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- May 15, 2017
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I know the CS exam is a source of great anxiety and dread for many medical students. Having just been through the process and thankfully passing with a good report I figured I could give my impressions on what is and isn't so important to passing this exam. I am an American born and raised who studies abroad. Took my exam recently and just got my score back a few days ago, pleased to see I did well. I usually was out of each encounter with about 2-3 minutes left. Here's what I did as I proceeded throughout each case (step by step):
-read door info carefully - write down important info only
-knock on door and then enter
-make eye contact. say 'hello ms. jones?. I'm dr. smith. I'll be taking care of you today'
-shake hands
-ask if its ok to sit and to take some notes - then sit properly
-make good eye contact - its ok to look down to write notes, but do not bury your face in your notes, look down to write, then look back up to make more eye contact- and repeat as necessary
-ask - 'so please tell me, what brings you in today' - then say something to demonstrate empathy like 'i'm sorry to hear about that' or 'that must be difficult' or 'let's try to figure out whats going on and get you feeling better'
-i never asked - what concerns you the most, or how has this affected you - im not saying its bad to ask this, just that i did not ask these things and still did very well in CIS
-ask about the hpi - I like to use the OPQRST acronym (onset, provocation, palliation, quality, radiation, severity, timing) also ask about relevant associated symptoms (nausea/vomitting/diarrhea for abdo pain - confusion/weakness/vomitting/fever for headache etc etc)
-do a brief summary after the hpi to let the patient know that you have been paying attention
-use a transition statement 'ok ms jones, at this point i would like to get to know more about your overall health'
-ask the PAMHUGSFOSS (preface the personal social questions by saying 'now i would like to ask you some personal questions. is that ok? do you smoke, drink, drugs, sex, protection etc etc)
-at this point about 8 minutes should have elapsed
-say 'ok ms. jones, thank you for sharing that information with me. at this point i would like to do a quick physical exam. is that ok?'
-use tiny tiny amount of hand sanitizer
-always narrate your entire physical exam - announce everything
-while sanitizer is drying just take a moment to look at overall appearance of patient - and mention it 'i am now just looking at your overall appearance' look at them from head to toe - also ask to look at hands and fingernails, and palms
-now go to most relevant phyiscal exam first - use your best judgement - abdominal pain=abdo exam / headache=neuro, extraocular movement, fundoscopy etc. etc.
-be thorough with the most relevant body system exam, try to search for findings, don't waste too much time examining probably unrelated systems. if doing good on time throw in CV/Resp/Abdomen if you havent done them and there is at least 3-4 minutes left
-make sure to use proper draping technique - i always asked patients for them to move their own gown - ex (would you please pull up your gown so that i can examine your belly?' or 'would you please pull down the gown so that i can listen to your heart?' and 'is it ok if i untie the back of the gown'
-for CV exam i only auscultated in the aortic and pulmonic areas. i would feel radial and dorsalis pedis pulses (you dont even have to actually feel it, just pretend you do feel it), and press on shin for edema
-for respiratory exam i only auscultated in four spots on the back, and only percussed once, never did fremitus etc etc
-for abdomen do all inspect, auscultate, palpate, percuss
-ask permission before pressing on abdomen and ask if they currently have any abdominal pain before even touching thier abdomen
-again MAKE SURE TO VERBALLY ANOUNCE ALL OF YOUR ACTIONS DURING THE PHYSICAL EXAM 'i am now going to press on your belly, i am now going to listen to your heart, i am now going to feel your pulses, i am now going to look into eyes'
-after physical exam say 'ok that concludes the physical exam, thank you'
-sit back down
-this is a CRITICAL POINT FOR MAJOR CS POINTS HERE - at this time you must summarize, counsel, and close - "YOU DON'T CLOSE, YOU DON'T PASS"
-example closure - 'ok ms jones i understand you have come in because of abdominal pain that has been bothering you for the past 3 weeks and that you have also been experiencing diarrhea and weight loss. and i understand that it has been difficult for you. i am glad that you came in so that we can figure out whats going on and decide upon a treatment plan for you. at this point i dont know exactly what you have but i am concerned you may have IBD, which is when your intestines are inflamed, IBS which is when you have pain from your gi organs, or infectious diarrhea due to a nasty bug. what we are going to do is take some blood tests, take a look at a stool sample, and perform a colonoscopy, that is when we use a camera to look at your colon. when we get the results we will know much more, and hopefully have a diagnosis and we can figure out a treatment plan.' - say 'how does that sound to you' this shows that you asked for the patients perspective
-counsel 'also you mentioned that you drink about 3 beers per day, and i would like to mention that excessive alcohol isn;t good for you and i reccomend that your cut back. are you interested'
-ask 'do you have any additional questions'
-ask 'do you have any additional concerns'
-say 'it was nice to meet you ms jones. i will go order the tests, and when the results are in we will meet to discuss them and decide on a treatment plan, bye'
-walk out the door and do not look back
-write your note like first aid - order appropriate tests - do not order totally crazy tests like a nuclear WBC scan for pyelonephritis - an US would be ok for pyelo though
there is so much more that i could write about but my wrists are starting to hurt. could it be carpal tunnel? or just overuse injury?
if you guys find this helpful, let me know and i will write more and try to answer your questions.
and i do know how to use proper spelling and grammar by the way, but for easiness sake i did not bother
edit- and by the way make sure to have a friendly demeanor and to ocassionaly smile when approprite such as introduction and when saying goodbye. and i never made small talk by the way
-read door info carefully - write down important info only
-knock on door and then enter
-make eye contact. say 'hello ms. jones?. I'm dr. smith. I'll be taking care of you today'
-shake hands
-ask if its ok to sit and to take some notes - then sit properly
-make good eye contact - its ok to look down to write notes, but do not bury your face in your notes, look down to write, then look back up to make more eye contact- and repeat as necessary
-ask - 'so please tell me, what brings you in today' - then say something to demonstrate empathy like 'i'm sorry to hear about that' or 'that must be difficult' or 'let's try to figure out whats going on and get you feeling better'
-i never asked - what concerns you the most, or how has this affected you - im not saying its bad to ask this, just that i did not ask these things and still did very well in CIS
-ask about the hpi - I like to use the OPQRST acronym (onset, provocation, palliation, quality, radiation, severity, timing) also ask about relevant associated symptoms (nausea/vomitting/diarrhea for abdo pain - confusion/weakness/vomitting/fever for headache etc etc)
-do a brief summary after the hpi to let the patient know that you have been paying attention
-use a transition statement 'ok ms jones, at this point i would like to get to know more about your overall health'
-ask the PAMHUGSFOSS (preface the personal social questions by saying 'now i would like to ask you some personal questions. is that ok? do you smoke, drink, drugs, sex, protection etc etc)
-at this point about 8 minutes should have elapsed
-say 'ok ms. jones, thank you for sharing that information with me. at this point i would like to do a quick physical exam. is that ok?'
-use tiny tiny amount of hand sanitizer
-always narrate your entire physical exam - announce everything
-while sanitizer is drying just take a moment to look at overall appearance of patient - and mention it 'i am now just looking at your overall appearance' look at them from head to toe - also ask to look at hands and fingernails, and palms
-now go to most relevant phyiscal exam first - use your best judgement - abdominal pain=abdo exam / headache=neuro, extraocular movement, fundoscopy etc. etc.
-be thorough with the most relevant body system exam, try to search for findings, don't waste too much time examining probably unrelated systems. if doing good on time throw in CV/Resp/Abdomen if you havent done them and there is at least 3-4 minutes left
-make sure to use proper draping technique - i always asked patients for them to move their own gown - ex (would you please pull up your gown so that i can examine your belly?' or 'would you please pull down the gown so that i can listen to your heart?' and 'is it ok if i untie the back of the gown'
-for CV exam i only auscultated in the aortic and pulmonic areas. i would feel radial and dorsalis pedis pulses (you dont even have to actually feel it, just pretend you do feel it), and press on shin for edema
-for respiratory exam i only auscultated in four spots on the back, and only percussed once, never did fremitus etc etc
-for abdomen do all inspect, auscultate, palpate, percuss
-ask permission before pressing on abdomen and ask if they currently have any abdominal pain before even touching thier abdomen
-again MAKE SURE TO VERBALLY ANOUNCE ALL OF YOUR ACTIONS DURING THE PHYSICAL EXAM 'i am now going to press on your belly, i am now going to listen to your heart, i am now going to feel your pulses, i am now going to look into eyes'
-after physical exam say 'ok that concludes the physical exam, thank you'
-sit back down
-this is a CRITICAL POINT FOR MAJOR CS POINTS HERE - at this time you must summarize, counsel, and close - "YOU DON'T CLOSE, YOU DON'T PASS"
-example closure - 'ok ms jones i understand you have come in because of abdominal pain that has been bothering you for the past 3 weeks and that you have also been experiencing diarrhea and weight loss. and i understand that it has been difficult for you. i am glad that you came in so that we can figure out whats going on and decide upon a treatment plan for you. at this point i dont know exactly what you have but i am concerned you may have IBD, which is when your intestines are inflamed, IBS which is when you have pain from your gi organs, or infectious diarrhea due to a nasty bug. what we are going to do is take some blood tests, take a look at a stool sample, and perform a colonoscopy, that is when we use a camera to look at your colon. when we get the results we will know much more, and hopefully have a diagnosis and we can figure out a treatment plan.' - say 'how does that sound to you' this shows that you asked for the patients perspective
-counsel 'also you mentioned that you drink about 3 beers per day, and i would like to mention that excessive alcohol isn;t good for you and i reccomend that your cut back. are you interested'
-ask 'do you have any additional questions'
-ask 'do you have any additional concerns'
-say 'it was nice to meet you ms jones. i will go order the tests, and when the results are in we will meet to discuss them and decide on a treatment plan, bye'
-walk out the door and do not look back
-write your note like first aid - order appropriate tests - do not order totally crazy tests like a nuclear WBC scan for pyelonephritis - an US would be ok for pyelo though
there is so much more that i could write about but my wrists are starting to hurt. could it be carpal tunnel? or just overuse injury?
if you guys find this helpful, let me know and i will write more and try to answer your questions.
and i do know how to use proper spelling and grammar by the way, but for easiness sake i did not bother
edit- and by the way make sure to have a friendly demeanor and to ocassionaly smile when approprite such as introduction and when saying goodbye. and i never made small talk by the way
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