S******1
发帖数: 44 | 1 今天得知了step3的成绩，210+，心里的石头终于落下。终于轮到我给USMLE说再见了。
回顾从step1自己闭门造车考了只带一个9的分数， step2开始参加小组学习，做了所有
能做的题只为拿个99，虽胸有成竹且考试感觉很好，最终但又得到一个9的分数。虽然
这次成绩不高，依然很高兴，毕竟不用发愁如果没过的话住院医开始后没有时间复习该
咋办。过去的3年中得到太多人的帮助 (此处略去人名20个)，绝大多数甚至从未谋面。
今天发贴也是为了回报我们这个社区吧。
自我介绍：毕业>15年，220+/220+/1st/210+；
复习时间：6月，头4个月每天约2-3小时，周末由于陪孩子们玩（前两年欠的太多，你
懂得）及做点家务（再不做但心被老婆炒掉），反而复习不了多少；最后2个月每天4小
时，鼓励自己考了这个2年内再不用受这个罪。
复习资料：随大流，MTB 3, UW CCS, UW step3 Qbank, UW step2 Qbank;
模拟：考前2月，NBME 1 190+, 考前1周，NBME 2 220+;
体会：难，考过不容易，考高分更难。主要是因为没有合适的复习资料。UW的1300... 阅读全帖 |
|
d******g
发帖数: 258 | 2 How to manage step3 CCS?
It’s hard in the beginning, kind of clueless for me. But you will be able
to get the idea pretty quickly after 5-6 cases in computer. Here’s my
thoughts how to manage it quickly and try not to miss things.
1. Differential if need urgent care.
All Chest pain, SOB, AMS, post-trauma, little infant all need to be ordered
with ER order before physical exam.
ER order mnemonic will be POC IV, ( have to poke someone for IV line)
Pulse oxygen
Oxygen
Cardiac monitor and BP mon... 阅读全帖 |
|
e******e
发帖数: 118 | 3 was the cervical lymph node biopsied?
any signs or labs suggest hemolysis? |
|
e******e
发帖数: 118 | 4 was the cervical lymph node biopsied?
any signs or labs suggest hemolysis? |
|
b****k
发帖数: 409 | 5 DVT ppx 的确是在住院方面两国很大的不同。 没有仔细查有没有这方面资料，中国人出
现血栓风险低。一些有高危因素的应该需要，如长期卧床的，不知道现在国内积极的预
防吗。
不过一些美国要求的mammogram，pap smear什么的中国也没有去做，难道breast
cancer， cervical cancer也比美国低的多？不是医生的错，而是医疗大体制的问题。
中国肝癌比美国高的多，应该全民筛查HBV，没有感染的统一注射疫苗。可现实是基层
缺乏规范的家庭医生门诊，没有去推动普及。比较一下两国的异同，没必要过度敏感。
医生只是整个医疗大环境的很小的一份子罢了，没必要医生间相互排斥 |
|
s*y
发帖数: 18644 | 6 一个clinic里面只有一个provider受到intervention，有下面几组数据
April June Change
clinic ProviderA clinic ProviderA clinic ProviderA
Cancer Screening
Breast 78.3% 59.1% 78.3% 65.5% 0.04% 6.37%
Cervical 56.2% 36.5% 56.5% 39.1% 0.36% 2.61%
Colo 73.0% 70.5% 75.4% 73.3% 2.43% 2.84%
Composite 66.9% 52.5% 71.6% 61.2% 4.70% 9.68%
want to test the change in ProviderA is sig larger than the rest of the
clinic. what test can I use? (clinic=rest of the clinic)
Provider level num/den ... 阅读全帖 |
|
A*******s
发帖数: 9638 | 7 A real case of mine.
A 21 years old male with severe mental retardation, was sent to ER for
mental status change and ataxia.
He was found to be dehydrated and had a UTI. After the dehydration and
sepsis being corrected, he still could not walk. Because he was not able to
cooperate for MRI, a CT of C-Spine and L-spine was ordered. Results were
not remarkable.
The patient was discharged back to nursing home.
At the followup, his family member finally showed up and told me that about
1 month a... 阅读全帖 |
|
A*******s
发帖数: 9638 | 8 Thanks.
MRI should always be considered for cervical disc disease. If any
contraindications for MRI, myelogram can be the alternative.
first time, patient deserved an EMG at that time but I can understand
sometimes triage decision is indeed dependent upon who the patient is. In
this case, a challenging mental status and concurrent infection probably
misled the diagnosis. Importantly you were able to talk to the parents
therefore made the pivotal diagnostic work up eventually preserved this poo... 阅读全帖 |
|
A*******s
发帖数: 9638 | 9 有人提到了spinal cord compression。 我想跟大家再提醒一下，特别是PCP， 不要忘
了cervical stenosis。 这是最容易miss的， 产生的后果也最容易打官司。
这个病人我上周看到他， 手术后已经可以独立行走， 没有任何后遗症。 |
|
A*******s
发帖数: 9638 | 10 Because of the disc disease.
Depending on your exam, you can do cervical spine for UMN lesions, and
Lumbar spine for LMN problems.
But there are always exceptions. |
|
h*********t
发帖数: 116 | 11 是你说的"Depending on your exam, you can do cervical spine for UMN lesions,
and
根本就理解错了，能解释一下么。
谢谢你的案例。学习了
我本人的神经内科太弱，可还是很有兴趣，所以在这儿学习呢 |
|
C*****D
发帖数: 1299 | 12 因为报告不规范。
虽然都是T1， 但AJCC分得很细， 大小和深度更重要，且要明确有无入子宫。临床是否
有意义，取决于临床y医生。
切缘用法不明确： there are only 2 margins: radial and vagina.
Angiolymphatic invasion in cervical SCC not commonly seen, most are due to
the misinterpretation of cancer involving underlying glands/ducts
Adenomyosis is commonly seen in 经产妇或c-section.其他人不常见。
These 2 diagnosis have to be verified |
|
C*****D
发帖数: 1299 | 13 因为报告不规范。
虽然都是T1， 但AJCC分得很细， 大小和深度更重要，且要明确有无入子宫。临床是否
有意义，取决于临床y医生。
切缘用法不明确： there are only 2 margins: radial and vagina.
Angiolymphatic invasion in cervical SCC not commonly seen, most are due to
the misinterpretation of cancer involving underlying glands/ducts
Adenomyosis is commonly seen in 经产妇或c-section.其他人不常见。
These 2 diagnosis have to be verified |
|
A*******s
发帖数: 9638 | 14 Let me guess:
Your initial diagnosis is stroke.
The patient has cervical myelopathy/radiculopathy.
Any headaches? |
|
A*******s
发帖数: 9638 | 15 Let me guess:
Your initial diagnosis is stroke.
The patient has cervical myelopathy/radiculopathy.
Any headaches? |
|
s******t
发帖数: 579 | 16
r/o Horner's symdrome
r/o stroke?
respiratory failure is not from Uncal herniation.
close angle glaucoma can cause a fixed, mid-dilated pupil. We need to
measure the intraocular pressure for possible acute close angle glaucoma.
How about glaucoma and/or pharmacological papillary changes and cervical
myelopathy causing right arm weakness?
Is anti-M used for the biPAP?
Is right arm weakness new or residual symptom? |
|
A*******s
发帖数: 9638 | 17 You got the right answer.
The family brought in her eyedrops for glucoma and the nurse only put the
drops in her left eye. That's why her left pupil is constricted and right
pupil appeared to be bigger than normal that family usually sees.
Her right arm weakness is from surgery and myelopathy.
The lesson we learn from the case is: for the anisocoria, the very first
step is to make sure this is not a pharmacological pupil. Since this patient
has a history of glaucoma, what I did was to pick up th... 阅读全帖 |
|
A*******s
发帖数: 9638 | 18 She likely has failed back surgery syndrome.
DDx: 1. Cervical stenosis.
2. DM amyotrophy
Rec:
1. MRI of C-spine.
2. EMG/NCV.
3. HgA1c. I guess elevated Glu is not fasting.
4. Hold PT. |
|
s******t
发帖数: 579 | 19 Why cervical but not lumbar? Thanks. |
|
s******t
发帖数: 579 | 20 Thanks. I'd like to know that what make you think about cervical stenosis.
She does not have neurological deficit in her upper extremities. |
|
A*******s
发帖数: 9638 | 21 Cervical myelopathy is the most common missed diagnosis because of its
uncertain presentation. UEs sparing does not spare the cervial myelopathy.
Missed diagnosis could end up with permanent disability. |
|
A*******s
发帖数: 9638 | 22 I noticed there are some changes. Thanks for the updates.
For a case like that, you have to make sure if the patient has true weakness
. In some cases, the patient could not walk or feel weak just because of
PAIN. I haven't noticed you mentioned the pain which I believe she has.
I would check ERS/CRP and CK, a lot of cases like that, especially an aged
woman, could have PMR.
DM amyotrophy is another DDx if PMR can be R/O.
With both sensory/motor involvement on a single leg, radiculopathy is mo... 阅读全帖 |
|
s******t
发帖数: 579 | 23 多谢A＋＋的详细耐心的回答！
在psych unit，他们倾向于将病人的躯体症状归罪于精神因素，我提了CK，和再测一次
BMP或CMP，但是他们不想测。更别提会测cervical MRI了。他们一直想push病人多做PT。
不过你是对的，第一次测glucose的时候病人不是fasting的，病人也没有DM 的病史。
不过，再测一次也不过分的不是？
病人的ESR是正常的，一直afebrile，有4/10 back pain,没有其它地方的pain。她下肢
的力气还是很大的，力量上基本上很对称。没见过PMR case，但感觉应该是有比较
general的疼痛的吧?
上次测gait时忘了做heel to toe。几天特意看了看，她做起来有时不稳，但有时很好
，感觉她的左下肢有些僵直的样子，但muscle tone没问题。
她反复说感觉下肢的tightness，也不是muscle spasm，也不是pain，我真搞不明白这
个tightness是指什么。她说这个tightness在运动之后会加重，所以她都不出去和老公
散步了。谁有经验的给咱解解迷？ |
|
C*****D
发帖数: 1299 | 24 还是探讨一下工作中的实际问题吧。
今天医院risk management 的律师给我们讲一实例。
现许多病人喜欢用email联系，过去医院不主张，但现在大事所趋。有一女病人和丈夫
公用一email帐号用来和医生联系。有一次做完PAP smear 后，护士就把报告结果email
病人：CIN1。（cervical intraepithelial neoplasia）， please come by to pick
up the report and your contraceptive pills.
悲剧了：丈夫读到这个mail， 且他已vasectomy。 一对质，原来是红杏。离婚。病人
就把医院告了。问：医院有liability 吗？ |
|
D*********r
发帖数: 371 | 25 cervical paranoia, etiology: mistrust one holds against his pcp. risk factor
spectrum antibiotics, usually the "4th" or "5th" generation cephalosporin,
which I heard temporarily cure all kinds of paranoia ;P
, |
|
V**y
发帖数: 788 | 26 Cervical Degenerative Disc Disease |
|
b*******s
发帖数: 954 | 27 妈妈颈椎病引起的头晕。不是特别厉害。但是我很担心。
请问A++ 有什么建议吗？
去年妈妈在国内的时候，核磁共振啊等各种方法都查过了。没有查出什么不好的地方。
去年她也是头晕，严重的时候走路有些走不稳。好像是天冷的时候特别厉害。后来就好
了。她有的时候吃点天麻片。速效救心丸也备着。妈妈在美国的时候颈椎病一直没有发
。她说大概是因为我们这儿天气暖和。妈妈年轻的时候是椎间盘突出，后来做牵引好的
。现在她好像腰还好。
今天妈妈有点头晕。我爸爸给她按摩了一下。我家小宝又上去狂敲了一下外婆的背 (没
有敲颈部，敲的基本是肩膀）。结果大概二十分钟以后，妈妈从一个矮凳子上站起来以
后，就说头晕。就躺下了。其他她没有说有不舒服的。我爸爸是赤脚医生，给妈妈吃了
五个速效救心丸。后来妈妈自己起来吃饭了。 看上去精神还好。
在网上看了一圈"cervical spine disease", 看看我妈妈的头晕和走路不稳的症状和网
上的描述是符合的。看到网上还说不能很重的按摩。我就很后悔。不知道妈妈的头晕是
不是因为家里小宝敲外婆的背引起的？小宝手挺重的。
本来我想带妈妈去做physical therapy, 但是... 阅读全帖 |
|
A*******s
发帖数: 9638 | 28 回答你的问题，首先我们要搞清楚一些基本概念， 大家有不同意见，请随便。
眩晕vertigo可以理解为位置感觉的错觉。 一个晕字可以是各种各样的症状。 眩晕分
为central和peripheral， central是CNS， 主要是脑干，小脑的问题； peripheral是
内耳的问题。
就像楼上说的，cervical degenerative disc disease or spondylosis是描述颈椎的
病变，如果引起vertigo， 主要是血液供应的问题， 可能你知道Vertibrobasilar
artery insufficiency， MRA可以看到basilar stenosis， 但vertibral artery
stenosis是不是可以引起临床症状有争论， 很多病人一侧的vertibral artery都封闭
了， 却没有任何临床症状。 所以如果MRA正常，central vertigo可能性就不大（当然
MRA经常underestimate）。 对于颈椎病， 因为骨刺引起椎动脉供血不足我是很少听说
， 但有一种情况我在一个thread里提过， 叫bow hu... 阅读全帖 |
|
A*******s
发帖数: 9638 | 29 老年人或多或少有所谓的颈椎病， 但与头晕的关系应该不大。 很容易理解，
inflammation可以影响spine， 当然可以影响内耳。 所以当cervical arthritis
flares up one day， you may also have BPPV relapse. |
|
b*******s
发帖数: 954 | 30 BPPV/BPPV on the background of cervical arthritis makes much sense.
(1) 我应该没有颈椎病，但非常偶尔会有像妈妈一样的眩晕状况。我猜应该也是你说
BPPV, 大概是遗传的。
(2) 妈妈昨天头晕之前，确实做了一个一下子站起来的动作。
(3) 颈椎arthritis进而影响内耳，也是很有可能的。
知道头晕很可能是良性的。我就放心多了。
多谢A++！
P.S. 虽然楼上各位不是House, 但是觉得大家分析问题的方法，好像解决puzzle似的。
It is a lot of fun and thanks for helping others! |
|
j****r
发帖数: 200 | 31 From what you described, your kid is not likely to have strep throat. You
can google: centor criteria. The highlighted part are attached below. But
severe and prolonged cough with fever, you should rule out the possibility
of pneumonia. You might want to see your doctor and get a X-ray, especially
if the cough is getting worse with time.
*************************************************
The patients are judged on four criteria, with one point added for each
positive criterion:[1]
History of feve... 阅读全帖 |
|
z****u
发帖数: 1007 | 32 对implant经验不算多。如果病人所说全部属实，那这医生做得确实不算太好。
没有在拔牙后立刻进行bone graft来防止bone
resorption. 在4个月愈合期后没有评估bone resorption状况和牙龈萎缩的后果。
也没有采取gingival graft的方式来补救。最退后一步，PFM还可在cervical 那里用
gingival color porcelain来模仿gingival margin.
BTW,下面show出来的几张国内图片其实是残根上面的post+BU,而不是implant. |
|
a**e
发帖数: 5094 | 33 来自主题: Medicalpractice版 - EPIC门诊 最倒霉的是medicare/medcaid的病人，昨天一个cervical dystonia病人要用botox，
EPIC死活说medicare不能批，大家折腾了4个小时还是搞不定
nurses |
|
A**N
发帖数: 26 | 34 我在国内体检胸腔x-ray发现肺右上页肿瘤，手术摘除肺右上页。
肿瘤大小是9X9X3cm，已经侵入胸腔肌肉。PET/CT没有发现其它部位有肿瘤。
病理分析是小细胞肺癌。出院后回美国治疗。在美国的病理分析结果是，atypical
lung carcinoid，PET/CT显示胸腔上还有肿瘤残余，也可能是手术后的炎症（我背部还
有疼痛感，距手术2个月），但医生更倾向于肿瘤。Bronchoscopy, cervical
mediastionoscopy 结果没有发现向淋巴结的转移，MRI没有发现脑部肿瘤。治疗方案是
化疗4个疗程（cisplatin+etoposide），中间有放疗。医生担心这个肿瘤长得太快（一
年前x-ray没有发现），所以按照小细胞来治疗。
我在想是不是可以等一等，确定胸腔上的手术伤口愈合后再治疗。如果PET/CT的影像不
是肿瘤，就不考虑放疗了。
不知我这个想法是不是有道理，请给位医生提供指导意见。 |
|
B****r
发帖数: 1737 | 35 看了三次医生，没有任何进展。可能下周要收入院了。小地方没有儿童医院，也不知道
该不该换个别的医生。恳请大家帮着瞧瞧 （病人情况如下）。万分感谢。
5 yo female with persistent cough x 14 days and fever x 10 days. Fever runs
102-104 F, but does normalize when given motrin or tylenol. Symptom no
improvement after 4 days of Azithromycin. Began to have loose stool /watery
diarrhea for past 3-4 days. She had complained of abdominal pain (mostly
peri-umbilical) intermittently for the past 2-3 weeks. Has a history of
problems with constipation. Slightly decreased PO intake, ... 阅读全帖 |
|
m******r
发帖数: 1904 | 36 【 以下文字转载自 MedicalCareer 讨论区 】
发信人: Blazer (--), 信区: MedicalCareer
标 题: 求助：５岁小孩高烧１０天
发信站: BBS 未名空间站 (Sat Feb 2 23:01:40 2013, 美东)
看了三次医生，没有任何进展。可能下周要收入院了。小地方没有儿童医院，也不知道
该不该换个别的医生。恳请大家帮着瞧瞧 （病人情况如下）。万分感谢。
5 yo female with persistent cough x 14 days and fever x 10 days. Fever runs
102-104 F, but does normalize when given motrin or tylenol. Symptom no
improvement after 4 days of Azithromycin. Began to have loose stool /watery
diarrhea for past 3-4 days. She had complained of abdominal pain (mostly... 阅读全帖 |
|
A*******s
发帖数: 9638 | 37 我建议您手刃丫的， 以出心中恶气，lol
LZ其实说出了一个悲凉的现实，就是化了大把的钱，病人却没有被治好，这个理到哪里
讲？
我对这个病人的情况不了解，但从楼主的寥寥数语可以推断，这个病人很可能得了
cervical myelopathy， 原因就是disc herniation。 所以跌倒不是意外，而很可能是
椎间盘突出压迫脊髓引起的。 这种情况，手术可以减压，但预后却取决于压迫的程度
和时间。 我问这个病人的年龄也是想知道是不是高龄手术后出现了并发症。 年龄越大
，手术的并发症越容易出现。 这就是我不主张老年病人轻易做手术，但这个病人没有
选择，不做的后果就是瘫痪。
手术本身应该不是问题，这个手术前的脊髓压迫状况和手术后的并发症最可能是病人瘫
痪在床和呼吸衰竭的原因。
我同意楼上的，国内有国内的现状，如果在手术前把可能的预后跟病人讲清楚了，楼主
可能就不会这么恶从胆边生了。
|
|
a*********d
发帖数: 2763 | 38 case 3
A 30-year-old man sees his primary care physician for routine follow-up and
is documented to have a serum calcium concentration of 12.9 mg/dL. He is
admitted to the hospital directly from the clinic for further evaluation and
treatment. The patient states that he has a 5-year history of sarcoidosis,
but admits to nonadherence to his follow-up care and treatment regimen. He
had 1 episode of nephrolithiasis approximately 1 year ago and was told that
his kidneys are “abnormal.” Before admiss... 阅读全帖 |
|
A*******s
发帖数: 9638 | 39 "右手臂明显细了，看病时医生发现右腿也明显比左腿细"
"左腿左臂明显肌肉萎缩"
I am confused.
Do you have neurological examination on paper?
Do you have a MRI of cervical spine?
I wish she would not have ALS. |
|
f**********n
发帖数: 246 | 40 USPSTF recommends that screening for cervical cancer in women ages 21 to 65
years with cytology (Pap smear) every 3 years or, for women ages 30 to 65
years who want to lengthen the screening interval, screening with a
combination of cytology and human papillomavirus (HPV) testing every 5 years
. |
|
m****9
发帖数: 26 | 41 这是neurologist的结论:
MRI shows nothing concerning intracranially or with the soft tissue of his
neck. He does have some narrowing in his cervical region that warrant a
neurosurgical opinion.
不知道看ENT的作用是什么？ 谢谢。 |
|
d**o
发帖数: 618 | 42 So, I suppose an MRI cervical spine may be indicated to r/o C5-C6
impingement? |
|
g****f
发帖数: 5 | 43 我同学的女儿，13岁，刚被诊断胸椎侧弯。北京的医院有的建议保守治疗，有的建议赶
紧手术。考虑手术的风险，父母十分担心。望熟悉这方面的朋友可以帮忙建议。十分感
谢。 如果可以介绍美国这边的医院也十分感谢。
MR检查报告单
胸椎平扫
扫描技术：Cor、 Sag、T1WI、T2WI
检查所见：胸椎稍显侧弯，以Th2为中心向左突，Cobb角约19.48°，胸椎生理曲度存在
，椎体及附件未见明显骨质增生征象，椎间隙未见明显狭窄，未见明显椎间盘膨出或突
出征象，胸段脊髓未见明显异常号影。
意见：胸椎稍显侧弯，以Th2为中心稍向左突，请结合临床。
MR examination report
T-spine Routine Scan
Scanning Technology: Cor、Sag、T1WI、T2WI
Examination findings: Thoracic vertebrae are showed T2-centered left
scoliosis. The Cobb angle is about 19.48°. Physiological curvature of
thorac... 阅读全帖 |
|
|
k**a
发帖数: 1124 | 45 i had three mature follicles each time i used clomid (100 mg for 5 days).
i have read that clomid may dry out your cervical mucus but if you are doing
IUI, probably not a big deal.
as far as long term effect, at this point, you really can't worry about that
much. just don't do that many cycles le lah. i only did two cycles with
clomid. |
|
e******3
发帖数: 773 | 46 Clomid can also cause excessive cervical mucus (which was my case), which
means no sperms from xxx can go through. Basically this means the sperms
sent up through IUI were your only hope. Considering in a natural cycle
couples would xxx multiple times, there is a good chance that with IUI less
sperms end up where one wants them to be. I had 4 clomid+IUI cycles without
success. But this is just my singular case. There are heaps of women who
indeed got pregnant from clomid IUI cycle, so I think it |
|
j*******2
发帖数: 309 | 47 这种蛋清状的粘液是cervical fluid，是排卵前激素作用下，宫颈分泌的。一般这种蛋
清状的白带会持续几天，有蛋清状白带的最后一天一般就是排卵日。这种蛋清状白带是
要排卵的标志，不是卵子死了什么的。我有几个周期这种白带也很少，但温度说明还是
有排卵的。
我不确定的是，是不是没有或者很少蛋清状白带说明这个周期的卵子质量不好。。。我
上次怀孕的那个周期就是没有这种白带，后来7w的时候流产了。 |
|
j*******d
发帖数: 14 | 48 今天问我的OB关于IUI,可能是我搞错了，我只想口服clomid,然后自己检测排卵的状态和
intercourse.结果接电话的护士跟我说我的clomid是要注射的，并且非要在医院做超声
检测和跟
踪。这样算下来每个cycle自掏腰包要至少1500块。可是我嫂子说一般像我这种情况，
不应该一下子先
跳到IUI这么复杂的步骤，应该和她一样就口服clomid就行了,说是一般的美国医生都是
先给口服
clomid，不行在试IUI。
我嫂子跟我同龄，已经是两个孩子的妈了。最近刚生的这个女儿也是用clomid才有的。
我嫂子有
Hostile cervical mucous这个病，据说只能用clomid才能怀孕。她用了clomid两试两
种。
不知道我的OB是否有只想赚钱的嫌疑，所以我想问问这么姐妹用clomid都是口服还是注
射方式的呢？先
谢谢了。 |
|
