l********y
发帖数: 2295 | 1 【 以下文字转载自 Pre_Resident_Club 俱乐部 】
发信人: lovelypony (pony), 信区: Pre_Resident_Club
标 题: case presentation 学习笔记
发信站: BBS 未名空间站 (Tue Feb 22 20:03:05 2011, 美东)
昨天第一次参加了由现任斑竹chipmunk和元老knockingdown主持的case presentation
，觉得收获很大，后面慢慢的把自己的学习笔记贴出来，后面的同学看了可以少犯些我
们犯过的低级错误，这样前辈们也可以省些力气。前辈们牺牲自己宝贵的私人时间，聆听我们支离破碎，毫无章法的presentation ，耐心细致的指出错误，提出建议，pony真的觉得没有更好的语言来表达自己的感激之情。就希望能抛砖引玉，大家能互帮互助，提高我们CMG的整体水平，这样前辈们的心思也算没有白花，希望大家都能来补充和指出错误，多谢了！
要present一个case，结构一定要完整。
1. CC: 第一句话永远是chief complaint，怎么样用一句话简明扼要的把CC说好了，还是要花大力气的。CC应该只是一句话，但要包括下列4个基本元素：The patient’s age and sex；The patient’s active ongoing medical problems；The patient’s reason for presentation；The duration of symptoms。这个我们练习CS的时候都练习过了，但是要怎么很好的口头表达清晰还是要再练习。CC里面一定要涵盖patient最重要的信息，不能在后面HPI或者PMH的时候给attending一个big surprise，从CC里attending大概就知道patient的主要毛病了。
2. HPI：三段论：阳性症状+阴性症状+workup
先说阳性症状，按照时间顺序叙述，而且要详细。这时候我们CS背的OCD FP, LIQR AAA就上吧，CS还是有用的，嘻嘻～
阳性的说完了再说阴性症状。注意阴性症状的阐述也很重要，要包括3部分：一是有没有全身症状，二是同系统其他症状(比如说cough是respiratory系统，就要再详细说有没有phlem,chest pain, dyspnea, wheezing, etc.)，三是risk factors.
阴性症状说完了就可以说workup了。
3. PMH：这时候CS的PAM HUGS FOSS就可以上了，这个pony也有待practice，这么多信息有点啰嗦的说，好像挑些重要的说说？有待前辈指点。
4. PE：也是三段论：总体印象+阳性体检+阴性体检。这里pony还是有点糊涂，如果是一个full－size presentation的话，是先把阳性的说了，再按系统说阴性体征呢，还是就按照系统一个一个系统的说？
开始先给一个总体印象：general description and vital signs。这个昨天鼠大大专门强调了，我们昨天present一个A-fib，这个很重要，第一印象决定patient是stable还是unstable，直接决定后面的诊疗计划呢。
然后all abnormal findings：
最后是normal findings, include only those essential to the understanding of the chief complaint
5. lab：这个直接从网站摘抄的：
•Include all abnormal labs, with comparison to previous value
•Among normal labs, includes only those relevant to the chief complaint
•Any labs presented should appear in traditional order (electrolytes/creatinine/glucose, complete blood count, other chemistries, urinalysis, CXR, ECG, gram stains and analysis of body fluids)
6. A&P：这个网站上写的很好，大段抄袭。
1）.Begin with a positive statement of the patient’s problem。
2）.Ask yourself "At the moment I am presenting the case, what is the principal unresolved issue?"
a.If the principal unresolved issue is diagnosis, your assessment focuses on differential diagnosis。
b.If the principal unresolved issue is therapy, your assessment: (i) states the diagnosis or problem, (ii) states which therapy you gave or plan to give, and why you made this decision, (iii) states which complications you might anticipate.
3）.If you are presenting the morning after overnight call, the case presentation usually ends with a 1-2 sentence summary of what happened overnight, after implementation of your initial decisions.
present case应该是基于记忆的，和attending一定要有eye contact，尽量避免看note。
先发一部分，后面有空了慢慢改，见谅。 | l********y
发帖数: 2295 | 2 一楼主要是结构问题，二楼留给一些琐碎的笔记。
Can’t say qd (outdated), have to say once daily. Even for prescription.
Can say UTI, 不一定非要说urinary tract infection.
3 vessel CABG的念法是：Triple vessel cabbage, NOT three vessel, or C-A-B-G.
Can say IV push or bolus, which is different from drip.
Can say drip, don’t have to say intravenous drip.
Can say two-D echo, don’t have to say two-dimension echo.
Say D/C or discontinuous, don’t say cancel. D/C stands for discharge too.
Can say either P.O or oral. | u*****0
发帖数: 156 | 3 Thanks very much for your support of our medi. Hope everyone will be as
generous as you.
presentation
聆听我们支离破碎，毫无章法的presentation ，耐心细致的指出错误，提出建议，
pony真的觉得没有更好的语言来表达自己的感激之情。就希望能抛砖引玉，大家能互帮
互助，提高我们CMG的整体水平，这样前辈们的心思也算没有白花，希望大家都能来补
充和指出错误，多谢了！
还是要花大力气的。CC应该只是一句话，但要包括下列4个基本元素：The patient’s
age and sex；The patient’s active ongoing medical problems；The patient’s
reason for presentation；The duration of symptoms。这个我们练习CS的时候都练
习过了，但是要怎么很好的口头表达清晰还是要再练习。CC里面一定要涵盖patient最
重要的信息，不能在后面HPI或者PMH的时候给attending一个big surprise，从CC里
attending大概就知道patient的主要毛病了。
AAA就上吧，CS还是有用的，嘻嘻～
【在 l********y 的大作中提到】
: 一楼主要是结构问题，二楼留给一些琐碎的笔记。
: Can’t say qd (outdated), have to say once daily. Even for prescription.
: Can say UTI, 不一定非要说urinary tract infection.
: 3 vessel CABG的念法是：Triple vessel cabbage, NOT three vessel, or C-A-B-G.
: Can say IV push or bolus, which is different from drip.
: Can say drip, don’t have to say intravenous drip.
: Can say two-D echo, don’t have to say two-dimension echo.
: Say D/C or discontinuous, don’t say cancel. D/C stands for discharge too.
: Can say either P.O or oral.
| l********y
发帖数: 2295 | 4 Kaye BZ, how about a huge baozi for this one too? hehe~~it took Pony 2 hr to
finish this note~ | k**e
发帖数: 2728 | 5 sounds good. i'll give you 10 baozi from my pocket, hows that? :)
i don't know how to use the bank for this forum. blush...
to
【在 l********y 的大作中提到】
: Kaye BZ, how about a huge baozi for this one too? hehe~~it took Pony 2 hr to
: finish this note~
| l********y
发帖数: 2295 | 6 thanks~~~I spent a lot of baozi recently so am very poor now :-(
【在 k**e 的大作中提到】
: sounds good. i'll give you 10 baozi from my pocket, hows that? :)
: i don't know how to use the bank for this forum. blush...
:
: to
| m********4
发帖数: 607 | 7 Thank you so much. I don't have too many Baozi. But, I do want to give you
one baozi because of your nice job.
I am shame on myself because I don't know how to give your Baozi. Can you
teach how to do that? Thanks.
presentation
聆听我们支离破碎，毫无章法的presentation ，耐心细致的指出错误，提出建议，
pony真的觉得没有更好的语言来表达自己的感激之情。就希望能抛砖引玉，大家能互帮
互助，提高我们CMG的整体水平，这样前辈们的心思也算没有白花，希望大家都能来补
充和指出错误，多谢了！
还是要花大力气的。CC应该只是一句话，但要包括下列4个基本元素：The patient’s
age and sex；The patient’s active ongoing medical problems；The patient’s
reason for presentation；The duration of symptoms。这个我们练习CS的时候都练
习过了，但是要怎么很好的口头表达清晰还是要再练习。CC里面一定要涵盖patient最
重要的信息，不能在后面HPI或者PMH的时候给attending一个big surprise，从CC里
attending大概就知道patient的主要毛病了。
AAA就上吧，CS还是有用的，嘻嘻～
【在 l********y 的大作中提到】
: thanks~~~I spent a lot of baozi recently so am very poor now :-(
| m****8
发帖数: 419 | | l********y
发帖数: 2295 | 9 谢谢您的包子啦～～～pony最近厚着脸皮到处讨包子，现在脱贫啦～～嘻嘻～～
【在 m****8 的大作中提到】
: 家页
: 金融中心
| m********4
发帖数: 607 | 10 Thank you. One more question, Is the account number the same as mitbbs ID?
Should I fill the spcae for account number with the ID whom I want to give
BaoZi?
Please don't laugh at me. I am not familiar with Baozi bussiness. At first,
I was wonder what Baozi means? Then, I did my homework. I learned "BaoZi" is
"wei bi".
There is a space for account number. Because I am a poor, I don't want to
waste because of wrong doing. Once again, Is the account number the same as
mitbbs ID?
have a good day.
【在 m****8 的大作中提到】
: 家页
: 金融中心
| d**********n
发帖数: 96 | 11 thank you for sharing!
presentation
聆听我们支离破碎，毫无章法的presentation ，耐心细致的指出错误，提出建议，
pony真的觉得没有更好的语言来表达自己的感激之情。就希望能抛砖引玉，大家能互帮
互助，提高我们CMG的整体水平，这样前辈们的心思也算没有白花，希望大家都能来补
充和指出错误，多谢了！
还是要花大力气的。CC应该只是一句话，但要包括下列4个基本元素：The patient’s
age and sex；The patient’s active ongoing medical problems；The patient’s
reason for presentation；The duration of symptoms。这个我们练习CS的时候都练
习过了，但是要怎么很好的口头表达清晰还是要再练习。CC里面一定要涵盖patient最
重要的信息，不能在后面HPI或者PMH的时候给attending一个big surprise，从CC里
attending大概就知道patient的主要毛病了。
AAA就上吧，CS还是有用的，嘻嘻～
【在 l********y 的大作中提到】
: 谢谢您的包子啦～～～pony最近厚着脸皮到处讨包子，现在脱贫啦～～嘻嘻～～
| dd
发帖数: 73 | 12 Thanks for the detailed work, that's why you can always get great score.
presentation
聆听我们支离破碎，毫无章法的
presentation ，耐心细致的指出错误，提出建议，pony真的觉得没有更好的语言来表
达自己的感激之情。就希望能抛砖引
玉，大家能互帮互助，提高我们CMG的整体水平，这样前辈们的心思也算没有白花，希
望大家都能来补充和指出错误，多
谢了！
还是要花大力气的。CC应该只是一
句话，但要包括下列4个基本元素：The patient’s age and sex；The patient’s
active ongoing medical problems；
The patient’s reason for presentation；The duration of symptoms。这个我们练
习CS的时候都练习过了，但是要怎
么很好的口头表达清晰还是要再练习。CC里面一定要涵盖patient最重要的信息，不能
在后面HPI或者PMH的时候给
attending一个big surprise，从CC里attending大概就知道patient的主要毛病了。
AAA就上吧，CS还是有用的，嘻嘻～
【在 l********y 的大作中提到】
: 谢谢您的包子啦～～～pony最近厚着脸皮到处讨包子，现在脱贫啦～～嘻嘻～～
| d*******1
发帖数: 5 | 13 Thanks, Can I still join in | l********y
发帖数: 2295 | 14 i am sorry i am not the leader of the group. currently we already have 25ppl
which is the up-limit for skype. it depends on how the leader thinks.
hope this helps.
【在 d*******1 的大作中提到】
: Thanks, Can I still join in
|
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