醫實注行
專家解讀“麻醉痛症專科”（亦稱“疼痛科”）及＂麻醉科＂專業知識及應用問題 - pain management
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 |
- 介紹及問候：
“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:
- 定位（Location）:
查問病症部位：
“Where is the problem?”或
“Could you please show me exactly where it hurts?”
- 發生時間及時程
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;
- 病症強度:
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?”
- 病症性質：
疼痛性質可能與疼痛原因有關，你可問：
“How do you describe your pain?”
- 發作頻率：
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?”
- 症狀放射性：
如果症狀是疼痛，需問
“Does the pain go somewhere?”
- 加重與減輕因素
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?”
- 藥物治療及效果
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
Next 三.赴美考試及旅行
