Advice4u
Wednesday, August 20, 2008
STEP 2 CS CASES......MUST READ
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
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.
Friday, August 15, 2008
FIRST AID KITS
revise the materials. First aid is available for all the steps.
Here are few links for the first aid to usmle-
Thursday, August 14, 2008
100 BUZZ WORDS FOR STEP 2 CK
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Sunday, August 10, 2008
USMLE Step 3 Guide
What is USMLE Step 3 ?
Step 3 is designed to see whether student/ resident can apply the medical knowledge in managing the patients after making a diagnosis. It goes a step further from Step 2 where emphasis is mainly on the diagnosis of the medical condition. Here examinee is expected to make a diagnosis and properly manage the patient too. USMLE Step 3 is designed to assess whether a medical school graduate can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine. Graduates of US medical schools typically take this exam at the end of the first year of residency. Foreign medical graduates can take Step 3 before starting residency in about ten U.S. states, as this exam helps to get the H1 visa for the residency.
Step 3 is a two-day examination. Each day of testing must be completed within eight hours. The first day of testing includes 336 multiple-choice items divided into blocks, each consisting of 48 items. Examinees must complete each block within sixty minutes.
The second day of testing includes 144 multiple-choice items, divided into blocks of 36 items. Examinees are required to complete each block within forty-five minutes. Approximately 3 hours are allowed for these multiple-choice item blocks. Also on the second day are nine Clinical Case Simulations, where the examinees are required to 'manage' patients in real-time case simulations. Examinees enter orders for medications and/or investigations into the simulation software, and the condition of the patient changes accordingly. Each case must be managed in a maximum of 25 minutes of actual time.
About USMLE
United States Medical Licensing Examination
The United States Medical Licensing Examination is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB and the National Board of Medical Examiners (NBME). Medical doctors are required to pass before being permitted to practice medicine in the United States of America. It consists of three steps; all three must be passed before a physician is eligible to apply for a license to practice medicine.
The USMLE steps are:
USMLE Step 2-CK
USMLE Step 2-CS
USMLE Step 3
STEP 2 CS Guide
What is USMLE Step 2 ?
This exam is to see whether the medical student can use the medical knowledge to diagnose and identify various problems encountered in medicine. USMLE Step 2 is designed to assess whether medical school students or graduates can apply medical knowledge, skills and understanding of clinical science essential for provision of patient care under supervision. US medical students typically take Step 2 during the fourth year of medical school. Step 2 is further divided into two separate exams.
1. USMLE Step 2-CK
2. USMLE Step 2 CS
USMLE Step 2-CS
USMLE Step 2-CS is designed to assess clinical skills through simulated patient interactions, in which the examinee interacts with standardized patients portrayed by actors. Each examinee faces 12 Standardized Patients (SPs) and has 15 minutes to complete history taking and clinical examination for each patient, and then 10 more minutes to write a patient note describing the findings, initial differential diagnosis list and a list of initial tests. Administration of the Step 2-CS began in 2004.
The examination is offered in five cities across the country:
Philadelphia (PA)
Chicago (IL)
Atlanta (GA)
Houston (TX)
Los Angeles (CA)
The result of the exam takes about 2 months and it is always better to plan it early enough to get the desired date for the exam as most of the exam centers are full and dont have dates available for next 3-4 months. Before 2004, a similar exam, the Clinical Skills Assessment (CSA) was used to assess the clinical skills of foreign medical graduates.
Step 2 CK Guide
USMLE Step 2
This exam is top see whether the medical student can use the medical knowledge to diagnose and identify various problems encountered in medicine. USMLE Step 2 is designed to assess whether medical school students or graduates can apply medical knowledge, skills and understanding of clinical science essential for provision of patient care under supervision. US medical students typically take Step 2 during the fourth year of medical school. Step 2 is further divided into two separate exams.
1. USMLE Step 2-CK
2. USMLE Step 2 CS
USMLE Step 2-CK
USMLE step 2 CK can be taken before the Step 1 also. USMLE Step 2-CK is designed to assess clinical knowledge through a traditional, multiple-choice examination. It is a 9 hour exam consisting of 8 blocks of 46 or 47 questions each. The subjects included in this exam are clinical sciences like Internal Medicine, Surgery, Pediatrics, Psychiatry and Obstetrics & Gynecology.
Saturday, August 9, 2008
Step 3 CCS - Golden Advice
LOGICAL APPROACH TO ANY CCS CASE :
First ------ Take a deep breath and select 'Start Case' button to begin.
You will see the case introduction.
Wait!
Note on the erasable board:
1. Setting
2. Age of the patient
3. Race of the Patient
4. Sex of the patient
Then click 'OK' and you will see the initial vital signs.
Wait!
Note on the erasable board: Stable or unstable?
Then click 'OK' and you will see the initial history.
Wait!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Think !!!!!!!!!!!!!!!!!!!!!!
and write on the erasable board: Differential Diagnosis : Allergies Habits – smoking , alcohol , drugs , etc. Anything worrisome?
Then ask: Is the patient stable or is it an emergency? A clue to this would be in the history - for emergency cases, you will see only the basic history of present illness and not the detailed history (social, past, etc). All other history will be 'unobtainable'.
If unstable, do a EMERGENT physical exam. No emergency case should get a full physical exam - it's an emergency!! For the EMERGENT physical, choose the 'general appearance' and the relevant system. If needed, add one or two relevant systems.
After you note the results of the EMERGENT physical, stabilize patient immediately: Airway – Intubation? Breathing – Oxygen mask? Chest tube? Circulation – IV fluids? Dopamine? Drugs – Naloxone? Dextrose? Thiamine? IV Access?
Then ask: Does the patient's condition correlate to the setting? Emergency or unstable patient in office needs to go to the ER immediately!! Change location if necessary. After the patient is stable and in the right setting, proceed to 'Interval/follow-up history' and a more detailed RELEVANT physical exam.
BUT If the patient is already a STABLE case in the right setting, proceed straight to the RELEVANT physical exam. Then ask: Is the case limited to one particular system? Like Asthma or MI? Choose the particular system and a few related systems, based on the most likely diagnosis. Is the case not limited to one particular system?
Choose a COMPLETE physical exam. This option is available on the top of the physical exam choices. Examples of such cases include Case for Annual Physical Exam, Child Abuse, Depression, Asymptomatic Hypertensive for Office Management, etc. Note the significant findings on the physical exam and go back to your erasable paper and revise your Differential Diagnosis. Strike out those which are less likely and add those are more likely.
Then -- keeping the Differential Diagnosis in mind, consider the labs to be done. When considering labs use this mnemonic:
I B U O P
I – Imaging –> X-Rays, CT, USG, MRI, Echo, Scopy, VQ Scan, etc.
B – Blood –> CBC, Basic Metabolic Panel, Lipid Profile, LFT, Smears, Cultures, etc.
U – Urine –> Urinalysis, Toxicology Screen, Ketones, etc.
O – Others –> Other tests which do not fall under IBU, like EKG, PEFR for Asthma, Pulse oximetry, Biopsies, etc.
P – Pregnancy test –> For any female of reproductive age presenting with abdominal or pelvic symptoms, or trauma.
When ordering labs, consider:
Is this test time-effective/time-consuming? Choose time-effective.
Is this test initial screening/confirmatory? Choose initial screening.
Is this test cheap/expensive? Choose cheap.
Is this test non-invasive/invasive? Choose non-invasive.
Then ask:
Will this test tell me anything useful? Tests like CBC, ESR, Chem 7, etc might satisfy the above criteria but will not tell you anything useful.
Are there any specific tests for this condition? Examples are Cardiac Enzymes for MI, Sweat Chloride test for Cystic Fibrosis, etc.
Are the tests in the right order? Example – Pulse Oximetry before ABG, CT before Spinal Tap, etc. Order the labs using the Order button.
Then advance clock to the 'Next Available Result'. Understand the results.
Ask: Is the diagnosis clear or do I need any confirmatory tests? If diagnosis is clear, start treatment. If confirmation is needed, order confirmatory tests and then start treatment. Treatment :
Determine if the patient is in the right setting. If patient is in office and needs to be admitted, change location to ward. If patient is in ward and is in a serious condition, change location to ICU. If case is admitted, order: IV access (unless IV drugs are not indicated) – Type 'IV Access'. Vital Signs – Type Vitals and click on 'Every 1,2, 4 or 6 hours' depending on the condition of patient. Activity – Type 'Bed Rest' and choose 'Complete bed rest' or 'Bed rest with bathroom privileges' or type restrain and choose 'Restrain patient in bed'. Diet – Normal, liquid, NPO, 2 gram Sodium, ADA, etc. Order 'Diet' and you will see the list of options, choose which is the best for this case. Tubes – NG Tube? Foley's catheter? Fluids – Saline, Ringer, etc. Type 'Fluids' and choose which is the best for this case. Urine output – Type 'Urine Output' and choose frequency. There is no option for Input/output chart. Medications : Stop! Check for allergies on erasable board! Order standard drugs for this case. Decide IV or Oral. Decide bolus or continuous. Decide frequency. Labs : Additional labs to confirm diagnosis? Labs to monitor? Cardiac Monitor? Pulse Oximetry? Consults : Order consults if necessary. GI, Ophthalmology, Psychiatry, Genetics, Social worker, etc.
Then move clock!
Depending on severity of case, move by 30 minutes/1 hour/2 hours/3 hours/6 hours/12 hours/1 day/2 days/1 week.
Do Interval/follow-up history. Understand the results of the labs. Then ask: Has the patient's condition changed significantly? If yes, change locations.
If the condition has improved, move the patient to the next location in the order ER --> ICU --> Ward --> Office/Home.
If the condition has worsened, move the patient to the next location in the order Home/Office --> Ward/ER or Ward/ER --> ICU.
If you are changing location from inpatient (ER/ICU/Ward) to outpatient (Office/Home): Stop unnecessary medications and change IV medications to oral. Discontinue IV fluids. Remove tubes. Remove IV access.
Schedule followup visit in 1 or 2 weeks as relevant. Patient education or counseling or diet specific and vital to this case.
Type 'patient education' and 'counsel' and see if anything is relevant to this specific case.
Type 'Diet' and see if anything is relevant to this specific case. By this time, the 5 minute screen will appear!
Then type 'counsel' and choose the relevant things. You can choose multiple things at a time. See your erasable board for any worrisome habits like alcohol or smoking!
Type 'patient education' and choose the relevant things. You can choose multiple things at a time
Wednesday, August 6, 2008
STEP 1 Guide
USMLE Step 1 is the first step towards residency in US. It assesses whether medical school students or graduates understand and can apply important concepts of the sciences basic to the practice of medicine. It covers the following subjects: Anatomy, Physiology, Biochemistry, Genetics, Behavioral Medicine, Statistics, Microbiology (including Parasitology), Ethics, Pathology, Pharmacology, Histology, Immunology, Molecular Biology, and Epidemiology. US medical students usually take Step 1 at the end of the second year of medical school. It is an eight-hour computer-based exam consisting of 350 multiple-choice questions (MCQs) divided into seven blocks each consisting of 50 questions. Each block must be finished within an hour. The remaining hour is break time. An optional tutorial about how to use the computer program of the exam is offered at the beginning of the exam and takes 15 minutes. This time is deducted from the hour of allotted break time.
The scores are reported with a three digit score and a two digit score. As of January 1, 2007, the passing score has been raised to 185 from a previous score of 182. The average score is approximately 215. If the student passes the exam, he or she may not repeat the exam to achieve a higher score. But if a student fails the exam, the exam can be taken multiple times.
The scores are valid for 7 years after taking the exam. While not recommended by the creators of the USMLE, the Step 1 score is frequently used in medical residency applications as a measure of a candidate's likelihood to succeed in that particular residency (and on that specialty's board exams). More competitive residency programs usually accept applications with higher Step 1 scores. The Step 1 exam is arguably the hardest and most important examination a medical student will take during his/her career .
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