CS by Hammad Bhai

BOOKS
1... usmle world (uw) (there r almost 70 cases ..u need to prepare all of em..there is one case missing ..depression
also psychiatry case questions need to b done from first aid...

2... first aid...wen ur done wid ur cases(uw) 3-4 times..take a mock history on a rough paper n then write the notes
history physical d/d investigations on first aid.they hav provided space just for that..on the next page they hav
indicated how it shud hav bn done...almost 26 cases..
3..if u can..kaplan csa has a gud examination section ..u can memorize the exact commands to b used during physical..

PREPARATION
..get a partner..memorize the scheme(appears undrneath)...take one case..read it for say 15 minutes..leave the book...
start doing the case while ur friend is the simulated pt..at the end ur frend will tell u ur mistakes..take few moments to go over em..n then go
onto the next case...those who think ratalizing the book first n practise later is the way do it..are truly at fault..PRACTISE FROM THE WORD GO..
THOSE WHO ARE GOOD WITH THEIR ROUTINE WILL B successful coz u need to hav everything at ur spinal level..making it a reflex.. don't hav time
to think everything....PRACTICE...

go thru usmle world 4-5 times..may take one month...practise ur notes on first aid...

SCHEME
ull b given 2 pens n 2 papers for each case(total 24 papers)...one paper is 4ruff work n the other one 4 actual
notes that will count...once u r standing facing the door..first the pt will b asked to take his position inside
the room n then ull b asked to slide open the doorway info infront of u..

wat u need to do is that..

1..write the name of pt on top left corner coz ull forget it once ur inside n u need to repeatedly address him/her
using the name..say mr steven or ms barbara not just steven...

2..write all ur pneumonics coz then ull b free to ask questions acc to a set pattern without blacking out..

3..there r actually 2 ways to take history...one is that u memorize all the d/d n go by em...2nd is that
u make pnumonics of the cases n practise em..cases r mostly the common ones so i made all the pneumonics n
wrote em before i went in..this way i didnt had to think ...i just went thru with my routine...which ever
woks for u...

4..take 45 sec to write all ur pneumonics..pts name..n if u r missing something in previous cases or ur prone to miss
something to say to the pt ..e.g i kept forgetting i had to take the ob/gyn history,u need to mention pr exam
in a git case , same goes for pv exam in a gyn case,u need to ask mother to bring her child to the hospital n give
her antiyretics on the way..so write these things on the top right corner...

5..i use to prepare my ruff sheet in three columns as following ..in 45 sec..

ruff sheet
pt name mr arnolD mention pr exam etc




QUESTIONS(first ask 7 standard q that
apply to all cases)

H how long hav u bn having his condition
S was it sudden or gradual
C constant or intermittent(if int wat is the frequency)
P wat is the progression inc/dec/same
A association wat were u doing wen it started
A aggravating factors
A alleviating factors

SPECIFIC QUESTIONS(PNEUMONICS/ D/D)
e.g ACC TO THE CASE AT HAND
L
I
Q
O
R
A
A
A

ETC (ill write pneumonics at the end of discussion)

ruff sheet
ROS (REVIEW OF systems )

F fever
E eye complaint
V vomiting/nausea
E ear complaint
R racing heart/palpitations

W wEight CHANGE(recent+unintentional)
A apetite CHANGE(recent inc/dec)
S sleep problems+shortness breath+swelling feet

C couhg + chest pain
O
U urinary complaint
G git complaint
H headache

ruff sheet
P PAST MEDICAL H/O
A ALLERGY
M MEDICATION

H HOSPITALIZATION
U URINARY COMPLIAINT
G GIT COMPLAINT
S SLEEP

F FAMILY H/O
O OCCUPATION/obgyn
S SEXUAL H/O
S SOCIAL H/O

ENTERING THE ROOM..
as u enter the room ul do th following steps in the same order..(memorize the sentences)


1..knock (u can say "may i come in")

2..greet ("hello mr baker good morning/good afternoon")

3..introduce ("my name is Dr Bhatti ill b ur physician today")

4..explain ur presence ("i am here to ask few questions abt ur health n then ill b performong a brief physical examination")

5..consent ("is that ok with u??")

6..assure comfort(look around(drama) n say "is everthing comfortable in here for u")

7..drape ("let me drape u first so that ull feel more comfortable"..there will b a white sheet on a stool..find it..fold it n cover pt s thighs..
he has a half sleeve gown on so u need to cover his thighs)

8..how do u feel now..are u more comfortable now

9..what brings u in today ..once he is finished say.."is it ok if I take notes while u talk"(so that he wont object to ur not having an eye contact wen
taking notes)..try to break down watever he says into small notes n write em on ur ruff sheet coz if u dont..once ur out of the room n abt to write the
pt notes..u mite forget wat the pt had said...

10..now ask those 7 questions i mentioned...then ask specific questions..

11..after that say.."now i need to ask few questions relatig to other systems of ur body..is that ok with u"...imp thing is that u take notes

SUMMARIZE
12..SUMMARIZE...it definitely has a point n u need to say the following sentence."before i go on to ur past medical history(pam hugs foss)i will SUMMARIZE
(say loud) ur complaint for u...u hav told me....do u hav anything to add?? "at this time or may b later pt will ask u a question...ALL OF EM r written in uw
n also u can consult the dufficult question section of first aid...

past medical history
13..now say "i will ask few questins about your past medical history is that ok with u"(these r kald transition sentences n r v.v imp)
ask the following 5 questions..

a..hav u ever had this condition before(complaint at hand)
b..do u hav any other medical condition that ull like to mention.
c..do u hav high blood pressure.if no.did u ever chek it.wen was the last time ur doc cheked it.
d..do u hav high blood sugar showing if no.did u ever chek it.wen was the last time ur doc cheked it.
e..do u hav high bloood cholesterol..if no.did u ever chek it.wen was the last time ur doc cheked it.

if ans to any question is yes..ask..
1..wen was it diagnosed
2..wat r the drugs u take
3..their doses n timings
4 do u take em regularly
5 any side effect
6 is ur condition under gud control..range of ur bp/blood sugar..

if the pt is not taking his condition seriously e.g not drug compliant or not checking his bp regularly..ask y..n if no particular reason
...its v.v.vv. imp that u do the counselling..

"being ur physician its my duty to warn u that ur current behavior is a great risk to ur health...HTN is although
a manageable condition but if u dont do as advised it can b very harmfulto ur heart,brain n kidneys..it can lead
to stroke,mi,renal failure etc...its high time for u to understand that and start doing wat is necessary..if u hav any
trouble u can always contact me...hope i hav made it clear enuff" u sure did doc...moving on...


do the same for diabetes n high cholesterol... DONT MISS THE COUNSELLING...

if he is doing everything right..say..."nice to hear that mr baker".
14..ALLERGY are u allergic to anything...any drug....if yes..wat hapens(wat kind of rash n how controlled)

15..MEDICATIONS a.did u take anything for ur present codition..how many doses
b.did it work
c.are u currently taking any other medicaton..dose,.timing,.S.E,


16..HOSPITALIZATIONS were u hospitalized previously..wen..y..

17..URINARY COMPLAINTS..do u hav any urinary complaints.

18..GUT COMPLAINTS..how are ur bowels.

19..SLEEP..any problem with ur sleep

20..FAMILY..again a transiion sentence..."now i need to ask few quesions about your family..i hope its ok with you"

a.."are ur parents alive"..."yes nice to hear that".."are they suffering from any medical condition"...if the ans is no"would u b
kind enuff to share their cause of death wid me".

b..is there any medical condition running in ur family..

21..SEXUAL HISTORY..TRANSITION SENTENCE.."now i need to ask few quesions about ur sexual habits/health""is that ok with u""please dont feel embarrased
as watever u say will b kept cofidential n help me alot towards understanding ur problem".

a..are u sexually active'
b..with how many partners.
c..do u relate more to men or women or both.
d..do u use any barrier methods like condoms.
e..were u ever diagnosed with any sexually transmitted disease ike syphilis,gonorrhea.

if he has multiple sexual partners,past hisstory of STD,n doesnot use condoms..counsel..if he uses condoms congrtatulate him and let him
knw wat wud happen if he doesnot use condoms...

"as ur responsible physician its my duty to inform u that ur sexual behaviour exposes u to a great risk of aquiring Sexually
transmitted diseases like gonorrhea ,syphilis and even HIV.its time for u realize that n its recommended that u use condoms
to avoid these diseases..is it ok with u"

SOCIAL HISTORY..
22..SOCIAL HISTORY..transition sentence.."now i need to ask few questions about ur social habits""is that ok wid u".

a.."do u smoke..how long hav u bn smoking..how much/day"...even if he smokes 1 cigarette..u hav2do the counselling

"as ur physician its my respsibility to warn u that smoking is harmful for ur health...n i tell u y..its
injurious to ur health coz it causes heart attack stroke n carcinomas of many parts of the body including
lung,lip,tongue n even kidney..not to mention it causes copd n pneumonias...so its high time u realize the
gravity of the situation n QUIT this habit..have i made this clear enuff""if u need any help
im always available n i can give u the no of support groups that will help u quit ur habit.i can also
prescribe medication to stop the craving"" do consider wat i hav said""thnx"

social history
b.."do u drink".."how long".."how much"...anything above >=2 drinks n u need2 do the cage to assess abuse

1..hav u ever tried to cut down on the no of ur drinks.
2..get annoyed
3..felt guilty
4..ever used it as an eye-opener.(if ans to last quetion + or 2 uestions + u will do the following counselling)

"as ur physician its my respsibility to inform u that drinking in that much quantity is harmful for ur health...n i tell u y..its
injurious to ur health coz it causes it causes inflammation of ur liver n pancreas n bad
for ur heart ...causes carcinomas of many parts of the body including liver n pancreas...
...so its high time u realize the gravity of the situation n LIMIT Ur alcohol intake..have i made this clear enuff"
if u need any help im always available n i can give u the no of support groups that will help u quit ur habit.i can also
prescribe medication to stop the craving"" do consider wat i hav said""thnx"


c.. "do u use any illicit drugs" do the counselling acc to the drug..e.g like cocaine can cause stroke,mi,sudden death,
HTN,..mirajuana causes dependance n ofcourse injecting something in ur body has its own problems e.g endocardtis etc.

OBGYN HISTORY
23..OBGYN HISTORY..transition sentence.."now i need to ask few questions about ur gynaecological health i assure u watever u say
will b kept confidential".."is it ok wid u".

start with obs questions in the following order...


a..hav u ever bn pregnant..
b..how many children do u hav..if any discrepancy in the no..ull ask
c.wat happened...intentional etc..
d.which trimester..

going on to gynae questions..

a..at wat age did u start having menstrual flow.
b..are ur cycles regular.
c..how often do u hav ur cycle.
d..how long does menstrual flow last.
e..do u hav any intermenstrual bleeding.
f..any bleeding with sexual activity.
g..any pain withur menstrual flow.
h..do u use any method of contraception...which one..any SE
i..wen was ur last pap smear done..was it normal..(if no pap smear done..counsel).

24..once u hav gone thru pam hugs foss..say.."ok mr baker. im just abt done with ur history n before i go onto the physical exam
let me WASH MY HANDS FIRST"..after washing with soap dont close the tap..first dry em with tissue paper(they ll make u spend sometime
with all the equipment ull use..so dont worry ull knw where to look for things u need) n then close the tap using the tissue paper..


25..WHILE WASHING THE HANDS...u need to ask 5 questions...

a..occupation "wat do u do for a living".
b..travel "recently,did u travel any where out of us may b".
c..vaccination "recently,were u vacinated against any disease".
d..trauma "recently did uhav any trauma".
e..hands "tell me do my hands feel cold2u or r they oK"...touch his hands..its imp coz pt may scream out of proportion if u touch him
with cold hands or stethescope...so warm ur hands n steth....v.v.v.imp...

PHYSICAL EXAMINATION
26..PHYSICAL EXAMINATION..THE WORD IS ..COMMENTARY...does not matter whether u do it properly or not but it counts alot whether ur letting ur pt
knw wat u are u doing...so if ur looking at belly..narrrate..im looking for any visible veins pulsations,scar mark,mass,umblical position...
suppose ur looking inside the mouth say that..im lookig for any bleeding,swollen gums,teeth abnormallity....put appropriate trnsition sentences
as u gp frm one system to another while explaining wat ull b looking for..as mentioned earlier..kaplan csa has a list of commands that r very
useful n also ull get a cd with uw with exam scheme....the kind of prep we do for proff is far more than wat is required for csa so im sure
ul find physical to b a relatively easier part of the exam...

neuro exam is a bit lenghthy..make him close his eyes n do the sensory system of the whole body including face,arms n legs..
in a single go by exposing his limbs..will save alot of time...chek power in shoulders n then hands..similarly thighs n feett..coz pt
has only one point to award u..whether u chek power minutely or do only the imp muscle groups..u gain only one point..so save time..

CONCLUSION..
27..CONCLUSION..it is imp that u finish strong..will count alot towrds how simulated pt gives u points esp in the field of interpersonal skills
so ur concluding remarks must hav folowing points...


a..history
b..physical
d..d/d (2-3)
c..investigations
e..intervention/drug
f..shifting orders
g..lifestyle modification/counselling
h..questions/concern
i..thank u/smile
it shud sound something like this...

"ok mr baker.i hav taken ur history n done ur physical examination which was mostly normal except for the tenderness i was able to elicit
in the left lower part of ur tummy.im my (expert)opinion this cud b due to inflammation of ur appendix coz thats the most common cause
however this may as well b a pathology involving part of large intestine called caecum or an infection of local lymph nodes..without
performing urther investigations i cant b sure about ur conditio at this stage..that is y i am recommending few tests of ur blood,urine
n also an ultra sound of ur abdomen..

in the mean time im admitting u to our ward n prescribing these drugs to take care of the pain...a nurse will assist u shortly to give u
ur medicine...i would advise u to hav complete bedrest etc..

mr.baker hav u understood everything we hav discussed during this meeting..

do u hav anything to add..
do u hav any question or concern..

ok mr baker thank u very much for ur time..it ws really very nice working with u...kindly dont miss ur next appointment(if pt is seen on out
door basis)...goodbye..smile..

PNEUMONICS...
1..HEADACHE CASE...WENT..WEAKNESS+WARNING SIGNS..EAR+EYE COMPLAINTS...NUMBNESS +TINGLING+NAUSEA...TRAUMA+THYROID n ofcourse liqoraaa

2..ANY NEURO CASE...NOSE FT...N REPERSENTS numbness + tingling +weakness..o = lOss of consciousness..s=speech+seizure+swelling feet+swallowing
f=fall..t=thyroid


3..paeds case...u dont hav to do the examination..just ask mom to bring him over n give him paracetamol on the way..write one more pneumonic
on ur ruff sheet for this case....ABCDEFS...

A=antenatal care..representing any problem or complication before during or after birth..ULL hav to ask separately
B=breast feeding...
C=cry..how was his cry like wen born...was he breathing normally..
D=was his development normal..wen did he smile first..his first word ..his first steps..
E=else anybody else effected in the household sibling may b
F=any feeding problems... (failure to thrive)...
S=any smoking in the household..
v.v.v ,imp..counsel thaT its strongly related to URTI + otitis media.

4..urinary problems..BPH IS Continuous FUN...


BURNING..DO U HAV BURNING URINATION..ANY PAIN(LION GROIN pAIN)
PUS......IS THERE ANY PUS IN UR URINE..
HEMATURIA..WAT IS THE COLOUR OF UR URINE..RED..IS THERE BLOOD IN IT..DO U BLEED FROM ANYWHERE ELSE..
HESITANCY..DO U HAV TROUBLE STARTING IT/DOES IT TAKE LONG TIME TO START..
INCONTINENCE.DO U HAV TROUBLE HOLDING IT/ANY LOSS OF URINE WITHOUT UR KNOWLEDGE...
STREAM...HOW IS THE STREAM..STRONG WEAK..
CONTINUOUS STREAM OR DOES IT DRIBBLE
FREQUENCY..HOW MANY TIMES DO U URINATE.
URGENCY..DO U HAV TO RUSH TO THE WASHROOM TO URINATE..
NOCTURIA..HOW MANY TIMES DO U GET UP AT NIGHT TO URNATE..

5..GIT CASE..DCT

DIARRHEA
DISTENTION ANY MASS
COLOUR
CRAMPING + PAIN WHILE DEFECATING
CONTIPATION
CUANTITY/QUANTITY
CALIBRE OF STOOl
Consistency well formed/watery
COMING OUT SOMETHING( HAEMRRHOIDS)
THYROID do u ahv any trouble adjusting to temperatures...
TENESMUS

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