USMLE

Step 2 CSのchallenging questions〜その②

前回は、病歴聴取中のchallenging questionsの解答例(対処例)をシェアさせていただきました。CSでは、病歴聴取・診察後に、可能性のある診断名を伝えなければなりませんが、その際にも患者からchallenging questionsが聞かれることがあります。今回は、part 2として、そのようなclosure時のchallenging questionsの解答例をシェアいたします。

Closure時のchallenging questions

「大丈夫ですか?」と不安そうな患者

– Fortunately, it is treatable/manageable/temporary. After/when we control your disease, you can get rid of the symptoms/the symptom should disappear.

– I hope so. Your symptoms might be related to a disease that can be completely cured/treatable.

「もうダメだ」と悲観的な患者

– It is difficult to confidently answer your question right now, because it depends onyour diagnosis/your condition/how serious your disease is. Something serious, serious/permanent medical conditions.

– The knowledge about this disease is very advanced. There are a lot of treatment options available (medication, surgery, chemotherapy, radiation)/rehabilitation, weaken/improve your symptom/improve quality of life/slow down or delay the progression. After we get the results, let’s work on together.

– Recent advanced medical technology can help you to XX (be pregnant).

– Your symptoms may be caused by an emergency, so we will be monitoring you very closely from now.

子供の「おねしょ」で悩んでいる患者

– I understand your concern about XX (your son’s bed wetting).

– On the basis of the information I have gathered from you, it’s likely to be an isolated symptom. 15 (10-20) % of children keep wetting their bed until they are 12 years old. There is no reason for you and your child to feel bad (embarrassed or guilty) about this. There are a number of treatment options available for this condition.

「手術が要るの!?」と不安がる患者

– Your symptom might be caused by an illness that needs surgery. But, it will be less invasive. It can be done with a small incision and camera, and you will be home in a day or two and recover much quicker. And there might be other treatment options available.

「うつ病なの!?」

– Depression is a common disease. It is due to a chemical imbalance in the brain. Fortunately, we have medications and treatments for the disease.

「XX検査って必要なの!?」

– There are a number of examinations for the diagnosis and it is one of them. I’ll perform physical exam do some tests. After that, we can discuss with you the need of the examination.

– Medications to remove your uncomfortable feeling/pain during the exam. We’ll do our best to make you feel better.

「Why I have this symptom?」

– This may simply be due to dehydration, or it may be a sign of a disease such as XX (diabetes).

輸血を断る患者

– Can I ask you the reason?

宗教絡み

– I respect your opinion. I will make sure you don’t receive a blood transfusion until we have explained its benefit and have obtained your permission.

Side effectが心配

– I understand your concern/I’m sorry for your loss. As you know, there are rare side effects of a blood transfusion. I’ll give it to patients only when(it is absolutely) necessary/life-threatening.(I will not give it except when absolute necessary.)

Allergiesが心配

– Thank you for telling me this. I will determine the reason you had the reaction and will do everything before giving you any blood.

Herbal medicationsに固執する患者

– Some herbal medications have been suggested for many diseases. However, their safety and efficacy may not always be clear. Let me know the name of the herbal medicine and I will check it and come back to you with the answer/information.

Amputation (←Foot gangrene)の可能性を恐れる患者

– I understand your concern. XX is one of the complications of DM. The most important thing is that you are here now. You can avoid amputation by controlling DM strictly. Being compliant with your medication, following healthy diet and exercising regularly.

卵管結紮したのに妊娠した患者が「なぜ?」と聞いてきた時

– There is no single contraceptive method that is 100% effective. On rare occasions, pregnancy does occur.

中絶を希望する妊婦

– I understand youranxiety aboutyour unplanned pregnancy. I suggest that you discuss this with your husband/partner. Whatever you decide, I’ll be here to support you.

流産を恐れる妊婦

– Bleeding early in pregnancy increases your risk of losing pregnancy, but most women with bleeding carry the pregnancy to term without any problems.

Should I tell my partner?

I know that it’s difficult.

STD

– But, I recommend you to talk to your partner. There is a chance that your partner also has the disease. (After you are treated, you will be at risk of contracting the infection again.) The most important step is to have both of you evaluated and appropriately treated.

HIV

– However, telling your wife will allow you totake the appropriate precautions to treat. If you need any help, I’m here for you.

Malignancy

– I recommend you to talk to your partner. Cooperation and understanding by partner canhelp patient to receive treatment effectively. But the decision is up to you. If you need further counseling, I’ll be here for you.

STDを感染された患者が「Is he cheating on me?」

-I’m not sure your partner cheated on you. You could contract this infection from your partner. Could be recurrence of your past STD.

-It is an Infection with yeast, not STD.

Sexual assaultに遭い「my fault?」と聞いてきた時

– I’m sorry for what happened to you. It’s must be very difficult to handle. However, it is not your fault by any means. There is no reason to feel guilty andblame yourself for what happened. Whoever did this to you should be accountable.

電話でいろいろ聞いてくる患者

I understand your concern. Your symptoms might be related to XX. However, there are other possibilities that I need to think of. It is hard for me to give you an accurate answer over the phone. I would like you to bring your child to the hospital so that I can examine him/her and run some tests. After that, I can discuss this with you and come up with a good plan to treat your child.

(いろいろな理由で)病院には来れないという電話相手

I understand your XX is very important to you.

– However, your symptoms might be caused by life-threatening condition/medical condition that may require immediate intervention. I recommend you to postpone your XX until after we get the test results. / You are important to me. Let’s focus on you. I can arrange a meeting with your social worker, who can address your concern about childcare.

– Unfortunately, work/XX may worsen your condition and I recommend you to stay at home for now. I can write a letter to your employer explaining your situation.

I want to drink!!

I’m sorry, but I can’t give you anything to eat or drink right now, because your symptoms might be related to a disease that needs surgery.

No money/no insuranceで医療を拒否する患者

– I understand your concern. However, your symptoms might be caused by (life-threatening) condition that may require intervention. Your health is important. I can arrange a meeting with your social worker, who can who can address any financial concerns you may have.

交通手段がないから受診できないと言う患者

We have a social worker who can address your concern about transportation to the office. After we are done on the phone, I’ll transfer your call to him.

「I can’t go to the hospital」と電話で受診を拒否する患者

– I want you to come here. But if you insist, then watch for the warning signs as XX, XX, XX. If you have these symptoms,please call 911 or go to nearest ER.

Social worker関係

We will arrange for a meeting with our social worker

– , who can address any concerns about XX (you may have).

– , who can address your concern about transportation to the office

– , who can address any financial concerns you may have. (about finance)

– , who can address your concern about child care

– , who can provide you with phone numbers for support groups and other recourses. (sexual assault)

– , who can assess your social situation and provide you with other resources you need.

I am afraid of losing job

I understand your concern. We will do our best to help you recover. I can write a letter to your employer explaining your situation.

Could you have dinner with me / be friend?

– Thank you for the compliment, Ms XX. I’m glad to be your doctor (as well as a friend). You can come to see me anytime you need any help.

– I’m sorry but I can’t, because you are my patient and it would not be allowedin the context of a doctor-patient relationship.

「前医と言っていることが違う」と怒り出す患者

– We have to do our best to make a decision on the basis of what we discovered today. I’m sorry if this may be frustrating for you.

XXのせいでこんなことになってしまったと、自分を責める患者 

– It is a possibility. However, there are other risk factors that need to be considered. (A number of genetic and environment factors can play an important role in the disease.) (The cause of the disease is still unclear.) The most important thing is that you are here now. Let’s work on this together.

Obesityを家族(遺伝)のせいにする患者

– Genes play an important role in obesity, but lifestyle and diet are also major factors influencing weight. We can provide you with exercise program and diet instruction to lose your weight.

Why does my child have XX (DM)?

I understand your feelings.

– A number of genetic and environment factors can play an important role in the disease. The important thing is to avoid complications. We should control DM strictly by being compliant with your medication, following healthy diet and exercising regularly. To check his condition, I’ll also perform physical exam and do some tests.

– Some genetic or environment factor can play a role in the disease. But the exact cause of the disease is still unclear. It’s not your fault. The most important thing is that you are here now. Let’s work on this together.

– Sometimes, this occurs with a fixed probability. It’s not your fault. There wasnothing for you to be able to do. The most important thing is that you are here now. Let’s work on this together.

抗生剤の処方を求める患者

Most antibiotics is effective only for bacteria. I think you have viral infection. You don’t have to take the medications. Viral infections generally clear on their own. (Every medicine has side effect and can be more harmful than helpful.)

「Don’t tell my parents」と頼んでくる患者

– You are adult now, so you can take your decision in your life.

– We are required to keep your confidentiality about STD/contraception by US law.

「あなたも見えるでしょ?(←幻覚)」と同意を求めてくる精神病患者

– I can understand. But please don’t concentrate on them. I reassure you that you are in safe environment.

– These things might bea sign of diseases.Let me find what’s wrong.

閉経後のHRT (hormone replacement therapy)が不安な患者

– …., though HRT has very less side effect for short term. Weaken/improve your symptoms.

受診は三日後でもいい?

It’s good if you come earlier. If you insist, then watch for warning signs like fever, excess crying…

まとめ

どんなchallenging questionを聞かれても、答えた後には

Does that answer your question?

と聞いて、自分の答えで良いか確認しましょう。

ABOUT ME
木村聡
福岡県の研修病院で初期研修修了後、大学に入局。米国オハイオ州に臨床研究で留学するも、知識の欠如を痛感。ハーバード公衆衛生大学院に進学し、MPHを取得。マサチューセッツ工科大学メンバーとの共同研究などに関与。 日本では麻酔・集中治療医として働き、オーストラリアでは小児集中治療を一から学び直しています。 乗り越える壁を見つけ続けることは、なかなか簡単ではありませんよね。アラフォー目前、様々な壁にぶち当たり、それなりに多くの経験をしてきました。私の挑戦や経験・知識、失敗談などが、他の誰かの刺激になり、役に立つことを切に願っています。 プロフィールをもっと詳しく見る

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