Posted in COMLEX 2 PE, Health, medical school, Step 2 CS

How To Prep for Your PE/CS

Image above from CollegiateParent

The PE/CS are practical tests, examining one’s skill with a patient, and must be passed in order to graduate medical school and enter residency.  For some students, they find the test of their hands-on skills easy.  For others, stage fright can kick in and they worry they’ll forget everything they have learned.

Relax, review and rise to the occasion!!  And if in doubt….the following tips may help:


  • Greet the patient and thank them for waiting
  • Make them feel more comfortable if they are in distress
  • Respect their privacy when it comes to gowning and draping
  • Maintain good eye contact and reflectively listen
  • Allow the patient adequate speaking time to answer your questions, (i.e. no interrupting or rapid fire questioning)
  • “Intervene” by offering them assistance when they admit to having a daily habit that could contribute to a health condition (i.e. smoking, alcohol use, poor diet)
  • Ensure the patient understands the assessment or reasons for your line of questioning
  • Appear confident when you explain the assessment and plan
  • Suggest something to address the pain or distress of the patient
  • Avoid rattling on and remember closing the encounter confidently and friendly.
  • Suggest modifications that can help them at work or home if their complaints impede their job or home life.

humanism book cover final               CIS book cover

Humanism Prep Guide For the Boards
CIS Skills Prep Guide For The Boards


  • Remember to address other body systems that could be contributing to the chief complaint (i.e. a left shoulder pain complaint may also need questioning regarding the heart in addition to musculoskeletal symptoms)
  • Ask associated symptoms or pertinent positives/negatives (i.e. in a patient presenting with back pain, inquiring about lower extremity numbness and tingling, incontinence, hematuria, etc.)
  • Address medical symptoms that may stem from a habit they have (i.e. urethral discharge if they partake in unprotected sex)
  • Address medical symptoms from a medication they may take excessively (i.e. abdominal pain or blood in the stool of a patient who takes NSAIDS often)
  • Examine the appropriate body parts that could be contributing to the illness, (i.e. thyroid and carotids in a patient presenting with dizziness)
  • Ask “why” when they take excessive medication – they may be self treating another medical condition
  • Ask “why” they came in for a physical (family member may have been worried about their memory, eating habits, etc.)

Data Gathering Prep Guide For The Boards

Data Gathering Prep Guide For The Boards

SOAP note

  • Complete all four sections (S O A P) consistently in each case
  • Address the chief complaint in all four sections (i.e. if one presents with back pain, did the note address the subjective complaints, an exam of the back, differentials of what the back pain could be, and testing/OMM in the plan that addressed the back pain?)
  • Include associated symptoms (i.e. in a patient presenting with a headache, were they negative for photophobia and neck stiffness, etc.)
  • Document appropriate history and physical
  • With the physical make sure 5-6 categories were documented (i.e. Vitals, General, Cardiac, Pulmonary, and then one or two more depending on their chief compliant – if back pain also include MSK and Neuro)
  • List the differentials that the presenting complaint could be (i.e. a patient presenting with fatigue may have depression, anemia, sleep apnea, hypothyroidism, antihistamine overuse)
  • Include testing, medications, work/home modifications, OMM (DO students), and follow up in the plan.

OMM (for DO Students)

  • Ask permission prior to performing the OMM
  • Explain what OMM is and why you are choosing to perform it
  • Do not appear “rough” in technique
  • After performing the OMM, ask how the patient felt and its effect on symptomatology


Most students who study and practice, PASS their PE/CS and match, going on to residency.  If you need help, reach out to your school, students who passed, or even me for tips.  You got this!!


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Great Gift!!!

The Ultimate Medical Student HandBook


Daliah Wachs, MD, FAAFP is a nationally syndicated radio personality on GCN Network, KDWN, and iHeart Radio.

Posted in coronavirus, Covid-19, Health, masks, news

Easy Options For Face Mask/Coverings

With the CDC’s (Center for Disease Control’s) recommendation to cover one’s face to prevent the spread of coronavirus, many Americans are searching for ways to cover their nose and mouth.

They write:

The CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission.

It is critical to emphasize that maintaining 6-feet social distancing remains important to slowing the spread of the virus.  CDC is additionally advising the use of simple cloth face coverings to slow the spread of the virus and help people who may have the virus and do not know it from transmitting it to others.  Cloth face coverings fashioned from household items or made at home from common materials at low cost can be used as an additional, voluntary public health measure.

The cloth face coverings recommended are not surgical masks or N-95 respirators.  Those are critical supplies that must continue to be reserved for healthcare workers and other medical first responders, as recommended by current CDC guidance.

So what can be used for a substitute?

According to this chart, materials such those found in kitchen towels and vacuum bags may be the next best thing.


Although they pale in comparison to the efficacy and protection offered by N95 masks they can be used in light of the CDC’s recommendations.

So here are some options on how to cover your nose and mouth:

Vacuum Bag Mask

FQD30N1K84NECL4.LARGE.jpg offers instructions on how to make a mask out of a vacuum bag.

Dishtowels and T-Shirts


Heddel’s gives you the step by step breakdown of how to cut and create earloops for a T-shirt, and similar instructions can be used for a dishtowel.


Bandanna or scarves




These can be easily folded and manipulated to cover both mouth and nose.  The more folds the better to allow extra layers over nose and mouth but ensure mouth and chin are covered.

Avoid large gaps between eyes and cheeks as pathogens can sneak down under the covering.

Ace Wraps

Assuring you can breathe and don’t wrap the ace too tightly, an ace wrap/elastic bandage may also provide a barrier over your nose and mouth.

ace wrap.png


Although not the most politically correct these days, panties do have the elastic and variety of shapes that may conform to the face and allow protection.



And of course a bra with an ample cup size may also be used if an adequate seal can be secured around the face and mouth.

bra mouth cover.jpg

Image by @HopClear

Other do-it-it yourself ideas

For those of you with more artistic qualities, these are other ideas:


CNN and Tom’s Guide gives the following options for face protection.

And Julie Eigenmann offers a video demonstrating how to make a simple face mask here.


Again, surgical masks and N95 respirators are not available and if become available are necessary for the front line healthcare workers.  So if you do make your own mask  remember that social distancing, hand washing and changing out one’s facial covering if it becomes wet or soiled are also crucial to preventing the spread of COVID.



ultimate book cover final

Great Gift!!!

The Ultimate Medical Student HandBook


Daliah Wachs, MD, FAAFP is a nationally syndicated radio personality on GCN Network, KDWN, and iHeart Radio.

Posted in coronavirus, Covid-19, Health, news, pets

Cats Can Infect Other Cats With COVID, Not Humans

A study from Harbin Veterinary Research Institute in China found that not only can cats become infected with COVID-19 but can also transmit it to other felines.


Ferrets may also be vulnerable to the virus, however dogs, ducks, pigs and chickens appear to be less susceptible.

Researchers used 8 month old cats and exposed 5 of them intranasally with the virus.  They then euthanized 2 of them and found evidence of infection along their respiratory tree (nasal turbinates, soft palates, tonsils, trachea, and in one, the small intestines) signifying infection susceptibility.

For the transmission portion of the study, the other exposed cats were put into cages separately with non-infected cats and the latter were subsequently tested days later to see if they were exposed.  Evidence of the virus particles were found in their feces. None of the animals exhibited symptoms however of coronavirus.



Ferrets too were found to be susceptible but dogs did not appear to carry the virus as did their whiskered counterparts.


Although no cat to human transmission of COVID has been found, study authors suggest, “Surveillance for SARS-CoV-2 in cats should be considered as an adjunct to elimination of of COVID-19 in humans.”

The full text of the study can be found here.


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Great Gift!!!

The Ultimate Medical Student HandBook


Daliah Wachs, MD, FAAFP is a nationally syndicated radio personality on GCN Network, KDWN, and iHeart Radio.


Posted in drugs, Health, medications, news, recall

FDA Orders Zantac and Ranitidine To Be Removed From Store Shelves Immediately

In September, the FDA  announced that samples of ranitidine, an H2 Blocker used for stomach upset, reflux and ulcers sold generically and under the brand name of Zantac, were found to have the contaminant N-nitrosodimethylamine (NDMA).  This is one of the chemicals that prompted the generic ARB blood pressure medication recalls last year.

Now drugmakers are mandated to pull all Zantac brand name and generic products off the shelves and stop online sales.

Patients are also urged to stop taking any of the products they currently have and discard them immediately following the FDA’s drug disposal guidelines.  Discussions with one’s healthcare provider should be done if consumers need medication alternatives.

Other similar medications in its class such as: famotidine (Pepcid), cimetidine (Tagamet), esomeprazole (Nexium), lansoprazole (Prevacid) or omeprazole (Prilosec), are not believed to have the same risks of NDMA exposure.

We don’t believe there have been reports of consumers becoming ill.  In animals, N-nitrosodimethylamine (NDMA) is known to cause liver and lung cancer.  It has been linked to tumor production in a variety of human organs, including the tongue, esophagus, lung, pancreas, liver, kidney and bladder (Ciemniak A., 2006). Additionally, the CDC states it may cause liver function impairment and cirrhosis.

The FDA writes:

The agency has determined that the impurity in some ranitidine products increases over time and when stored at higher than room temperatures and may result in consumer exposure to unacceptable levels of this impurity. As a result of this immediate market withdrawal request, ranitidine products will not be available for new or existing prescriptions or OTC use in the U.S.

Hence the FDA believes unsafe levels of NDMA could exist in the medications if the product was stored in higher than normal room temperatures.

They also state:

NDMA is a probable human carcinogen (a substance that could cause cancer). In the summer of 2019, the FDA became aware of independent laboratory testing that found NDMA in ranitidine. Low levels of NDMA are commonly ingested in the diet, for example NDMA is present in foods and in water. These low levels would not be expected to lead to an increase in the risk of cancer. However, sustained higher levels of exposure may increase the risk of cancer in humans. The FDA conducted thorough laboratory tests and found NDMA in ranitidine at low levels. At the time, the agency did not have enough scientific evidence to recommend whether individuals should continue or stop taking ranitidine medicines, and continued its investigation and warned the public in September 2019 of the potential risks and to consider alternative OTC and prescription treatments.

New FDA testing and evaluation prompted by information from third-party laboratories confirmed that NDMA levels increase in ranitidine even under normal storage conditions, and NDMA has been found to increase significantly in samples stored at higher temperatures, including temperatures the product may be exposed to during distribution and handling by consumers. The testing also showed that the older a ranitidine product is, or the longer the length of time since it was manufactured, the greater the level of NDMA. These conditions may raise the level of NDMA in the ranitidine product above the acceptable daily intake limit.

With today’s announcement, the FDA is sending letters to all manufacturers of ranitidine requesting they withdraw their products from the market. The FDA is also advising consumers taking OTC ranitidine to stop taking any tablets or liquid they currently have, dispose of them properly and not buy more; for those who wish to continue treating their condition, they should consider using other approved OTC products. Patients taking prescription ranitidine should speak with their health care professional about other treatment options before stopping the medicine, as there are multiple drugs approved for the same or similar uses as ranitidine that do not carry the same risks from NDMA. To date, the FDA’s testing has not found NDMA in famotidine (Pepcid), cimetidine (Tagamet), esomeprazole (Nexium), lansoprazole (Prevacid) or omeprazole (Prilosec).

The investigation is ongoing and more needs to be looked at when it comes to this manufacturing process suspected to result in these “impurities” being made.



Last year NDEA was also found in the generic  blood pressure medications that were the subject of recall, however has not yet been suggested as being present in ranitidine.

N-Nitroso-N-methyl-4-aminobutyric acid (NMBA) was the third chemical detected resulting in the latest two recalls of losartan, an angiotensin receptor blocker commonly used to treat hypertension (high blood pressure).  It is believed to have been created during the manufacturing process of the generic drug.


NMBA, according to Toronto Research Chemicals, is a known carcinogen in a wide range of animal species.

Previously, ScieGen Pharmaceuticals, Inc. recalled certain lots of irbesartan, a similar angiotensin receptor blocker used in blood pressure management.

The recalls initially began in 2018 when the FDA recalled a number of lots of valsartan due to an “impurity”, N-nitrosodimethylamine (NDMA) that is known to cause cancer in animals.  Weeks later they additionally found traces of N-nitrosodiethylamine (NDEA).

According to Reuters, earlier that year, the MHRA, Medicines and Healthcare Products Regulatory Agency, located in the UK, said the appearance of the impurity, N-nitrosodimethylamine (NDMA), came after a change in the process for making valsartan at one facility owned by Zhejiang Huahai Pharmaceuticals, a company in Linhai, China.

With NDEA, data is limited, but due to its classification as a nitrosamine and its prevalence in tobacco smoke it is classified as a probable human carcinogen.

According to New Jersey Department of Health’s website, NDEA has been linked to liver, lung and gastrointestinal tract cancer in animals.

Losartan, valsartan and irbesartan are medications in the class of angiotensin receptor blockers (ARBs) used for high blood pressure and congestive heart failure.

Those taking either tablet for their blood pressure are urged to not abruptly stop their medication but rather check with their medical provider and pharmacy to see if their particular prescription is involved in the recall.

I suspect more recalls will follow as processes may be similar across multiple pharmaceutical facilities and NMBA, NDMA and NDEA are byproducts that may not be individually unique to just one “brand” of medication manufacturing.


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Great Gift!!!

The Ultimate Medical Student HandBook


Daliah Wachs, MD, FAAFP is a nationally syndicated radio personality on GCN Network, KDWN, and iHeart Radio.

Posted in coronavirus, Covid-19, Health, news

Your State’s Coronavirus Peak Will Occur On….

University of Washington’s Institute for Health Metric’s Evaluation created a model for when COVID-19 resource use would peak in each state.

The infographic also projects how many hospital beds, ICU beds, bed shortage (if any) and ventilators may be necessary in each state to address patient need.

The numbers change slightly as information is updated.

Nevada for example is expected to see peak need by April 20th (updated to April 22 on 3/31), having an ICU bed shortage of 100 beds.

Authors write:

In addition to a large number of deaths from COVID-19, the epidemic in the US will place a load well beyond the current capacity of hospitals to manage, especially for ICU care. These estimates can help inform the development and implementation of strategies to mitigate this gap, including reducing non-COVID-19 demand for services and temporarily increasing system capacity. These are urgently needed given that peak volumes are estimated to be only three weeks away. The estimated excess demand on hospital systems is predicated on the enactment of social distancing measures in all states that have not done so already within the next week and maintenance of these measures throughout the epidemic, emphasizing the importance of implementing, enforcing, and maintaining these measures to mitigate hospital system overload and prevent deaths.

When a state is chosen under the drop down menu, local mandates and travel restrictions are reported as well.

Anticipation of what will be needed helps local authorities prepare.

The following is a summary of each state’s projected peak resource use in 2020 taken from stats from March 31 and March 30 (these are subject to change):

March 31 Predictions

covid march 31 a

covid march 31 b

March 30 Predictions

covid table

covid table 2

These projections assume “continuation of strong social distancing measures and other protective measures.”

More regarding each state’s resources and death projections can be found here.

This is a developing story….


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Great Gift!!!

The Ultimate Medical Student HandBook

Daliah Wachs, MD, FAAFP is a nationally syndicated radio personality on GCN Network, KDWN, iHeart Radio and is Board Certified Family Physician

Posted in college, coronavirus, Covid-19, Health, news, school

Students Across America Petition Their College to Give Partial Refunds for Tuition

In an effort to protect students and abide by state mandates to close “non-essential” businesses during the COVID-19 epidemic, schools closed and moved students to an online learning platform.  Access to libraries, learning spaces, equipment, faculty and labs were thereby limited among other education necessities.

Students at NYU Tisch School of Arts approached administration with a request for partial tuition refund for the Spring 2020 semester but did not like the response they received.

Dean Allyson Green responded to their request with a video of herself lip syncing and dancing to R.E.M’s “Losing My Religion” in an attempt to explain how it would be challenging to give the students’ their money back.

In an already stressful time, some criticized Dean Green’s video as “embarrassing” and apathetic to the student’s plight.  Dean Green however, explained her dance was an attempt to use art to keep people connected.

The question, however, of will students get a partial tuition refund for being off campus, remains to be answered.

Thousands of students have petitioned their respective schools, asking for partial reimbursement of tuition, housing and food. Some universities will be offering refunds for dormitory and food expenses paid. But offering tuition refunds may be more difficult as much of that money is spent or accounted for in the school budget, and not easily liquid if they cannot displace funds for salaries and rent with government stimulus money.

Students who pay tens of thousands of dollars in tuition each year however are frustrated that their fees including labs, equipment, security, parking, facility access, campus transportation, medical clinic, student government, etc. are not justified when they are home engaged in online learning.

So many have turned to and created petitions to the following schools, as well as others:

As stated previously, headway has been made for those students living in dormitories and requiring meal plans. However, a partial tuition refund for the conversion to online learning can be very challenging and has yet to be seen.


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Learning Medical Spanish is Easy!!!


Daliah Wachs, MD, FAAFP is a nationally syndicated radio personality on GCN Network, KDWN, and iHeart Radio.



Posted in coronavirus, Covid-19, dating, Health, news, relationships, sex

Is Coronavirus Killing Your Sex Life?

As Americans grapple with community lockdowns amid the coronavirus epidemic, those who are single, and not single, find COVID-19 to be devastatingly cramping their style.

In some cities, bars, restaurants, and movie theaters are shuttered, so options for a first date become slim.

Clubs and gyms are closed, impeding the casual run in or bump into to someone new.

And salons for hair and nails may be closed, being “non essential”, hence at home beauty regimens need to tackle overgrown nails and roots, resulting in a “hibernation” during the lockdown if one’s unsuccessful.

And for those using dating sites for strictly hook-ups, “social distancing” can be a challenge in any bedroom.

Married people don’t have it that much easier…..spending 24 hours a day at home together rarely makes the heart grow fonder…..

So America’s sex life may be locking down faster than stores shuttering.

But there are options……lot’s of them. Let’s look at these…

Virtual “Sex”

Assuming you have a secure server, many conversations and expressions of desire can be conveyed online. Keep in mind apps like “Zoom” do not imply image enhancement.



Bring Back Romance

Couples tend to think this is a given and once it slips away, is very difficult to get back. Likewise those on the single scene believe initial flirtation will brew the romance automatically.  Wrong.

Use the lockdown as a time to be creative.  So consider wooing your partner by…

  • Making them laugh
  • Share your feelings
  • Rewrite a song with lyrics about them (and yep sing it to them)
  • Poetry – even if its funny
  • Sending them virtual gifts
  • Doing something special
  • Pampering them
  • Being playful, creative with foreplay
  • Try something new in the bedroom


Make Friends

Most long lasting relationships start with a solid foundation of friendship.  Making friends can be at times difficult on the dating scene, as intentions could be easily misconstrued.  So while we are in a period of “social distancing”, your “getting to know someone better” will be just that….. allowing a friendship to blossom.

Get In Shape and Eat Right

Most of us could use an opportunity to improve our diet and our shape, so use this time to increase your exercise and plan better meals.  Beauty on the outside requires health from within.

workout home.jpeg

Hone In On Your Skills

No one is perfect when it comes to seduction or skill, so use this time to brush up on long overdue learning and refreshers.  Myself….I could sure learn how to dance……

Stay safe and healthy out there!



The Baby Boomer’s Guide to Online Dating


Daliah Wachs, MD, FAAFP is a nationally syndicated radio personality on GCN Network, KDWN, and iHeart Radio.