USMLE Step 2 CS Deneyimi - Hazırlayan "cheesy"

2007 yılına ait bir CS tecrübesi:
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Ben son iki hafta kalana kadar cok konsantre olamadim. Son iki hafta gunde 4-5 saat calistim bence yeterli ama benim ingilizcem cok iyidir ona gore biraz daha uzun olabilir kisiye gore. Kaplan ve First aid kullandim. Son derece iyi kaynaklardi bircok yerde usmleworldunde cok iyi oldugunu duydum. Kurslari ise bilmiyorum gitmedigim icin ama sahsi kanaatimce cok sart, olmazsa olmaz degiller hele kaplan gibi 2500 dolar vermeye hic degmezler, az parami ya!!!

Simdi, ilk genel seylerden bahsetmiycem, el yikamak, kapi calmak gibi zaten her kitapta yaziyor ve en temel sart seyler.

Ben hikaye ile baslayim. Ben sorulacak sorulari standart hale getirdim ve birazda calisirken kendi sistemini gelistiriyorsun, bu herkeste farkli olacaktir. Benim taktigim bu listeyi sekillendirdikten sonra her vaka orneginde sikayetine bakip ona gore kagida sorulmasi gereken sorulari yazip sonra hikayenin geri kalanina kitapta goz atip nereye gittigini anlayip ek sorularimi yazdim kagida. Sonra onlarin verdigi checkliste bakip kontrol ettim atladigim birsey varmi diye. Sonra FM’ye gectim onuda standard yaptim tabi her hastaya gore modifiye edilecek sekilde. FM’de yapilmasi gerekenleri ve yazilmasi gerekenleri kagida doktum ve onlarida kontrol ettim. En sonunda ayirici tanilarimi yazip tetkikleri istedim.

HIKAYE:

LIQOR AAA: location, intensity, quantitiy, onset, radiation, alleviating, aggravating, associated
When did it start
Where did it start
What kind of a pain is it (sharp-dull, burning-aching-cramping-pressure like)
How intese is it on a scale from 0 to 10
Sudden-gradual
Constant-intermittent
Progression (worse-better)
Previous episodes
Allev-aggr: food, position, exertion, time of day, breating, medication)
Does it move anywhere
Associated: iste bu kisimda ben biraz taktik farki yaptim ve bence cok ise yaradi hikayede birsey atlamamak icin burda genel sistem sorgulamasi yaptim daha sonra yapmak yerine ve tabiki oncelikle sikayetle alakali olanlari sordum. Sistem sorgulamasinda bazi maddeler genel her hastaya sorulurken karin agrisiyla gelene norolojik sorular sormadim, zaten soylemeye gerek yok. Listem:

1- fever-chills, night sweats, weight-appetite change, sleep problems
2- chest pain, palpitations, sweating
3- shortness of breath, cough
4- bowel habit change, constipation-diarrhea, blood in stool, nausea-vomiting
5- difficulty urinating, frequency, nocturia(how many times do you wake up at night to urinate), burning on urination
6- dizziness, loss of consciousness, numbness-tingling, weakness, headaches, loss of bowel-bladder control, head trauma, shaking movements, seizures, visual changes, speech difficulty, gait problems
7- joint pain, skin complaints

Sira geldi hikayenin geri kalanina, liste gozunuzu korkutmasin, bir zaten o heycanla ve o ortamda unutuluyor bircok sey sadece yarisini sorabiliyorsunuz bide hastaya gore zaten bircok madde elimine edilir. Hastalarda cok kisa ve hizli evet hayirli cevaplar veriyor panik olup sonra ne sorcagini unutuyo insan.

PMH: related diseases, other diseases (DM, HTN, CAD)
Allergey:
Medications: over the counter, prescribed

Hospitalization-trauma-surgery

Family History: related or other significant diseases?

OB&GYN: LMP(regular? Amount? Duration?), abortions?, children #,

xxxxual: active?/# of partners/male-female-both/condoms/STD history

Social: Tobacco use-Alcohol use-Drugs-occupation, sick contacts, travel history, diet, exercising habits,
Bu kisimda unutmadan once bi sorun varsa hemen consulting yapilmali benden soylemesi. Alkol kullanimi haftada 2’den fazlaysa CAGE sorularina geciniz:
Have you tried to Cut down your drinking?
Are you Annoyed when others comment on your drinking?
Have you felt Guilty because of your drinking?
Are you and Eye opener/ do you drink the first thing in the morning

Bide ozel durumlar icin hikaye listem var


OB:
Have you ever been pregnant?/how many times?
How many children do you have?
Any miscarriages abortions?

GYN:
First menstural period
Last menstural period
Frequency/duration/regularity/how heavy are they(#of pads or tampons)
Do you get cramps
Change in cycles
Spotting/breakthrough bleeding
Pain during intercourse
Vaginal discharge(blood, amount, color, odor, consistency, constant-intermittent)
Urinary problems-bladder control
Pap smear before?

MENOPAUSE:
Hot flushes
Mood changes
Sleep disturbances
Urinary problems
Vaginal dryness

MENSTURAL IRREGULARITY:
LMP
Regular before?
xxxxually active/contraception?
Exercise/stress level/nutritional level (hypothalamic)
Discharge from breast/headaches/double vision (prolactinoma)
Cold-heat intolerence/diarrhea-constipation/weight gain-loss/hair falling/skin changes/palpitations (thyroid scanning)
Excessive hair/obesity/infertility (PCOS, CAH, testicular feminization=PRL, LH-FSH, testosteron, DHEA istenir)
Medication effect??
Breast tenderness, nausea, urinary frequency, LMP-contraception method (pregnancy)
D&C/tbc history: Asherman’s
Hypovolemic shock: Sheehan’s

ABUSE:

SAFE GUARD:
Safety
Afraid??
Family&friends aware?
Emergency plan?
Guns at home?
Alcohol?
Relationships with partner?
Drugs/depression


PSYCHIATRIC

1- How do you feel?
Since when?
Constant? Daytime-night effect?
Is there a specific reason/any recent financial, emotional problems

2- SIG E CAPS
sleep
interest
guilt/worthlessness
energy level/can you make it to work?
Concentration/memory
Appetite/weight loss
Psychomotor/ daily routine effected?/ functions, activities changed?
Suicide/homocide intentions?

3- plans for future/ feelings of hopelessness

4- hallucination/delusion/paranoia
do you hear or see things that others don’t
do you have thoughts that others find unrealistic
do you feel as if other people are trying to harm or control you

5- hows you relationship with friends/family/work

6- Thyroid questioning!!

7- FH: anyone having similar experiences in the family

8- SH: ETOH/drugs!!! (always consider intoxication)


PEDIATRIC

HPI (history of present illness)
PMH
any serious illness, any previous episodes
medication
allergy
hospital, trauma, surgery

FH
any serious illness in family
sick contacts
smokers at home
attending day care/

Prenatal:
Routine check ups, USG
Complications (illness, infection, discharge…)
Smoke-drink-drugs

Natal:
? weeks birth
way of birth (vaginal, forceps assisted, C&S)
complications, hospital stay

Postnatal:
Development= when did the child sit up/crawl/walk/speek
Weight gain (appropriate to charts??)
Feeding/appetite: iron supplements with formula?/breast feeding/pediatric multivitamins/solid foods
Immunizations up to date??
Last routine check up

Fever questioning in pediatric patients:
Vomiting?
Ear-nose discharge?
Cough, wheezing, shortness of breath
Diarrhea
Irratability, sleep increase (lethargic), shaking movements (seizures)
Ill contacts (family, daycare)
Rash


MINI MENTAL STATUS EXAM

Orientation:
What’s the date
Where are we
What’s your president’s name

Registration:
Pencil, door, clock / please repeat (immediate memory)
say the patient that, you’ll ask you these words again later on

Attention and Calculation:
-serial 7’s: please reduce 7 from 100 and keep reducing until I tell you to stop, 100, 93, 86….
-Spell “world” backwards please: d-l-r-o-w

Recall:
Do you remember the 3 objects (short term memory)
Ask for what the patient had for breakfast (recent memory)
Ask anniversary or mother’s birthdate (remote memory)

Language tests:
Name: pencil, watch (show the object and ask the patient to name it)
Repeat: “no ifs, ands, or buts”
3 step command: take the paper with your right hand fold it into 2 and place it on the floor

Read and obey:
-close your eyes
-write a sentence
-copy the design (make them copy a triangle in a square)

Questioning for dementia patients other than MMSE:
DEATH SHAFT
Consider thyroid problems
B12/folate def.
Underlying medical condition (delirium)
Risk factors (HTN, DM, CAD, high Chol..)=multienfarkt demans
Masked depression
Drug intox.


FUNCTIONAL STATUS EXAM:

DEATH SHAFT:
Dressing
Eating
Ambulating
Toiletting (+bowel and bladder control)
Hygeine (can you bathe yourself)
Shopping
House-keeping
Accounting
Food preparation
Transportation
+trouble taking medications on your own?