Saturday, April 30, 2016

Step 2 CS: Introduction

Here's how I introduced myself -

"Mr. Smith? Hi. I am doctor D. I'm the attending physician and I'll be taking care of you."
"Are you comfortable in the room?" (Yes.)
"May I take a seat and write a few notes as we talk?" (Yes.)
"So can you tell me what brought you to the clinic?" (Blah blah blah...)
"Can you tell me more about it?"

Monday, April 25, 2016

Step 2 CS: Counselling for PTSD

I can see that you are distressed about an event that occurred in your life. We have some medical therapy available that can help you with this. Medicines take time to work, in the mean while I can get you in touch with some support groups and social help organizations that have patients who have witnessed similar traumatic events in their life.

Sunday, April 24, 2016

Step 2 CS: Physical exam findings in a patient with calf pain

We were practicing a case of calf pain (DVT / cellulitis) today and my friends told me that I documented the physical examination findings well, which is why I posted the note on the blog :)

Things in brackets are for reference only and I didn't type those in my 10 minutes encounter.

Thursday, April 21, 2016

Step 2 CS: Headache LOC tip

In a case of headache or loss of consciousness, any weakness or numbness is the first question you ask - because if there is anything suggestive of stroke or transient ischemic attack, you can time yourself to do a neuro exam which includes cranial nerves and strength, reflexes and sensations.

Monday, April 18, 2016

Step 2 CS: Musculoskeletal patient note

IPROM MRSP is a brilliant mnemonic
You can use it for patient notes as well!

For shoulder pain:
Inspection - R arm is closely held to the chest wall. R shoulder appears red compared to the L.
Palpation - Non localized tenderness on palpation of R shoulder, arm and clavicle.
ROM - Pain and restricted flexion, extension, abduction, adduction, internal rotation and external rotation.
Motor - Unable to assess strength due to pain.
DTR's - 2+ intact, symmetric (If time, mention - Biceps, triceps and supinator)
Sensations - Intact to pin prick and light touch
Pulses - 2+ in brachial and radial arteries

For wrist pain:
Palpation - Non tender to palpation
ROM - Flexion, extension, abduction, adduction are WNL
Motor - 5/5 strength in shoulder, elbow and wrist
DTR's - 2+ intact, symmetric
Sensations - Intact to pin prick and light touch except decreased sensation in the palmar aspect of right arm
Pulse - 2+ in brachial and radial arteries
Tinels, Phalens test +ve. Finkelsteins test -ve.

Friday, April 15, 2016

Step 2 CS: Memory loss / confusion

Soo.. I wanted to remember "medical terms" to report my findings in my patient note. I made a mnemonic for remembering "findings in Alzheimer's disease:

AC MI EF

- Decline in Activities of daily living
- Cognitive decline
- Memory Impairment
- Executive Functioning

For activities of daily living, DEATH SHAFT is a tedious mnemonic. Keep it simple -ABCD
Ask for ABCD - accounts, bathing, cooking, dressing and transport - Can you walk in the house / drive a car?

Other diagnoses:

Normal Pressure Hydrocephalus - Ask for urinary incontinence, gait disturbance

Syphilis / AIDS - Have you ever been diagnosed with a STD in the past?

Major depressive disorder (Psuedodementia) - SIGECAPS

Hypothyroidism - Cold intolerance, constipation, slowing of movement, etc

Step 2 CS: Writing a psychiatry note and mini mental status

Mnemonic: ABC MATTS

Appearance - Well groomed / Dishevealed
Behaviour - Appropritate / Inappropriate
Co-operation - Cooperative / Non-cooperative

Mood - Euphoric / Depressed
Affect - Normal / Blunt affect with poor eye contact
Thought Process- Direct / Disorganized
Thought Content - Normal / Delusional
Speech - Fluent speech / Slow speech

"Now I am going to ask you a few questions that may seem odd, but these are just to assess your mental status."

"What is your name?"
"Do you know where we are?"
"Do you know what time is it?"
AAOx 3

"I will name three objects for you, can you repeat them after me? I will ask you to repeat the same objects after a while."
3/3 registration, 3/3 recall at 3 minutes

Step 2 CS: Headache / photophobia

Think of differentials, then ask  -

Migraine - Ask about aura, catamenial migraine

Cluster headache - Ask about tearing of eyes, rhinorrhea

Tension headache - Ask about stresses in life

Meningitis - Ask for neck stiffness, fever

Thursday, April 14, 2016

Excess use of antibiotics can cause Diabetes

New research has pointed out that excess of antibiotics in children can increase there risk of getting diabetes in future.

Why?

Step 2 CS: Hoarseness

This is a very easy case because there are limited number of  things that can cause hoarseness of voice.

Wednesday, April 13, 2016

Step 2 CS: What to ask in cases involving joint

Any case of joint pain, ask OPDFCS LIQRAA first.

Then, ask - Calor, dolor, rubor, tumor, functio laesa (Mnemonic: CRaFTeD)

Calor - Is the joint warm?
Dolor - Is it painful on movement?
Rubor - Does it look red to you?
Tumor - Does the joint look swollen to you?
Functio laesa - How has this affected your day to day activities?

Blast cells - Acute or chronic leukemia? Mnemonic!

Hope you are having a good day so far! :D

Acute leukemias are characterized by a predominance of blasts. Chronic leukemias are characterized by proliferation of lymphoid or hematopoietic cells that are more mature than those of acute leukemias.

Opportunity for Medical students to be part of a research study!

Hello!

We are doing a study on internet addiction among medical students in south east Asia ( Mainly 4 countries: India, Pakistan, Bangladesh and Nepal).

Monday, April 11, 2016

It’s a desi (Indian) Medico’s thing! Part 2

Neighbours/Relatives: (Knowing that I am taking up internal medicine) So, you want to become a cardiologist later?
Me: Yes, it’s a possibility.
N/R: Nice. So, how long before you start performing surgeries?
Me: Never
N/R: WHAT?!?! Why?

Sunday, April 10, 2016

It's a desi (Indian) Medico's thing!

Neighbours/Relatives: What specialization are you taking?
Me: Internal Medicine/General Medicine
N/R: You mean general physician?
Me: Yes
N/R: Chi, Yuck, Thuuu, Ayyoo (disgusted)

Step 2 CS: Blue sheet

What's a blue sheet? A blue colored paper given to you during the step 2 CS exam.

I finally figured out what my blue sheet will be like before entering the room and maybe it will be helpful for you guys too!

I tailored it from existing mnemonics and things I used to forget. You should make a personalized blue sheet according to your need too.

This is what my sheet would look like before I enter the room:

Step 2 CS blue sheet

Step 2 CS: Asking for sexual history

Sexual history is always a dilemma for step 2 Cs exam takers. Here's a simplification.

Are you sexually active?
Patient will answer either "Yes" or "No"

If no: Don't ask why and make it awkward. If the patient has problems, he will tell you.

If yes: With whom if you don't mind sharing?

Step 2 CS: Transition phrases

Once you are done with History, do a Review Of Systems:

Transition phrase: "Just for the sake of completion, I would like to ask you a few more questions - You can answer these questions with a 'Yes' or a 'No'."

These are the questions I would usually ask:
"WAD FUG"
Any changes in your Weight?
Any Appetite changes?
Any changes in your Diet?

Do you have any Fever? (Night sweats / Chills)
Any changes in your Urinary habits?

Gastrointestinal complaints:
Any abdominal pain?
Any diarrhea or constipation?
Any nausea?
Vomiting?

Saturday, April 9, 2016

Step 2 CS: Child with diarrhea mnemonic

For a child with diarrhea, make sure you ask these things (D's).

Diarrhea characteristics - Amount, Blood, Color, Consistency, Duration, Frequency, Odor,
Dehydration features - Dry mouth, sunken spot on forehead, Drowsy
Diet - Any new foods introduced that may have caused the diarrhea?

Friday, April 8, 2016

Dr. Thinker: Personal Statement

-          Some say it is very important and some say they only read it after you are offered an interview.
-          Either way, I would say not to take it easy. Just think it as one of those minimum things which we can do to secure our future.

1.      When to start writing?

-          Start writing it as early possible. Don’t delay. The correct time to start writing or think about it is NOW.
-          You will end up making many drafts and corrections.  You would want to make changes even few seconds before applying. You would literally cry if you keep it for the end.

Dr. Thinker: FAQs asked by the members of the USMLE page

1.      Second match guys did you tell the program its your second match and did they ask u?
A.      I mentioned it in my PS that I didn’t match last year. The interviewers mentioned that they noticed it.  At a couple of places where the interviewer didn’t read the PS, they asked me whether I applied for last match.

2.      IM LOR for neuro advisable?
A.      Only, if you don’t have enough LORs from Neuro.

3.      Please mention what extracurricular activities we could add on to our CV and if it is really necessary?

Dr. Thinker: What to expect during the interview season?

-          Accept the fact asap that the whole process is UNCERTAIN.
-          Be ready to face many depressive circumstances.
-          On the good side, you will see new places, meet many people and some of them become your support for the rest of the season and friends for life.

Dr. Thinker: SOAP

-          Everyone who doesn’t match will be automatically eligible for SOAP.
-          Everyone gets an email regarding SOAP 2-3 days before the match results are out. This is a common email for everyone. It doesn’t mean that you will go unmatched.
-          There is a very common saying – “ SOAP is a LOST Cause”.
-          It is very difficult for an IMG to match in soap as they usually take unmatched AMGs in Soap. But, don’t give up. Try till the end. You could be an exception.

Dr. Thinker: Rank order list (ROL)

-          You can start making the list from mid Jan until the last Wednesday of Feruary.
-          The deadline for ROL submission would be on the last Wednesday of Feb. The programs have the same deadline as you.
-          You can create a list and keep changing it until the deadline. But, everytime you edit the list make sure to certify it. You will get an email notification saying your ROL has been submitted succefully.
-          Start working on your list as soon as possible so that you can do enough research about the programs where you had an interivew.

Misconceptions and the way to rank:

Dr. Thinker: Contacts in the USA

When you say you don’t have any contacts in the USA, if you give up because of it or if you blame everything on this factor, then you are only ridiculing yourself.
-          Yes, having contacts will help in a big way.
-          With a proper strong contact it can be a cake to matching. And, yes you will come across such people. Don’t be jealous of them. Remember, you would have done the same thing if you had such contacts.
-          But, you will also many people reaching the end without any contacts, without even a family member to support in the USA.
-          So, don’t worry about something which you can do nothing about.

CONTACTS don’t just happen for everyone, you have to make them!

Dr. Thinker: Factors related to the MATCH

What are the factors that go into one’s match?
-          It is a mixture of various things.
a.      Contacts
b.      A word from your attending – if they personally email or call

Dr. Thinker: Post interview communication with the programs

1.      Whom should you send you a thank you note?
-          You can email
A.      Program director
B.      Program coordinators – they are important
C.      Your interviewers
D.     The residents you met on the iv day

2.      Should you email or send a hand written thank you letter?

Dr. Thinker: Phone interview

-          Some programs might do a phone pre-interview first before they select you for an actual in person interview.
-          Otherwise, phone interview is common during SOAP.
-          It’s just like a regular interview. It’s a little easier as you don’t have to dress up, don’t have to worry about your expressions.
-          But, you have to take care about the length of your answers and your tone.

Dr. Thinker: Interview season and FAQs related to interviews

1.      When should you be in the USA?
-          I would advise you to be in the USA, at least from the 1st of Oct until end of Feb (Rand order list submission) or Match day ( if things doesn’t go as planned, it’s better to be in the USA for SOAP).
-          If you are in the USA, you can contact programs by telling that you are in the vicinity and so can make it to the interview at a moment’s notice.
-          Even in February there are chances to get an interview due to last minute cancellation by others.

Dr. Thinker: Contacting the programs after Sep 15th

1.      Can you contact the programs to review your application? If so, when is the right time?
-          Of course, you can contact the program coordinators to review your application.
-          One of the biggest misconceptions during the interview season is to NOT contact the program early (like until end of October).
-          You will see a lot of people especially on facebook pages and usmle forums strongly advising you not to contact them. Don’t believe them. Most of those, especially the ones with fake identities would be just trying to screw with you. They would mislead you to cut down their competition.
-          You can start emailing program coordinators from the end of September or preferably
first weeks of October.
-          The tone of your email should be in a requesting manner.
-          You can even call the program coordinators. But, before you rub your information on them, first enquire if they are free and comfortable to talk about your application. Proceed only if they say yes.
-          I just stated this from my own experience. I am just clearing the misconceptions. I am in no way forcing you to do it.

Dr. Thinker: NRMP registration

-          Register as soon as possible, before the end of November to avoid late fee.
-          NRMP registration is a must to be able to participate in the MATCH.

Step 2 CS: How to introduce yourself

"Mr. XXX?"

"Hi. I am Dr. _______. I am the attending physician today and I am here to take care of you."

"Are you comfortable in the room?"

"Let me put this drape on you to make you more comfortable."

"Is it okay with you that I take some notes while interviewing you just so I don't miss out on any important points?"

"So tell me, what brought you to the clinic?"

Dr. Thinker: FAQs related to programs

1.      When to start searching about the programs?
-          The best time is from July as most of the programs update their requirement info by the end of june or start of July.

Dr. Thinker: ERAS CV

-          It is automatically made as you fill your details on ERAS.
-          Make sure you make no grammatical errors.
-          DO NOT LIE about anything on your CV.
-          Present mailing address: Give your US address. Sometimes programs like to call those that live in the same region.
-          Permanent mailing address: I would suggest US address for this too, for the same reason as above. Programs would prefer those who have family or familiar to that region/state.
-          Medical school honors/Awards: Mention the awards you got in medical school, like distinctions or gold medals.

Dr. Thinker: MATCH season

-          Application for the Residency match starts on 15th September.

1.      What all should you ideally keep ready by the end of August?
-          Make sure your LOR’s are uploaded. Waived LORs take longer to get processed than the unwaived ones.  The processing time can be anywhere between 1 day to 2 weeks. The closer it gets to sept 15th the longer it takes.
-          Have your final draft of PS ready.
-          Have your MSPE/Dean’s letter uploaded (Dean’s letter can be a substitution for MSPE)
-          Your profile photo – keep it as professional as possible.
ERAS CV, PS can be uploaded or updated even in the last moment. There won’t be any processing time for this.

Dr. Thinker: Stay/Accommodation

Short duration: Especially when attending interviews.
1.      Airbnb: It’s a website where you can get rooms for a cheaper rate than the hotel. It’s the best option for a one night or a couple of nights stay.
a.      The rooms are usually in an apartment or a house and most often the owners live in the other room.
b.      You can search for shared or private rooms.
c.       You can search for the rooms according to the distance from the hospital.
d.      You can see the photos of the room and house before you book.
e.      You can read the reviews and then decide whether to take it or not. YOU MUST read the reviews.
f.        It is usually safe. I used it many times without any trouble and so did my friends.
           You can use this referral link to sign up in order to get 35$ off on your first booking. You must sign up clicking this link in order to get it.
            Link: www.airbnb.com/c/rchandra40?s=8
2.      Couch surfing: Like literally renting a couch in an apartment.
a.      Much cheaper option.
b.      Read reviews before you book.
https://www.couchsurfing.com                   
Longer duration:
During electives: It’s best you ask the coordinator to send a list of places where students usually live.

Dr. Thinker: Travelling in the USA

-          You would be spending a lot of money on this. So, always look for a couple of options and choose the best alternative.

Dr. Thinker: Letter of Recommendation (LOR)

FAQs
1.      How to get a good LOR?
-           It’s very simple.  The doctors in the USA are very friendly. They just expect you to know basic knowledge.
A.      Be on time – very important.
B.      Come to the hospital at the same time your resident or fellows come and leave along with them, even if they ask you to leave early.
C.      Read a topic, or something related to the cases you see and ask your resident or the attending some intelligent doubts in that topic. This way you are building up a rapport without sounding dumb when they talk about that topic.
D.     Volunteer to take a case or present a topic. Don’t wait for them to give you work.

Dr. Thinker: Research

FAQs  
1.      What are the types of visa on which you can join research?
A.      Research Volunteer/Intern: B1 visa
-          It is an unpaid position.
-          Your visa could be B1/B2, but at the port of entry the customs officer usually stamps B2. So, make sure you ask him to stamp  B1 if you are going for this kind of research.
B.      Research Assistant: J1 visa
-          This could be paid or unpaid position.
C.      Post doc: J1 visa
-          Paid or unpaid depending on the funds.
-          They usually have a commitment for 2 years. But, sometimes you can break it after an year depending on your attending.

Dr. Thinker: United States Clinical Experience (USCE)

USCE – United States Clinical Experience

Types of USCE:

A. Clerkship: It is considered hands on clinical experience.  You MUST try your best to do this no matter what.
Eligibility: You should be a medical student and not graduated yet.
(For Indians: Internship period is still considered as not yet graduated.)

- The best clinical experience.
- This is what the programs look for.
- The LORS from this have a great value.

B. Observership: Not a hands on, just shadowing another doctor.
Eligibility: Either a medical student or after graduation

- Not considered as a USCE by most of the programs.
- Some hospitals might let you touch and examine patients, but legally you are not supposed to.
- Best to fill the gap between graduation until residency application or end of the season.
- A reasonable time spent a big university or a community hospital that takes IMGs into residency is fruitful.

C. Externship: Hands on clinical experience.
Eligibility: After graduation

- Some programs doesn’t consider it as USCE as this kind of experience is mostly offered by private agencies or at private clinics.
- The LORS can mention it as hands on.
- Best to do if you haven’t had any clerkships

Dr. Thinker: USMLE STEP 2CK and STEP 3

I am not going to explain this in detail as I already did it for USMLE Step1. The approach is the same. Once you are done with Step1 exam, you will get a hang of it and you are going to become your own master of USMLEs.
USMLE STEP 2 CK
When is the ideal time to give it? – It’s best given asap after USMLE step1. It will save a lot of time as your basics would be strong and fresh.
Duration: 3 months if given immediately after USMLE STEP1. Otherwise 4-6 months.
Resources: MTB 2, MTB3, Uworld
Practice Tests:  1. UWSA    2. NBME forms 1-7

Dr. Thinker: USMLE STEP 2 CS

When to give it? 
1.      Ideally give it after your clerkship or observership, as you will get to know how to talk to patients in the USA.
2.      It can be given before step 1 or after. It doesn’t matter. I gave it before step 1.

Dr. Thinker: USMLE STEP 1

USMLE STEP 1
Ideal Duration: 6 months (But, remember it varies from individual to individual)
Resources: Kaplan notes, Kaplan Videos, First Aid, Uworld
 Alternative resources:  If  you are aiming for high scores    

Dr. Thinker: FAQs regarding the application for USMLE Step exams

These are some of the questions I had encountered on multiple occasions from many people.
1.      Can we change the testing center from some country to the USA or from the USA to some other country?
-          Yes, you can change from any country to another country.
-          Just call ECFMG customer care. They will give you a number to which you can fax your request. You will just have to write your details and the request “Please, change my testing center from “current country” to “the country you want”, on a white paper and sign at the bottom.
-          If you change your testing center from any other country to the USA, then you will get a refund for the testing center surcharge fee(150$) that was earlier charged in your country.
-          If you change your testing center from the USA to any other country, then you will be charged a testing center surcharge fee depending on the country you are changing it to.

Thursday, April 7, 2016

Dr. Thinker: My journey

I am sharing my story mainly for those who go unmatched or thinking of giving up at
every hurdle that comes in the USMLE path. I didn't match at my first attempt, too. We may not
have the same problems overall, but I totally understand what you would be going through. I
didn’t have any financial troubles ( thanks to my parents and brother), but emotionally it was a
nightmare until Mar 14, 2016, considering the fact that even my family wouldn't have been
happier with me giving it an another try( can't blame them).

Journey: We think we need some help or seniors for securing electives and all. In reality- it’s
just an excuse we give ourselves. Of course, having them will make it easy, but not having them
isn’t the end. I did it all by myself with the help of google. That's one reason I keep answering
queries on usmle pages, as not everyone has someone to back to them up. Remember -
Contacts don't just happen for everyone, you make them!!

Dr. Thinker: Note

DON’T GIVE UP
 You may not match this year,
 you may not match the next year.
 But, you will have to and for sure will match one season.
 As, matching can only be delayed and not denied.
 Provided, you don’t GIVE UP.

Dr. Thinker: A path to USMLE contents page

Hey everyone!

Our new awesome author Dr. Raja Chandra (Pen name: Dr. Thinker) is going to share his USMLE experience with us in the next few posts. He is also planning to write a few funny posts. Who is excited? :D

He took out his precious time and wrote everything he had come to learn about USMLE in the past couple of years. This is a contents page that helps you navigate so that you can read what is pertinent to you at this stage :)

Hope it helps! Good luck.

Thanks a lot for sharing this with us, Dr. Thinker! :D

Step 2 CS: Writing examination in patient note

Hello! In this post, I'll be noting some points how to write a patient note for step 2 CS. Especially, focusing on short forms that can be used in the exam.

I have noticed that writing the note in ALL CAPS is better and it does save a lot of time. Similarly, instead of using the "colon : " you could use the "dash - " and it'll make life simpler.

Wednesday, April 6, 2016

Step 2 CS: Loss of consciousness

Differentials:
Seizure - Ask for shaking, tongue biting, rolling of eyes, incontinence

Hypoglycemia - Sweating, fatigue, excessive hunger

Orthostatic hypotension - Ask for palpitations, positional syncope or hypotension associated with large meals. Medications can cause this. Counsel this patient properly by warning them and ask them to get up slowly, etc.

Vasovagal syncope: What were you doing when you lost consciousness?

Tuesday, April 5, 2016

Step 2 CS: Amenorrhea

I am just trying to set a sequence of questions to ask in the exam, tests to order and examination to do so that I am not all over the place in the exam.

So here's what I am going to do if a case of amenorrhea shows up - Ask about general menstrual history and then go to symptoms specific for differentials:

Monday, April 4, 2016

Anatomy and Neuroanatomy - How to Study

Hi guys, I'm Jay once again, and I passed my Anatomy and Neuroanatomy subjects today in my first year. yayyyy!! :D

So I thought I'd share some facts about how I studied anatomy in my MS1 or First year of Medicine.

First, which books to read?

Is Homosexuality a disease? Is Gay a gender? (Sex, Gender and Sexuality)

We got these questions, many times in our Whatsapp study groups! No, is the answer to both questions. Let's find out why and lets find out much more information about what is Sex, Gender and Sexuality(Sexual Orientation)!
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