考生還需注意另外二個方麵: 1. 標準病人:標準病人在美國醫學教學中已存在30餘年,所以每一個考生麵臨的標準病人具有相同和極為相式的臨床病例。標準病人本人隻具有普通醫學知識常識,所以考生不必關注你所陳述和回答病人問題的嚴格性和正確性,但要注意對病人的尊重和職業同情心態。 2. 考生方麵:考核過程重點在你的診療過程,不要把太多時間和工作用在“做出正確診斷”,而應做到整個病例的宏觀思維和時間的合理安排。 對每個病例,考生將會得到一份病人的基本資料:描述病人的姓名,年齡、性別、就診原因及生命體征。考核過程中,最困難的是保持正確的時間進度。 你必須在15分鍾內完成整個病情的詢問及檢查,所以對應該進行的每一步驟應相當熟悉: 病史: Step 2 CS Blueprint: Content Categories - Common and Important Medical problem/Patient Presentation -Acuity -Age -Gender -Race/Ethnicity
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“Hello, Mr./Ms. Smith, Good morning/Afternoon.” “I am Dr XX. It’s nice to meet you. ” (握手) 然後問: “What brings you to see me today?” or “What brings you in to day”. 標準病人(SP)會告訴你主訴:(CC) 接下來的一個開放式問話: “Could you please describe to me exactly what is going on or what were your problems (issues)?” 在SP答述後,你提醒式詢問他是否有其他相關的重要情況還未討論: 查問病症部位: “Where is the problem?”或 “Could you please show me exactly where it hurts?” 為了解病症是急性, 亞急性或性慢性, 應詢問: “When did it first start?”或 “When did you first notice the problem / pain?” 然後了解發作情況: “Was the onset all the sudden or progressive?” 接下來還要詢問有關主訴的其他情況; 應記錄病情的嚴重性及程度,如果是疼痛,你可詢問疼痛程度:輕、中、重, 或用0-10來記錄: “On a scale of 0-10, with 0 being the least painful and 10 being the most painful, how would you scale your pain from 0 to 10?” 疼痛性質可能與疼痛原因有關,你可問: “How do you describe your pain?” 總是詢問發作的頻率 如: “Is it constant?”或 “Does it come and go?” 如是間斷性的 “How often does if occur? How long does it last? How do you feel between attacks?” 如果症狀是疼痛,需問 “Does the pain go somewhere?” 詢問有否意識到病重或減輕症狀的因素有利於分析病和做出診斷,如食物的影響,運動的影響,體位的影響等等: “what were you doing when it first began?” “Have you ever found anything that makes your pain / problem worse?” “Do you have any idea of what might have brought this out?”或“what brings it on?” 了解是否進行過治療及治療效果,並注意治療副作用. - 過去史:
- 手術史:
- 家族史:
- 個人史:兒童應包括疫苗接種史; 婦女應有血經及生育史;
- 過敏史:
- 當前用藥:
體檢(PE): 體檢前總是用肥皂洗手,為節約時間,洗手時仍然保持與標準病人談話. 絕不要透過患者服裝檢查. 檢查時僅暴露檢查部分,其餘部分應遮蓋;對“女患者”檢查心髒時不要表現出猶豫不決,保留胸罩,清SP推起自己的乳房以便聽診心尖部;不要檢查乳房, 同時告訴“患者”你準備做的檢查,可以這樣開始: “Ok. Mr/Ms. Smith, now I would like to do a physical examination on you. For that, I need to untie your gown. Is that OK with you?” 標準病人(SP):“Yes, it’s ok.” 醫生:“Thank you.” 如果SP表示不願意:你應該解釋其檢查的重要性,比如:“Mr./Ms. Smith, I understand your feelings, but to clearly understand your problem. I have to do this examination. It won’t take more than 1 minute. Don’t worry, I am here to help you and I will let you know whatever I’m going to do. If you feel hurt, let me know. I’ll stop right away.” SP可能以麵部表情來表示病痛, 檢查時要留意SP的表情; 體檢時,由於時間關係,重點做與病史相關的檢查. 小結 在結束病情資料收集前,應向“SP”說明你的診治計劃和一些相關健康建議, 比如停止吸煙,參加運動或減少體重等等: “All right, Mr./Ms. Smith, thank you so much for your kind corporation. Now, I’d like to sit down and talk about what I think. First, let me summarize: · You just told me that … and …. Also, you mentioned that … and …. Is that right? · According to the information I got from you and the examination, I am considering a couple of possibilities. It may be..(probable diagnosis) or possibly (differential diagnosis). · I need to run some tests in order to find out exactly what the problem is. · As soon as I get the results, let’s meet again to go over everything. At that time, I will explain the details and we will talk about your options for treatment. Does this sound OK?
完成病情資料收集後,你有10分鍾時間完成病情記錄(patient note ). 以下是在進一步檢查(work-up)中可能考慮並應注意的治療計劃。 會診谘詢及轉診均不屬(work-up).
頭頸麵部(HEENT) - 頭:X-ray, CT , MRI
- 眼:Snellen’s 表,視力
- 耳:分泌物培養,聽力檢測 ( audiometric, tympanometry)
- 中樞神經係統:(CNS)
CBC + diff, ESR X-ray, CT, NRI Lumbar Puncture Carotid Doppler Study EEG EMG and Nerve Conduction Studies 常用檢測 - CBC(Complete Blood Count)/ Coags (PT、 PTT、 INR)
- Urinalysis
- Electrolytes
- Arterial Blood Gas
- EKG
- Chest x-ray
前麵已經講過,Step 2 CS 相對較Step 1和Step 2 CK 容易。隻是大多數中國醫學生在學醫過程中以自我消化知識為主,所以在以要求表達自我和交流能力為主的Setp 2 CS考核中多少有些吃虧。Step 2 CS 考試的重點並非醫學知識,而是interpersonal communication方麵,那麽從現在起如果你注意培養這方麵的能力. 當你把Step 1 和Step 2 CK 考完後,準備Step 2 CS 也就不成問題了。
臨床考核許分以通過或未通過(Pass/Fail)為準考評內容及報告為 Step 2 CS Scoring
ICE | CIS | SEP | Data Gathering Patient Note | Communication Inter Personal Skills | Spoken English Proficiency |
Sample Score Report Examination Components | Decision | Integrated Clinical Encounter | Pass | Communication/Interpersonal Skills | Fail | Spoken English Proficiency | Pass |
Examination Decision: Fail
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