How much time do parents spend time with him?
12. Who takes care of your child when you are working?
13. What kind of house do you live?
14. Has your family moved recently?
Ask HLHUGS. PHSAM, Birth history, daycare, regular checkup and immunization shots
Well, Mrs. X, thank you very much for answering my question. Is there anything else you would like to tell me about?
Ok, I would like to give you my impression right now. First let me summarize what you have just told me. ???.. Is that right?
Mrs. X, based on the information you told me, I think your son may be experiencing a habitual eating disorder, however, we also need to exclude some other possibilities, such as lead-poisoning or iron-deficiency anemia. For that reason, I would like to examine him personally and order some tests on him before I make any diagnosis or give any advises. Is it convenient for you to bring him here? (Provide help if she can not bring his son to the hospital)
Alright, then, I will see you once you get to the hospital. Take care.
D/D: Work-ups
1. Habitual eating disorder 1. CBC and electrolytes
2. Lead poisoning 2. Serum lead level
3. Iron-deficiency anemia 3. Stool for OVA and parasites
4. Fiber-lack diet
5. Parasitic Infections
3. Hallucination Case
History:
1. Onset ( How long have you been having this problem)
2. Would you tell me more about it? What did you hear/see?
3. Is it always there or does it come and go?
4. Frequency (how often..)
5. Course ( getting worse or better)
6. Do you have any idea what might be causing of it?
7. Is there any warning signs before you hear/see it?
8. Do you feel someone is controlling you?
9. Does it affect your daily activities?
10. How is your relationship with your friends and family members?
Ask FACE SLIPS(Qs for depression), HLHUGS, PHSAM FOSS(my own mnemonics for ROS and History, equal to those in FA and UW)
always ask about social support.
PE: MMSE, Hearing and visional exam, quick neurological exam, Heart and Chest
Counseling:
Need to interview family members and close friends for more information
Quit recreational drugs, it may be one of the causes of the hallucinations he experiences
Provide support groups and recommend staying at hospital if he is confused or not stable.
D/D Work-ups
1. Schizophrenia 1. CT-head
2. Brief psychotic disorder 2. TSH
3. Drug-induced hallucination 3. CBC
4.Thyroid Disease 4. UA and toxicity
5. Electrolyte imbalance
6. Grief reaction/PTSD
1. Enuresis
History:
When did it start?
How frequently does he wet the bed? How many times per week?
When does this happen? Only at night or at daytime too?
Have you tried any interventions or drugs before?
Does he drink or eat much late-night?
Do you know the volume of the urine?
What is the color of his urine?
Do you notice any blood in the urine?
Does he have any urgency for urination?
Does he have any other urination problem?
Does he snore?
Does he wake up during the night?
Is there any major stress for him?
How does he behave in school?
Is there any environmental changes related to wetting?
Ask HLHUGS
Is there anybody on your family has the same problem?
Ask PHSAM
Birth history, regular check up, immunization.
Counseling and Closure
Bed-wetting is much more common than most people believe, so there is no reason for you or your child to feel embarrassed or guilty. (Enuresis often runs in families.)
Bedwetting usually goes away on its own. Almost all kids who wet the bed eventually stop. But until it does, it can be embarrassing and uncomfortable for your child. So it's important to provide emotional support and reassurance during this process.
There are something may help: Reassure your child that bedwetting is a normal part of growing up and that it's not going to last forever.
It may comfort your child to hear about other family members who also struggled with it when they were young.
Tell your kid not to drink anything after dinner
Remind your child to go to the bathroom before bedtime.
When your child wakes with wet sheets, have your child help you change the sheets. Explain that this isn't punishment, but it is a part of the process. It may even help your child feel better knowing that he or she helped out.
There could be other possibilities causing bedwetting, like an infection of urinary system. Would you please bring your child here? So I can give him a complete physical exam and order urine test.
DD Work-ups
Monosymptomatic primary nocturnal enuresis Genital exam
Secondary enuresis UA
UTI Urine culture
Constipation First-morning urine specific gravity
Sleep apnea U/S- renal
Functional bladder disorder
2. Picky eater case
History taking:
1. How old is your son?
2. How long has he been a picky eater?
3. Why do you think you son is a picky eater?
4. Is his picky eating habit getting worse or getting better ?
5. Has he ever eaten well when he got really hungry?
6. Does he watch TV before dinner?
7. Does he have any pain in his belly?
8. Does he have any problems with his bowel movement?
9. How many times a week does he have bowel movements?
10. How many children do you have?
11. How much time do parents spend time with him?
12. Who takes care of your child when you are working?
13. What kind of house do you live?
14. Has your family moved recently?
Ask HLHUGS. PHSAM, Birth history, daycare, regular checkup and immunization shots
Well, Mrs. X, thank you very much for answering my question. Is there anything else you would like to tell me about?
Ok, I would like to give you my impression right now. First let me summarize what you have just told me. ???.. Is that right?
Mrs. X, based on the information you told me, I think your son may be experiencing a habitual eating disorder, however, we also need to exclude some other possibilities, such as lead-poisoning or iron-deficiency anemia. For that reason, I would like to examine him personally and order some tests on him before I make any diagnosis or give any advises. Is it convenient for you to bring him here? (Provide help if she can not bring his son to the hospital)
Alright, then, I will see you once you get to the hospital. Take care.
D/D: Work-ups
1. Habitual eating disorder 1. CBC and electrolytes
2. Lead poisoning 2. Serum lead level
3. Iron-deficiency anemia 3. Stool for OVA and parasites
4. Fiber-lack diet
5. Parasitic Infections
3. Hallucination Case
History:
1. Onset ( How long have you been having this problem)
2. Would you tell me more about it? What did you hear/see?
3. Is it always there or does it come and go?
4. Frequency (how often..)
5. Course ( getting worse or better)
6. Do you have any idea what might be causing of it?
7. Is there any warning signs before you hear/see it?
8. Do you feel someone is controlling you?
9. Does it affect your daily activities?
10. How is your relationship with your friends and family members?
Ask FACE SLIPS(Qs for depression), HLHUGS, PHSAM FOSS(my own mnemonics for ROS and History, equal to those in FA and UW)
always ask about social support.
PE: MMSE, Hearing and visional exam, quick neurological exam, Heart and Chest
Counseling:
Need to interview family members and close friends for more information
Quit recreational drugs, it may be one of the causes of the hallucinations he experiences
Provide support groups and recommend staying at hospital if he is confused or not stable.
D/D Work-ups
1. Schizophrenia 1. CT-head
2. Brief psychotic disorder 2. TSH
3. Drug-induced hallucination 3. CBC
4.Thyroid Disease 4. UA and toxicity
5. Electrolyte imbalance
6. Grief reaction/PTSD
Sunday, August 17, 2008
2008 - Latest IMG friendly Hot list
NEW ( 2009) IMG Friendly Hospitals
Alabama:
Stringfellow Hospital, Anniston, Alabama (GC)
California:
Alameda County Hospital, Highland, CA
Kern Medical Center, CA
St Mary's Hospital, San Francisco, CA
University of California, San Francisco, CA
USC, Los Angeles, CA
Connecticut:
Bridgeport Hospital, Bridgeport, CT (H1,J1,GC)
Danbury Hospital, Danbury, CT (H1,J1,GC)
Hospital of St Raphael, CT (H1,J1,GC)
Norwalk Hospital, Norwalk, CT (H1,J1,GC)
St Vincent's Medical Center, Bridgeport, CT (H1,J1,GC)
University of Connecticut, Farmington, CT (J1,GC)
District of Columbia (Washington, DC):
District of Columbia General Hospital, Washington, DC
Howard University Hospital, Washington, DC (H1,J1,GC)
Providence Hospital, Washington, DC (H1,J1,GC)
Illinois:
Cook County Hospital, Chicago, IL (H1,J1,GC)
Chicago Medical School/FUHS, Chicago, IL
Illinois Masonic Medical Center, Chicago, IL
Jackson Park Hospital, Chicago, IL(GC)
Mercy Hospital, Chicago, IL (J1,GC)
Ravenswood Hospital, Chicago, IL (J1,GC)
Rush Copley Medical Center, Aurora, IL (J1,GC)
Rush Presbyterian Hospital, Chicago, IL (J1,GC)
Rush Westlake, Melrose Park, IL (J1,GC)
St Francis hospital, Evanston, IL (H1,J1,GC)
University of Illinois at Urbana Champaign, IL (GC)
University of Illinois at Chicago, Chicago, IL (J1,GC)
University of Illinois/Michael Reese Hospital, Chicago, IL (J1,GC)
University of Illinois at Peoria, IL
Maryland:
Franklin Square Hospital, Baltimore, MD
Good Samaritan Hospital, Baltimore, MD
Harbor Hospital, Baltimore, MD (H1,J1,GC)
Maryland General Hospital, Baltimore, MD (H1,J1,GC)
Prince George's Hospital, Cheverly, MD (GC)
St Agnes Health Care, Baltimore, MD (J1,GC)
Michigan:
Henry Ford Hospital, Detroit, MI (J1,GC)
Hurley Med Center/MSU , Flint, MI (J1,GC)
McLaren Regional Medical Center, Flint, MI
Mid-Michigan Medical Center, Midland, MI
Providence Hospital, MI (J1,GC)
Saginaw Cooperative Hospitals, Saginaw, MI
St Joseph's Mercy Hospital, Pontiac, MI (H1,J1,GC)
St John Hospital, Detroit, MI (J1,GC)
Wayne State University, Detroit, MI (J1,GC)
William Beaumont Hospital, Royal Oak, MI (J1)
Missouri:
St Mary's Hospital, St. Louis, MO
St Lukes Hospital, St. Louis, MO
New Jersey:
Atlantic City Medical Center, Atlantic City, NJ (J1,GC)
Englewood Hospital/Mount Sinai, Englewood, NJ
Jersey City Medical Center/Mount Sinai, Jersey City,
NJ Jersey Shore Medical Center, Neptune, NJ (GC)
Monmouth Med Center, Long Branch, NJ (J1,GC)
Mountainside Hospital, Montclair, NJ
Muhlenberg Hospital , Plainfield, NJ (J1,GC)
Overlook Hospital, Summit, NJ (GC)
Raritan Bay Med Ctr., Perth Amboy, NJ
St Barnabas Medical Center, Livingston, NJ (GC)
St Joseph's Medical Center, Paterson, NJ (GC)
St Francis Med Ctr, Trenton, NJ
UMDNJ, Camden, NJ (J1,GC)
UMDNJ, Newark, NJ (GC)
UMDNJ, New Brunswick, NJ (J1,GC)
UMDNJ, Piscataway, NJ
New York:
Albert Einstein/ Jacobi Med Ctr., Bronx, NY (H1,J1,GC)
Bronx Lebanon Hospital, Bronx,
NY Brooklyn Hospital, Brooklyn, NY (GC)
Brookdale University Hospital, Brooklyn, NY
Cabrini Hospital, New York, NY
Catholic Med Center., Jamaica, NY (GC)
Lincoln Medical and Mental Health Center, Bronx,
NY Maimonides Hospital, Brooklyn, NY (H1,J1,GC)
Metropolitan Hospital/NY Medical College, NY (J1,GC)
New York Hospital and Medical Center of Queens/Cornell U., Flushing, NY
New York Methodist Hospital/ Wyckoff Heights, Brooklyn, NY (H1,J1,GC)
NYU VA Medical Center, NY New York
Flushing Hospital, Flushing, NY
Sound Shore Hospital/NY Medical College, New Rochelle, NY
Saint Barnabas Hospital, Bronx, NY (GC, J1, H1)
St Lukes Hospital, New York, NY (J1,GC)
St Joseph's Hospital, NY
St John's Episcopal South Shore Hospital, Fair Rockaway, NY (H1,J1,GC
SUNY at Brooklyn, NY (H1,J1,GC)
SUNY at Buffalo, Buffalo, NY (H1,J1,GC)
SUNY at Syracuse, NY (J1,GC)
Winthrop University Hospital, Mineola, NY (J1,GC)
Woodhull Medical Center, Brooklyn, NY (J1,GC)
Nevada:
University of Nevada, Reno, NV
University of Nevada, Las Vegas, NV
Ohio:
Fairview Hospital, Cleveland, OH (J1,GC)
Good Samaritan Hospital, Cincinnati, OH
Jewish Hospital of Cincinnati, Cincinnati, OH
Meridia Huron Hospital, East Cleveland, OH (H1,J1,GC)
Mount Sinai Hospital, Cleveland, OH
Pennsylvania:
Abington Memorial Hospital, Abington, PA (H1,J1,GC)
Allegheny General Hospital, Pittsburgh, PA (J1,GC)
Easton Hospital, Easton, PA Frankford Hospital, Philadelphia PA (H1,J1,GC)
Frankford Hospital, Philadelphia, PA
Guthrie Healthcare, Sayre, PA
Lehigh Valley Hospital, Allentown, PA
Mercy Hospital, Pittsburgh, PA MCP
Hahnemann University Hospital, Philadelphia, PA
Pinnacle Health/ Polyclinic Hospital, Harrisburg, PA
UPMC Health System/ Shadyside Hospital, PA
Rhode Island:
Miriam Hospital of Brown University, Providence, RI (J1,GC)
Roger Williams Hospital, Providence, RI
Texas:
Texas Tech University, Amarillo, TX
Texas Tech University, Odessa, TX
Texas Tech University, El Paso, TX (J1,GC)
Virginia:
University of Virginia, Roanoke Salem, VA (J1,GC)
West Virginia:
West Virginia University Hospital, WV (J1,GC)
Wisconsin:
Sinai Samaritan Medical Center, Milwaukee.
Alabama:
Stringfellow Hospital, Anniston, Alabama (GC)
California:
Alameda County Hospital, Highland, CA
Kern Medical Center, CA
St Mary's Hospital, San Francisco, CA
University of California, San Francisco, CA
USC, Los Angeles, CA
Connecticut:
Bridgeport Hospital, Bridgeport, CT (H1,J1,GC)
Danbury Hospital, Danbury, CT (H1,J1,GC)
Hospital of St Raphael, CT (H1,J1,GC)
Norwalk Hospital, Norwalk, CT (H1,J1,GC)
St Vincent's Medical Center, Bridgeport, CT (H1,J1,GC)
University of Connecticut, Farmington, CT (J1,GC)
District of Columbia (Washington, DC):
District of Columbia General Hospital, Washington, DC
Howard University Hospital, Washington, DC (H1,J1,GC)
Providence Hospital, Washington, DC (H1,J1,GC)
Illinois:
Cook County Hospital, Chicago, IL (H1,J1,GC)
Chicago Medical School/FUHS, Chicago, IL
Illinois Masonic Medical Center, Chicago, IL
Jackson Park Hospital, Chicago, IL(GC)
Mercy Hospital, Chicago, IL (J1,GC)
Ravenswood Hospital, Chicago, IL (J1,GC)
Rush Copley Medical Center, Aurora, IL (J1,GC)
Rush Presbyterian Hospital, Chicago, IL (J1,GC)
Rush Westlake, Melrose Park, IL (J1,GC)
St Francis hospital, Evanston, IL (H1,J1,GC)
University of Illinois at Urbana Champaign, IL (GC)
University of Illinois at Chicago, Chicago, IL (J1,GC)
University of Illinois/Michael Reese Hospital, Chicago, IL (J1,GC)
University of Illinois at Peoria, IL
Maryland:
Franklin Square Hospital, Baltimore, MD
Good Samaritan Hospital, Baltimore, MD
Harbor Hospital, Baltimore, MD (H1,J1,GC)
Maryland General Hospital, Baltimore, MD (H1,J1,GC)
Prince George's Hospital, Cheverly, MD (GC)
St Agnes Health Care, Baltimore, MD (J1,GC)
Michigan:
Henry Ford Hospital, Detroit, MI (J1,GC)
Hurley Med Center/MSU , Flint, MI (J1,GC)
McLaren Regional Medical Center, Flint, MI
Mid-Michigan Medical Center, Midland, MI
Providence Hospital, MI (J1,GC)
Saginaw Cooperative Hospitals, Saginaw, MI
St Joseph's Mercy Hospital, Pontiac, MI (H1,J1,GC)
St John Hospital, Detroit, MI (J1,GC)
Wayne State University, Detroit, MI (J1,GC)
William Beaumont Hospital, Royal Oak, MI (J1)
Missouri:
St Mary's Hospital, St. Louis, MO
St Lukes Hospital, St. Louis, MO
New Jersey:
Atlantic City Medical Center, Atlantic City, NJ (J1,GC)
Englewood Hospital/Mount Sinai, Englewood, NJ
Jersey City Medical Center/Mount Sinai, Jersey City,
NJ Jersey Shore Medical Center, Neptune, NJ (GC)
Monmouth Med Center, Long Branch, NJ (J1,GC)
Mountainside Hospital, Montclair, NJ
Muhlenberg Hospital , Plainfield, NJ (J1,GC)
Overlook Hospital, Summit, NJ (GC)
Raritan Bay Med Ctr., Perth Amboy, NJ
St Barnabas Medical Center, Livingston, NJ (GC)
St Joseph's Medical Center, Paterson, NJ (GC)
St Francis Med Ctr, Trenton, NJ
UMDNJ, Camden, NJ (J1,GC)
UMDNJ, Newark, NJ (GC)
UMDNJ, New Brunswick, NJ (J1,GC)
UMDNJ, Piscataway, NJ
New York:
Albert Einstein/ Jacobi Med Ctr., Bronx, NY (H1,J1,GC)
Bronx Lebanon Hospital, Bronx,
NY Brooklyn Hospital, Brooklyn, NY (GC)
Brookdale University Hospital, Brooklyn, NY
Cabrini Hospital, New York, NY
Catholic Med Center., Jamaica, NY (GC)
Lincoln Medical and Mental Health Center, Bronx,
NY Maimonides Hospital, Brooklyn, NY (H1,J1,GC)
Metropolitan Hospital/NY Medical College, NY (J1,GC)
New York Hospital and Medical Center of Queens/Cornell U., Flushing, NY
New York Methodist Hospital/ Wyckoff Heights, Brooklyn, NY (H1,J1,GC)
NYU VA Medical Center, NY New York
Flushing Hospital, Flushing, NY
Sound Shore Hospital/NY Medical College, New Rochelle, NY
Saint Barnabas Hospital, Bronx, NY (GC, J1, H1)
St Lukes Hospital, New York, NY (J1,GC)
St Joseph's Hospital, NY
St John's Episcopal South Shore Hospital, Fair Rockaway, NY (H1,J1,GC
SUNY at Brooklyn, NY (H1,J1,GC)
SUNY at Buffalo, Buffalo, NY (H1,J1,GC)
SUNY at Syracuse, NY (J1,GC)
Winthrop University Hospital, Mineola, NY (J1,GC)
Woodhull Medical Center, Brooklyn, NY (J1,GC)
Nevada:
University of Nevada, Reno, NV
University of Nevada, Las Vegas, NV
Ohio:
Fairview Hospital, Cleveland, OH (J1,GC)
Good Samaritan Hospital, Cincinnati, OH
Jewish Hospital of Cincinnati, Cincinnati, OH
Meridia Huron Hospital, East Cleveland, OH (H1,J1,GC)
Mount Sinai Hospital, Cleveland, OH
Pennsylvania:
Abington Memorial Hospital, Abington, PA (H1,J1,GC)
Allegheny General Hospital, Pittsburgh, PA (J1,GC)
Easton Hospital, Easton, PA Frankford Hospital, Philadelphia PA (H1,J1,GC)
Frankford Hospital, Philadelphia, PA
Guthrie Healthcare, Sayre, PA
Lehigh Valley Hospital, Allentown, PA
Mercy Hospital, Pittsburgh, PA MCP
Hahnemann University Hospital, Philadelphia, PA
Pinnacle Health/ Polyclinic Hospital, Harrisburg, PA
UPMC Health System/ Shadyside Hospital, PA
Rhode Island:
Miriam Hospital of Brown University, Providence, RI (J1,GC)
Roger Williams Hospital, Providence, RI
Texas:
Texas Tech University, Amarillo, TX
Texas Tech University, Odessa, TX
Texas Tech University, El Paso, TX (J1,GC)
Virginia:
University of Virginia, Roanoke Salem, VA (J1,GC)
West Virginia:
West Virginia University Hospital, WV (J1,GC)
Wisconsin:
Sinai Samaritan Medical Center, Milwaukee.
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