筆者目前也在準備STEP3, 來分享一下我對STEP3 2的粗淺準備心得
STEP 3 有 75%是選擇題, 另外25% 是CCS 電腦模擬病人
選擇題的部分: 以下是我自己開的書目
市面上的書寫關於STEP 3真的很貧乏, 以下列出我有讀過的書
kaplan master the board for step 3 很多人推, 我自己在準備 2CK的時候就買了
white coat pocket guide在逛 Rush university 書店的時候意外發現的2010年出的新書
掃過之後覺得寫的還比 Master the board 還好, 另外我也會做 Usmle world 配上我 step 2ck的筆記
我想既然是選擇題, 考過STEP 1 和 STEP 2 ck之後應該不陌生吧, 每個人應該都知道怎麼準備
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White coat pocket guide排版的很清爽, 重點有有標出來, 很適合step 2 CK 和step 3 , 不知道台灣目前進書了沒? |
CCS的部分
但是比較頭痛的是 CCS, 這個模擬病人的軟體要怎麼下手呢?1.我是先看 Strong Medicine for Step 3前面有寫USMLE CD 5個模擬病人的詳解下手, usmle CD有5 個 ccs case可以去網站上下載
2.另外可以看 Usmle world, 前41個CASE可以自己列印下來隨身看, 每個病人都有詳解我覺得寫的很棒, 軟體介面也很擬真
3.有人有推 USMLE consult的 CCS部分, 雖然說軟體界面不如 UW但是在詳解的部分寫的比UW好, ,如果我時間太多我再來準備這個
要寫order,開檢查,理學解查, 病史, advance time這一些如果自己試玩一下就會上手, 但是問題是css的評分不只是看你order下的對不對, 還要看你order下的順序有沒有正確, 我覺得可以自己先建立自己的 ccs protocol, 這樣寫 order 的時候就不會落東落西
我來分享一下我自己的 ccs protocol 給現在在準備 step 3 的人,CCS 還蠻好玩的, 可以去官網下載軟體玩看看
如果剛開始在office
稍微注意一下ABCD就好,有時候會喘就上oxymeter +O2
->General physcial examination: 因為時間很多所以PE 全作
->接下來再下order和檢查
->接下來看病人的情況要送到ward 還是home回家觀察
->如果送到ward檢查/治療完stable就可以discharge
->如果送回家記得回診
如果是輕微的毛病不要開一堆不必要的檢查
如果剛開始在ER
先看ABCD
->接下來再做"Focus PE" 因為要做完所有PE很耗時間, 不建議全作
->如果病人穩定, 可以直接送上ward 或 ICU, 如果病人不穩定，先開order等病人穩定了再送上去
->到了病房或ICU, 要看需要作一些檢查, 治療, monitor, nursing, 之類的, 一些檢查和history, PE要follow up
-> 如果stable 可以 ICU轉 ward, ward 穩定送回家
以下是常見到的檢查和我的protocol
ABCD
Airway: Airway suctionBreathing: Pulse oximetry(stat+contineous) ,O2, Intubation (SaO2 doesnt improve with 100%O2, PaO2<55, PaCO2>50)+Ventilation, mechanical 不能只打intubation沒有MV不然只有一跟管子插在那邊
Circulation: IV access, cardiac monitor, 12 lead EKG
Drugs: 看情況, 如 Unconscious unknown Px :Thiamine(stat), dextrose 50%(stat), naloxone(Stat), finger glucose stat, 如Anasphysis:epinephrine(SC)
Common labs(BFIO)
- Hema: CBC, CBC+DC, PT(INR)/PTT, bleeding time
- Electrolyte:SMA-7(glucose/BUN/Cre/Na/K/Cl/HCO3/Ca),SMA-14 ,Mg(Magnesium), P(phosphate), uric acid
- GI: LFT(bilirubin, albumin, alk-P, AST, ALT), PT, amylase, lipase
- Pregnancy (serum) 常忘掉的檢查
- Cardiac: CK-MB, troponin I(Cardiac enzymes)
- Others:ABG, toxicology
- Infection: Blood culture, CRP, VDRL, PT/PTT(DIC)
- Rheuma: ANA, ESR, CRP, RA,
- Endo:TSH, fT4, fT3,Lipid Profile, Glucometer check, HbA1C
- Urine: UA(Urinalysis), C&S, gram stain, toxicology, sodium, Cre
- Effusion: thoracocentesis(Gram stain, C&S, cell count, glucose, AFB, LDH, protein, pH cytology,+blood protein/LDH)
- Stool:72hr fat estimation, Gram stain, culture, O&P, c difficile toxin
- Sputum:C&S, Grain stain
- Spinal fluid:LP, for protein, glucose, Gram stain, cell count
- Echo, X ray(CXR， KUB), CT, MRI, Thallium scan
- 12 lead EKG, EEG, incentive spirometry, FEV1, PEFR Exercise treadmill, biopsy, PPD
Fluids
- Intravenous access, NSS, D5W
- Common: Cardiac monitor, Pulse Oximetry , BP monitor, Vitals, Input/ urine output,
- Uncommon: CVP or Swan-Ganz, Telemetry(給心內病人), weight(for CHF),
- Activity (bed rest, out of bed to chair, as tolerated)
- Diet:NPO, oral fluid
- Oxygen
- Physical therapy: chest physiotherapy
- Tube(NG, Foley)
- Seizure, aspiration precaution??, skin care, DVT(Heparin SQ Q12h) ,stress ulcer(IV ranitidine), Compression stocking
- 如:EGD consult GI, transcutaneous pacemaker consult cardiology
- -pain with IV morphine,ketorolac IV, naproxen PO
- -nausea with IV phenergan(promethazine )
- -constipation with PO docusate or PO milk of Mg
- -diarrhea with PO loperamide
- -insomnia with PO temazepam or PO Triazolam
- -Seizure with IV lorazepam
- -Fever >38: PO Acetaminophen
- -Anxiety: PO/IV Lorazepam
- -Transfusion: FFP(PT>1.5), pRBC
另外discharge 也要想discarge order
Discharge:(PAN RATED SEX).
- Preventive-
- GI: rectal exam, a FOBT, colonoscopy ->50y/o
- Lipid :fasting lipid profile-Men>35, Woman>45:
- Breast :yearly clinical breast exam and mammogram-> 40 (35 if risk factors are present),
- Tube: prostate exam/PSA -> 50 (45 if risk factors are present )Pap smear: >21 or sexual activity for 3 yr
- Vaccination
- Alert bracelet,給有可能會暈倒的病人, 另外也要告訴他們no driving
- Notify public health department-如TB, HAV等
- Reassurance
- Alcohol-alcoholcessation program
- Tobacco-smoking cessation program
- Exercise
- Diet (diabetic, low salt, high fiber diet for constipation, low protein for hepatic failure, low fat)/ Drugs use/ Drugs compliance/ DM care(diabetes teaching, patient educcation DM, DM Foot care, Home glucose monitoring)
- Seat belt / Safety plan / Suicide precautions
- Education (“patient education”)medication compliance
- X (stands for safe seX)
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