考生还需注意另外二个方面: 1. 标准病人:标准病人在美国医学教学中已存在30余年,所以每一个考生面临的标准病人具有相同和极为相式的临床病例。标准病人本人只具有普通医学知识常识,所以考生不必关注你所陈述和回答病人问题的严格性和正确性,但要注意对病人的尊重和职业同情心态。 2. 考生方面:考核过程重点在你的诊疗过程,不要把太多时间和工作用在“做出正确诊断”,而应做到整个病例的宏观思维和时间的合理安排。 对每个病例,考生将会得到一份病人的基本资料:描述病人的姓名,年龄、性别、就诊原因及生命体征。考核过程中,最困难的是保持正确的时间进度。 你必须在15分钟内完成整个病情的询问及检查,所以对应该进行的每一步骤应相当熟悉: 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) 然后问: “What brings you to see me today?” or “What brings you in to day”. 标准病人(SP)会告诉你主诉:(CC) 接下来的一个开放式问话: “Could you please describe to me exactly what is going on or what were your problems (issues)?” 在SP答述后,你提醒式询问他是否有其他相关的重要情况还未讨论: 查问病症部位: “Where is the problem?”或 “Could you please show me exactly where it hurts?” 为了解病症是急性, 亚急性或性慢性, 应询问: “When did it first start?”或 “When did you first notice the problem / pain?” 然后了解发作情况: “Was the onset all the sudden or progressive?” 接下来还要询问有关主诉的其他情况; 应记录病情的严重性及程度,如果是疼痛,你可询问疼痛程度:轻、中、重, 或用0-10来记录: “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?” 疼痛性质可能与疼痛原因有关,你可问: “How do you describe your pain?” 总是询问发作的频率 如: “Is it constant?”或 “Does it come and go?” 如是间断性的 “How often does if occur? How long does it last? How do you feel between attacks?” 如果症状是疼痛,需问 “Does the pain go somewhere?” 询问有否意识到病重或减轻症状的因素有利于分析病和做出诊断,如食物的影响,运动的影响,体位的影响等等: “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?” 了解是否进行过治疗及治疗效果,并注意治疗副作用. - 过去史:
- 手术史:
- 家族史:
- 个人史:儿童应包括疫苗接种史; 妇女应有血经及生育史;
- 过敏史:
- 当前用药:
体检(PE): 体检前总是用肥皂洗手,为节约时间,洗手时仍然保持与标准病人谈话. 绝不要透过患者服装检查. 检查时仅暴露检查部分,其余部分应遮盖;对“女患者”检查心脏时不要表现出犹豫不决,保留胸罩,清SP推起自己的乳房以便听诊心尖部;不要检查乳房, 同时告诉“患者”你准备做的检查,可以这样开始: “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?” 标准病人(SP):“Yes, it’s ok.” 医生:“Thank you.” 如果SP表示不愿意:你应该解释其检查的重要性,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可能以面部表情来表示病痛, 检查时要留意SP的表情; 体检时,由于时间关系,重点做与病史相关的检查. 小结 在结束病情资料收集前,应向“SP”说明你的诊治计划和一些相关健康建议, 比如停止吸烟,参加运动或减少体重等等: “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?
完成病情资料收集后,你有10分钟时间完成病情记录(patient note ). 以下是在进一步检查(work-up)中可能考虑并应注意的治疗计划。 会诊咨询及转诊均不属(work-up).
头颈面部(HEENT) - 头:X-ray, CT , MRI
- 眼:Snellen’s 表,视力
- 耳:分泌物培养,听力检测 ( audiometric, tympanometry)
- 中枢神经系统:(CNS)
CBC + diff, ESR X-ray, CT, NRI Lumbar Puncture Carotid Doppler Study EEG EMG and Nerve Conduction Studies 常用检测 - CBC(Complete Blood Count)/ Coags (PT、 PTT、 INR)
- Urinalysis
- Electrolytes
- Arterial Blood Gas
- EKG
- Chest x-ray
前面已经讲过,Step 2 CS 相对较Step 1和Step 2 CK 容易。只是大多数中国医学生在学医过程中以自我消化知识为主,所以在以要求表达自我和交流能力为主的Setp 2 CS考核中多少有些吃亏。Step 2 CS 考试的重点并非医学知识,而是interpersonal communication方面,那么从现在起如果你注意培养这方面的能力. 当你把Step 1 和Step 2 CK 考完后,准备Step 2 CS 也就不成问题了。
临床考核许分以通过或未通过(Pass/Fail)为准考评内容及报告为 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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