Step 2 CS...Panic Mode!!!!!

[colts]

Took CS recently in Philadelphia and I am worried that I will fail:

Here are my mistakes:
1) Forgot to mention to do a rectal/pelvic to the patient and write it down in the note
2) Forgot to write vitals and general appearance in the note for all cases (but I did write high temperature and normal blood pressure for 2 cases under supporting physical exam evidence for the ddx)
3) Forgot to order bilirubin level for suspected gallbladder cases for 2 cases
4) I did a ROS with the patient, but never had a separate title in my HPI (I did include it in the HPI for the most part though)
5) Did a thyroid exam for 1 patient, but forgot to write it down in the note
6) For 2 MSK patients, forgot some special maneuvers
7) Missed OB/GYN history, sexual history, alcohol, drugs, and tobacco use in a few patients (probably missed a few other questions, but not sure if it was pertinent or whether I would have time for asking it)
8) I felt a flustered or like I was moving a little quick in a few cases
9) For ROS, I sometime grouped symptoms together, instead of asking them one by one
10) Only wrote 2-3 ddx for each case, but my school told us thats all you needed
11) I feel that parts of my PE were lacking or not complete...like for heart and lungs I would just write: CTA b/l, no wheezes heard and RRR, S1 and S2 heard. No murmurs heard. Forgot to write down ronchi and rales for lungs, and gallops, heaves, lifts, and thrills for heart).
12) Probably missed a few diagnostic tests that I should have ordered.
13) Probably misdiagnosed a few patients

What I did:
1) I always introduced my self
2) washed my hands
3) asked if they had an questions and had a closure for each patient
4) answered the challenging questions to the best of my ability
5) explained what I thought was going on and a ddx and what tests we would order
6) shook their hands
7) was courteous empathetic for the most part (Always pulled out the leg rest, asked if they needed water if they coughed, asked how they were doing if they looked concerned or worried, etc.)
8) explained what I was doing for the physical exam for the most part
9) counseled for the most part
10) I maxed out the HPI box for almost all encounters, so I tried to include as much possible in that section
11) Tried to write as much as possible for pertinent negatives and pertinent positives for each ddx

I'm really worried that I missed some key parts of the patient encounter and patient note, do you guys think I will pass?

---

Members don't see this ad.

 

[colts]

bump

 

[Kaputt]

First off, no one here really knows what it takes to pass or fail this exam. It's all pure speculation. That being said, your "mistakes" are ridiculously benign. Having leisurely browsed Step 2 CS forums in the past, I think this is is easily the silliest list of "mistakes" I've ever seen. You should relax, and until you get your scores you'll never know for sure if you passed but the stats are on your side. The people who fail this test are the ones that don't know what they're doing, and forgetting to document palpation of the thyroid does not put you in that category.

 

[colts]

Thanks for your reply...i also just remembered a misdiagnosed a few patients probably too

I just feel that these mistakes are pretty big

 

[caveat87]

I agree with the assessment as noted by Kaputt above. Who knows how this exam is graded, but it sounds like you did fine from the empathy portion and I bet you will pass. I personally had a more embarrasing list but still passed with a comfortable margin if that makes you feel any better. Congrats on being done.

 

[Kaputt]

Thanks for your reply...i also just remembered a misdiagnosed a few patients probably too

I just feel that these mistakes are pretty big

If it makes you feel any better, there were at least 3 cases where my differential was crap and my exam was very broad and misguided cause I didn't know what was going on. I did virtually no special maneuvers and had 1 or 2 physical findings on my entire exam that warranted mentioning in the evidences below the differentials. My physical exams were very weak, and after each case was done I realized 2-3 questions I should have asked or PE things I wish I did or tests I should have ordered in the note. And I passed. Comfortably.

Also, you don't need to list "ROS" as "ROS"...there are character limits in each box, so it just wastes characters to do it that way. What you did is fine. And, there is a max of 3 differentials for each case, so when you say you put 2-3 per case you did exactly what was expected of you. It used to be up to 5 but now that you have to list things that support each diagnosis, they reduced the max number to 3. And who cares if you forgot to mention you'd want to do a pelvic or rectal while you were in the room...there were tons of tests I didn't mention to the patient that I decided I wanted to order while I was writing my notes, like endoscopy and stuff like that. Granted, you should tell the patient the plan, but that's hardly a red flag to ding someone for not explicitly telling the patient every test you are going to order. These "mistakes" are not "pretty big". 7 and 9 are the only ones I'd have been kicking myself over but they are extremely minor and making those tiny, tiny mistakes is not how people fail this exam. We are human beings and we can't flawlessly perform on this exam, and the graders know that, so the grading (I think) ends up being very reasonable.

 

[colts]

just realized...i don't think i ever summarized......what'd u guys think in addition to all those other mistakes?

this wait is gonna be brutal

 

[Kaputt]

just realized...i don't think i ever summarized......what'd u guys think in addition to all those other mistakes?

this wait is gonna be brutal

Alright dude it's clear you don't want reassurance and just want to vent/complain, so go ahead, good luck waiting for your scores.

 

[sakata8242]

Yeah I forgot a laundry list of minor things too. I'm not too concerned about those. What really worries me is that for on encounter I had no idea what was going on. SP came in with a physical complaint, but then innocently slipped in another. I suspect it was a psych-social issue, but when I prodded for more she wouldn't open up for me. By then I was running low on time, so I just ended up closing/counseling regarding her first physical complaint, despite there being no physical findings.

Gotta love how an exam that can make or break your entire future is 100% faked and is largely based on how the SP "feels" about you.

One other thing -- did anyone take a CS exam where the patients had makeup or other props to "simulate" physical findings? None of mine did, although I actually did have a guy with absent breath sounds on one side, which I'm guessing is pretty hard to fake!

 

[colts]

Alright dude it's clear you don't want reassurance and just want to vent/complain, so go ahead, good luck waiting for your scores.

i know, i'm just being paranoid, i hope...but just wanted to list all my mistakes to give a complete picture...what'd u guys think of my mistakes?

 

[tco]

i know, i'm just being paranoid, i hope...but just wanted to list all my mistakes to give a complete picture...what'd u guys think of my mistakes?

I took mine yesterday. I think your mistakes are minor in comparison to my mistakes. I did your mistakes plus one huge, mega glaring mistake equivalent of walking into the patient and saying, "Sup?" And staring at him for 15 minutes.

I also put, "Non-focal physical exam" for...Well, almost every patient for physical exam findings to justify diagnosis. That's such a silly thing to put for simulated patients.

 

[colts]

bump...another mistake lol: for one case, i wrote ovarian cyst, but didn't have time to write any supporting history or PE findings, it was my 3rd ddx...

 

[call me x]

bump...another mistake lol: for one case, i wrote ovarian cyst, but didn't have time to write any supporting history or PE findings, it was my 3rd ddx...

Seriously? Not having support for the 3rd ddx on 1 case? On 1 case I forgot I hadn't filled supporting findings for ANY of the ddxs. On another case that I suspected TIA/involved vision issues and I didn't do a neuro exam. Half the time I forgot to respin my stethoscope around after listening with the bell, so even if a patient was faking symptoms I certainly wasn't going to hear anything- I don't think I had one positive exam finding unless a pt was in pain. My exams were a hot mess in every case, and I can think of a solid 5 things that I missed with every single encounter. On one guy I wasn't planning on doing an abdominal exam, but then randomly felt the guy's belly from over his gown since the bed was already in an incline- no idea what I was doing! Regardless, I sucked, big time. I just took it and will be waiting 3 months to see if I f'ed up enough things to fail- really hoping I scraped by!

 

[tco]

Seriously? Not having support for the 3rd ddx on 1 case? On 1 case I forgot I hadn't filled supporting findings for ANY of the ddxs. On another case that I suspected TIA/involved vision issues and I didn't do a neuro exam. Half the time I forgot to respin my stethoscope around after listening with the bell, so even if a patient was faking symptoms I certainly wasn't going to hear anything- I don't think I had one positive exam finding unless a pt was in pain. My exams were a hot mess in every case, and I can think of a solid 5 things that I missed with every single encounter. On one guy I wasn't planning on doing an abdominal exam, but then randomly felt the guy's belly from over his gown since the bed was already in an incline- no idea what I was doing! Regardless, I sucked, big time. I just took it and will be waiting 3 months to see if I f'ed up enough things to fail- really hoping I scraped by!

I think this is more of the typical feel. OP is just extremely OCD. He's not trying to troll, but he's doing a great job at it.

 

[Bigeminy]

don't freak out.

I took it early october in the dreaded Philly location and had the sinking feeling since that day that I failed. didn't do one neuro exam the whole day. had one difficult patient that wasn't cooperating with the exam and i tried to convince him to comply and he wasn't having it so i just left the room after 5 minutes because i couldn't think of anything else to say to him. My friend who went with me said he was able to convince the patient to comply, so i definitely messed that up. my last patient, also difficult, was acting like she was in a ton of pain and as i wrapped up the encounter she yelled at me for never even asking her about it (which i hadn't). I showed probably very little empathy the whole day because the whole thing, IMO, is a valueless, expensive escapade. I simply cannot fake empathy, but i love my patients in real life. The only thing I can think of that went well were my notes and DDx. I had come off three EM rotations in a row, so I was pretty good at writing thorough notes quickly. I did not prep at all for it with any book. Just went in cold after my ER rotations.

Result? Passed, without anything even close to the borderline category. You must have to do something incredibly egregious to fail this test. Even in Philly.

 

[RosenthalFiber]

don't freak out.

I took it early october in the dreaded Philly location and had the sinking feeling since that day that I failed. didn't do one neuro exam the whole day. had one difficult patient that wasn't cooperating with the exam and i tried to convince him to comply and he wasn't having it so i just left the room after 5 minutes because i couldn't think of anything else to say to him. My friend who went with me said he was able to convince the patient to comply, so i definitely messed that up. my last patient, also difficult, was acting like she was in a ton of pain and as i wrapped up the encounter she yelled at me for never even asking her about it (which i hadn't). I showed probably very little empathy the whole day because the whole thing, IMO, is a valueless, expensive escapade. I simply cannot fake empathy, but i love my patients in real life. The only thing I can think of that went well were my notes and DDx. I had come off three EM rotations in a row, so I was pretty good at writing thorough notes quickly. I did not prep at all for it with any book. Just went in cold after my ER rotations.

Result? Passed, without anything even close to the borderline category. You must have to do something incredibly egregious to fail this test. Even in Philly.

Me? I felt great about it- gave very thorough and clear DDx on my notes. US (NOT img!) grad at a top 10, honored my OSCEs weeks before this.

Result? Failed ICE. Like ALL of the stars were below borderline.

FAILED. I get to waste money and time again now and not match now

 

[swamprat]

Me? I felt great about it- gave very thorough and clear DDx on my notes. US IMG grad at a top 10, honored my OSCEs weeks before this.

Result? Failed ICE. Like ALL of the stars were below borderline.

FAILED. I get to waste money and time again now and not match now

That sucks dude. What is a IMG top 10? You had borderline for english as well?

I thought I failed, worried for months about it. Miss several diagnoses, PE maneuvers, didn't feel like I was that empathetic due to poor acting etc and I passed with flying colors to my shock and disbelief. I am not trying to make fun or criticize but I feel like it really does take a lot to fail this exam and from what I heard people who fail it really have to mess it up and probably deserve to fail. I don't really have any suggestions other than maybe your school doesn't prepare you to the proper US standards in which case passing those OSCEs doesn't really mean jack. Good luck tho, everyone passes this dumb test eventually..

 

[RosenthalFiber]

That sucks dude. What is a IMG top 10? You had borderline for english as well?

I thought I failed, worried for months about it. Miss several diagnoses, PE maneuvers, didn't feel like I was that empathetic due to poor acting etc and I passed with flying colors to my shock and disbelief. I am not trying to make fun or criticize but I feel like it really does take a lot to fail this exam and from what I heard people who fail it really have to mess it up and probably deserve to fail. I don't really have any suggestions other than maybe your school doesn't prepare you to the proper US standards in which case passing those OSCEs doesn't really mean jack. Good luck tho, everyone passes this dumb test eventually..

Um I meant to type US top 10...and no your assessment is incorrect. I absolutely did everything there was. They had my performance bar 100% to the left...that is absolutely impossible. I had the ddx perfectly...if you believe they only fail people who deserve to fail you have a warped view IMO

 

[ashwilliams123]

Um I meant to type US top 10...and no your assessment is incorrect. I absolutely did everything there was. They had my performance bar 100% to the left...that is absolutely impossible. I had the ddx perfectly...if you believe they only fail people who deserve to fail you have a warped view IMO

I'm so sorry to hear that man. I completely feel your pain. You seem like a good candidate for a score recheck. But I failed my CS back in October (from US MD school) with low CIS score and retook it like 5 days after I failed and this time my CIS score was off the charts to the right. And I really didn't change anything up that much, just focused on closures a little more. It's a stupid test.

 

[swamprat]

Um I meant to type US top 10...and no your assessment is incorrect. I absolutely did everything there was. They had my performance bar 100% to the left...that is absolutely impossible. I had the ddx perfectly...if you believe they only fail people who deserve to fail you have a warped view IMO

Even english? You can't speak english fluently? I'm just skeptical when I hear these things because from what I have heard from people who failed at my school is that they were horrible at patient interactions and deserved to fail. If your from a US top 10 I don't think a failed CS will matter much in the match, school name is pretty important just show a passing CS attempt on a second try and be ready to explain what went wrong without pointing fingers at the nbme for being unfair.

 

[RosenthalFiber]

Even english? You can't speak english fluently? I'm just skeptical when I hear these things because from what I have heard from people who failed at my school is that they were horrible at patient interactions and deserved to fail. If your from a US top 10 I don't think a failed CS will matter much in the match, school name is pretty important just show a passing CS attempt on a second try and be ready to explain what went wrong without pointing fingers at the nbme for being unfair.

I would post my score report bars if it were not somewhat identifying-

But I "aced" CIS and english, ICE was 100% to the left. Seems impossible to fail every case like that...I had thorough notes with a SOLID ddx.

 

[ThatQuestionGuy]

I would post my score report bars if it were not somewhat identifying-

But I "aced" CIS and english, ICE was 100% to the left. Seems impossible to fail every case like that...I had thorough notes with a SOLID ddx.

What do you mean not match? Can't you just retake it?

 

[RosenthalFiber]

What do you mean not match? Can't you just retake it?

You have to retake it by Jan I believe otherwise you can't match.

 

[ashwilliams123]

You have to retake it by Jan I believe otherwise you can't match.

Download check4change and firefox and i guarantee you will get a date before Jan.

 

[call me x]

You have to retake it by Jan I believe otherwise you can't match.

Is this true? I took it in November and thought it went horrible- I'm not scheduled to get results until Jan 29th- am I completed SOL if I need to retake?

 

[flyingleaf]

It only affects matching at some places. Massachusetts programs and UCSF have deadlines in February for when the reports are due. Other places don't need the scores until right before starting intern year (to apply for limited license) so it shouldn't affect ranking. Passing Steps 1, 2CK, and 2CS are required by some schools for graduation but not all. There is def time to re-register using check4change, retake, and meet the requirements if they apply though.

 

[Bigeminy]

Is this true? I took it in November and thought it went horrible- I'm not scheduled to get results until Jan 29th- am I completed SOL if I need to retake?

Maybe. I know that the school my friend goes to has a deadline of Nov 1 for taking CS to allow time for re-taking. My school has no such deadline, but I now see why it's a good idea.

 

[everjustinxp]

That sucks dude. What is a IMG top 10? You had borderline for english as well?

I thought I failed, worried for months about it. Miss several diagnoses, PE maneuvers, didn't feel like I was that empathetic due to poor acting etc and I passed with flying colors to my shock and disbelief. I am not trying to make fun or criticize but I feel like it really does take a lot to fail this exam and from what I heard people who fail it really have to mess it up and probably deserve to fail. I don't really have any suggestions other than maybe your school doesn't prepare you to the proper US standards in which case passing those OSCEs doesn't really mean jack. Good luck tho, everyone passes this dumb test eventually..

you're really being a d** for questioning if someone is IMG/AMG when he/she just failed the test, and for saying that people who fail are just failures who messed up the test. I wonder how you're able to pass CIS with your empathy skill-- probably very good at acting during the test.

 

[swamprat]

you're really being a d** for questioning if someone is IMG/AMG when he/she just failed the test, and for saying that people who fail are just failures who messed up the test. I wonder how you're able to pass CIS with your empathy skill-- probably very good at acting during the test.

Not really.. he said IMG initially..which would make a lot more sense if he messed up the test since the test was initially used for IMGs only or so they say. And yep, your right, im very good at acting.. which must be the case because how can one show actual empathy to a fake problem a fake patient has on the test.

 

[colts]

Passed!!!!! Thank God!!!!!

 

[tco]

You have to retake it by Jan I believe otherwise you can't match.

This is definitely not true. It is program dependent.

 

[Laryngophed]

I think maybe half of my notes I was able to fit in my ROS. I just didn't have room against the character limit. I tried to list pertinent negs in the HPI though. And there were several DDXs for which I couldn't come up with solid support in one of the two categories. I'm more than a little nervous I'll drop the ICE component.


Edit - Anybody have any idea how long it is taking to get scores back? This late in the year, I'd think it'd have to be pretty quick so that if you fail, you can get a retest date PDQ.

 

[hoopie]

I never once had a ROS section in my noted. Whatever pertinent positive/negative ROS stuff I had, I put in my HPI. And I routinely had little to support some of my differentials. If those are your biggest mistakes you are fine.

 

[Laryngophed]

Now that I think back, there were a few other mistakes, but I'm not sure how critical they are. Like in a few cases I forgot to mention the "forbidden exams." But if your notes and mine were similar, that makes me feel better. Now, I suppose I just sit and wait.

 

[uzzet]

Now that I think back, there were a few other mistakes, but I'm not sure how critical they are. Like in a few cases I forgot to mention the "forbidden exams." But if your notes and mine were similar, that makes me feel better. Now, I suppose I just sit and wait.

Ok so I just stepped out of some interviews and I'm taking Step 2 CS in a few days. I'm calling on my fellow SDN'ers to help me out.

1. What do I need to bring to the test?

2. If I only have a couple days left, what should I focus on?

3. For those of you who have recently taken it or more so those of you who have passed, what are your recommendations and tips for test day?

Thanks so much in advance.

 

[mercaptovizadeh]

Ok so I just stepped out of some interviews and I'm taking Step 2 CS in a few days. I'm calling on my fellow SDN'ers to help me out.

1. What do I need to bring to the test?

2. If I only have a couple days left, what should I focus on?

3. For those of you who have recently taken it or more so those of you who have passed, what are your recommendations and tips for test day?

Thanks so much in advance.

1.) You are only allowed your stethoscope. You also need ID such as a passport of drivers license, and a credit card.

2.) Get a copy of First Aid for step 2 CS ASAP and study the whole thing. Read over all the possible case scenarios and sample notes. If there was any segment that was particularly weak for me (and I think lots of med students), and showed up twice on my exam, it was musculoskeletal. Study your joint/limb/back pain well.

3.) For test day, do not panick, but be very fast. Always do the absolute musts (gloves/wash hands, introduce self, respectful draping and requesting permission for exam maneuvers, express empathy, etc.) but keep the questioning and exam focused.

 

[uzzet]

1.) You are only allowed your stethoscope. You also need ID such as a passport of drivers license, and a credit card.

2.) Get a copy of First Aid for step 2 CS ASAP and study the whole thing. Read over all the possible case scenarios and sample notes. If there was any segment that was particularly weak for me (and I think lots of med students), and showed up twice on my exam, it was musculoskeletal. Study your joint/limb/back pain well.

3.) For test day, do not panick, but be very fast. Always do the absolute musts (gloves/wash hands, introduce self, respectful draping and requesting permission for exam maneuvers, express empathy, etc.) but keep the questioning and exam focused.

Do I not need my scheduling permit?

What are the most important parts of First Aid to go through if I can't make it through all of it?

Thanks in advance.

 

[hoopie]

Yeah bring your scheduling permit.

If you don't have time to read FA, I'd just focus on comingnup with a strategy for each patient so that you can hit the basics more or less on auto pilot, because once you're in there time starts ticking, nerves start acting up, and you can easily lose your way.

Here's what I suggest:

To start, when you are allowed to reveal the patient scenario on the door, just come up with three possible differentials based on the chief complaint. This way you have something going in to base your ROS on.

Make sure you knock, say the patient's name, make eye contact and smile, introduce yourself (either as Dr whatever or Student doctor whatever), shake hands.

Do your typical FAR COLDER or whatever pnemonic you use. Make sure you throw in a "Sorry you're having this ____" or "that must be tough" etc. Also use open ended questions whenever possible, they'll typically give you kost of what you need that way anyway. After you get the basic story, ask some pertinent ROS questions. Stuff like fevers, chills, sweats, nausea, vomiting, fatigue, etc are usually applicable if you get stuck. After that is the point where I'd do a basic summary and ask them if they have any questions or if there's anything else they want you to know. If you missed anything big, they'll probably offer it up or they might have a challenge question for you. Typically for those some version of "that is possible but we need to do an exam and run some tests until we're sure" will suffice.

Next move on the past medical stuff. I didn't go overboard here. Ask if they have any other medical problems in the past, any previous surgeries, any medication use, any allergies, any medical problems in their family - then comes social history. It's good here to say something like " I'm about to ask you some personal questions that I ask all my patients, this is all confidential, etc." I just asked any tobacco, alcohol, or drug use. Then for sexual just asked if they are sexually active. If yes you can ask men, women, or both and about condom usage but I wouldn't go any further unless it's necessary. Finally I typically asked about their diet and exercise because those are things you're supposed to counsel on. Other people suggest conseling right away rather than waiting until the closing portion, and I think that's a good suggestion. I always planned to do it during my closing but I forgot every time, so I practically did no clunseling at all.

After that, ask if they have any questions or concerns again. Then ask for permission to carry on with the physical exam. At this point I washed my hands and thought about what maneuvers I'd do. Some people apparently do small talk here but I stayed silent and it was fine. Just don't talk to them with your back to them while you are washing hands.

For PE I would stick to what is pertinent to your differential. You can certainly do heart and lungs on everyone if you want but do the pertinent exam first and then heart, lungs, abdomen or whatever if you feel like you have time. Your physicals can be far from perfect. I think it would be helpful to go through what manuevers you would do ahead of time so that you aren't fumbling around while you're on the room. Again, basic stuff. If it's a neuro patient, there's no way you'll have time for a complete neuro exam so just stick to the most important parts of it for your patient. Oh, and always ask for permission to untie gown, cover them back up when you're done, pull out leg rest for them when they're going supine, all easy points for that kind of stuff.

Finally comes the closure. Just rattle off a couple possible diagnoses and tell them in genersl terms what you're going to do next ("we're going to run some blood tests and do some imaging"). Then you can say something generic like once we get these results we'll have you come back to the office for another visit in about a week, in the meantime don't hesitate to call if you have any issues or something like that.

As long as you give yourself the allotted time the note shouldn't be too bad. Again, it's helpful to practice going over beforehand the typical things you will include. I didn't do that and forgot some silly minor things that I fretted over - eg didn't have a separate section for ROS (which would have just said negative except as mentioned in HPI anyway), didn't have a general section in my exam, stupid little things like that which I didn't think I'd forget. For your differentials you'll probably have trouble supporting them sometimes, especially with PE findings but that is typical. One thing I'll say is that when they say to use negative findings to support a differential, don't do what I did - I would say something like "lack of fever makes this differential less likely." That's not what they want. Rather it would be something like lack of cough making strep throat more likely. But again don't fret with those, you'll probably have trouble coming up with many negative findings to support. You should be able to come up with 3 or 4 history findings to support your top differential and maybe a PE finding too. Probably less for the less likely differentials.

That's about it. This post got kind of long winded but those really are the basics. I read through FA but I wish I had more actively come up with a basic framework to avoid a lot of the little stupid mistakes I made which added up and freaked me out. If all else fails, just be polite, be sensible, and try to be as complete as possible. You'll probably think you messed up bad like everybody does but chances are you will do plenty fine even if you feel like you bombed it.

 

[rocketbooster]

You guys just need to calm down and you'll be fine.

I walked into mine without studying anything and passed. I read the first chapter of FA on the plane there to familiarize myself with the test format and that's it. If you're an IMG then I can understand wanting to "study" more, but I feel most of you here are at American med schools. Even with the "harder" grading system, you'll still pass by just walking in. If anything I think FA could make you do worse because they have preset questions for you to ask in each case. If you do it'll come off unnatural and you probably will fail haha. By 4th year, you should naturally know what to ask when it comes to these basic cases. All you really need to do is familiarize yourself with the note format since it's weird and annoying having to repeat yourself 10x under the DDx after you just typed it all under the H&P.

 

[kaleerkalut]

1.) You are only allowed your stethoscope. You also need ID such as a passport of drivers license, and a credit card.

2.) Get a copy of First Aid for step 2 CS ASAP and study the whole thing. Read over all the possible case scenarios and sample notes. If there was any segment that was particularly weak for me (and I think lots of med students), and showed up twice on my exam, it was musculoskeletal. Study your joint/limb/back pain well.

3.) For test day, do not panick, but be very fast. Always do the absolute musts (gloves/wash hands, introduce self, respectful draping and requesting permission for exam maneuvers, express empathy, etc.) but keep the questioning and exam focused.

Yeah bring your scheduling permit.

If you don't have time to read FA, I'd just focus on comingnup with a strategy for each patient so that you can hit the basics more or less on auto pilot, because once you're in there time starts ticking, nerves start acting up, and you can easily lose your way.

Here's what I suggest:

To start, when you are allowed to reveal the patient scenario on the door, just come up with three possible differentials based on the chief complaint. This way you have something going in to base your ROS on.

Make sure you knock, say the patient's name, make eye contact and smile, introduce yourself (either as Dr whatever or Student doctor whatever), shake hands.

Do your typical FAR COLDER or whatever pnemonic you use. Make sure you throw in a "Sorry you're having this ____" or "that must be tough" etc. Also use open ended questions whenever possible, they'll typically give you kost of what you need that way anyway. After you get the basic story, ask some pertinent ROS questions. Stuff like fevers, chills, sweats, nausea, vomiting, fatigue, etc are usually applicable if you get stuck. After that is the point where I'd do a basic summary and ask them if they have any questions or if there's anything else they want you to know. If you missed anything big, they'll probably offer it up or they might have a challenge question for you. Typically for those some version of "that is possible but we need to do an exam and run some tests until we're sure" will suffice.

Next move on the past medical stuff. I didn't go overboard here. Ask if they have any other medical problems in the past, any previous surgeries, any medication use, any allergies, any medical problems in their family - then comes social history. It's good here to say something like " I'm about to ask you some personal questions that I ask all my patients, this is all confidential, etc." I just asked any tobacco, alcohol, or drug use. Then for sexual just asked if they are sexually active. If yes you can ask men, women, or both and about condom usage but I wouldn't go any further unless it's necessary. Finally I typically asked about their diet and exercise because those are things you're supposed to counsel on. Other people suggest conseling right away rather than waiting until the closing portion, and I think that's a good suggestion. I always planned to do it during my closing but I forgot every time, so I practically did no clunseling at all.

After that, ask if they have any questions or concerns again. Then ask for permission to carry on with the physical exam. At this point I washed my hands and thought about what maneuvers I'd do. Some people apparently do small talk here but I stayed silent and it was fine. Just don't talk to them with your back to them while you are washing hands.

For PE I would stick to what is pertinent to your differential. You can certainly do heart and lungs on everyone if you want but do the pertinent exam first and then heart, lungs, abdomen or whatever if you feel like you have time. Your physicals can be far from perfect. I think it would be helpful to go through what manuevers you would do ahead of time so that you aren't fumbling around while you're on the room. Again, basic stuff. If it's a neuro patient, there's no way you'll have time for a complete neuro exam so just stick to the most important parts of it for your patient. Oh, and always ask for permission to untie gown, cover them back up when you're done, pull out leg rest for them when they're going supine, all easy points for that kind of stuff.

Finally comes the closure. Just rattle off a couple possible diagnoses and tell them in genersl terms what you're going to do next ("we're going to run some blood tests and do some imaging"). Then you can say something generic like once we get these results we'll have you come back to the office for another visit in about a week, in the meantime don't hesitate to call if you have any issues or something like that.

As long as you give yourself the allotted time the note shouldn't be too bad. Again, it's helpful to practice going over beforehand the typical things you will include. I didn't do that and forgot some silly minor things that I fretted over - eg didn't have a separate section for ROS (which would have just said negative except as mentioned in HPI anyway), didn't have a general section in my exam, stupid little things like that which I didn't think I'd forget. For your differentials you'll probably have trouble supporting them sometimes, especially with PE findings but that is typical. One thing I'll say is that when they say to use negative findings to support a differential, don't do what I did - I would say something like "lack of fever makes this differential less likely." That's not what they want. Rather it would be something like lack of cough making strep throat more likely. But again don't fret with those, you'll probably have trouble coming up with many negative findings to support. You should be able to come up with 3 or 4 history findings to support your top differential and maybe a PE finding too. Probably less for the less likely differentials.

That's about it. This post got kind of long winded but those really are the basics. I read through FA but I wish I had more actively come up with a basic framework to avoid a lot of the little stupid mistakes I made which added up and freaked me out. If all else fails, just be polite, be sensible, and try to be as complete as possible. You'll probably think you messed up bad like everybody does but chances are you will do plenty fine even if you feel like you bombed it.

Are the patients already draped? I read in First Aid that there is some sheet of paper on the stool and that we have to drape the patients ourselves. Is this true?

 

[HelpPleaseMD]

Are the patients already draped? I read in First Aid that there is some sheet of paper on the stool and that we have to drape the patients ourselves. Is this true?

some are draped some arent. if they arent draped drape them during the PE exam. solved

the drapes are in an obvious location if you look for them.

 

[hoopie]

I thought they were all draped now.

Just make sure you ask permission to untie or uncover their drape, and always cover back up after you're done with the uncovered area.

 

[kaleerkalut]

I thought they were all draped now.

Just make sure you ask permission to untie or uncover their drape, and always cover back up after you're done with the uncovered area.

Anybody actually do the Dix-Hallpike maneuver or do you just write it in your note?

Edit: Also, anybody actually take orthostatics or just put it in the note?

 

[hoopie]

Anybody actually do the Dix-Hallpike maneuver or do you just write it in your note?

Edit: Also, anybody actually take orthostatics or just put it in the note?

Just put them in your note.

 

[mercaptovizadeh]

Anybody actually do the Dix-Hallpike maneuver or do you just write it in your note?

Edit: Also, anybody actually take orthostatics or just put it in the note?

Properly done orthostatics is time consuming. Dix-Hallpike could lead to awkward patient responses "I didn't feel comfortable when you slammed me back on the table, blablabla." Just put in the note. This is "1st pass" diagnosis. Dizzy, tinnitus, hearing loss > cobble together vestibular neuronitis, labyrinthitis, BPPV, Meniere's, acoustic neuroma, Ramsay hunt, vertebrobasilar insufficiency, etc. and put in the differential. No need to do intense diagnostic maneuvers to distinguish between them. Do the Weber and Rinne tests and listen for carotid and vertebral bruits, and leave it at that. Likewise for chest pain, ddx is aortic dissection, acute pericarditis, pericardial tamponade, MI, angina, esophageal spasm or rupture, etc. No need to assess for pulsus paradoxus, listening to the heart and lungs is enough.

 

[Laryngophed]

Since I was in panic mode and doing some whining after the exam, I should say that I got my results yesterday and I passed. Apparently there is a really high tolerance for forgetting things in the patient's exam room.

 

[step2csscared]

Hey guys, I just took my cs a few weeks ago and really scared about how it went. Especially the ICE part, if someone could shed some light:

1) can't remember it
2) should've put the the 2nd ddx as first and vice versa but they were both good. 3rd ddx was way off, had one supporting point, don't know why I even put it
3) first 2 ddx pretty wrong. 3rd ddx was way off (had supporting points but only 1-2)
4) went well
5) went well
6) went ok
7) encounter went ok, ddx were also ok (i didn't have more than 2 supporting points for each ddx)
8) really wasn't sure what patient had, weak ddx and 1-2 points supporting them
9) went well, but forgot 1-2 important questions about chief complaint
10) went well, but forgot 1-2 important questions about chief complaint as well
11) went well
12) went well


Aside from that I would usually finish with 1-2 minutes to spare after closure, counseling and the basics (washing hands, proper draping, knocking, physical exam etc). I'm mostly worried about the ICE but then again who knows about the other sections, I just feel I messed up a bunch of diagnosis that I should've gotten.

Thanks for any advice

 

[Uhl88]

Amg here.. Failed the CS. Failed the CIS and was borderline on the ICE. Took the test again back in March after preparing with 3-4 colleagues who passed at first attempt with flying colors and worked with my OSCE professor to remediate . I am still freaking out about all the mistakes i made. I realize this is a normal response to the test but I just can't sleep or eat right now. Having small panic attacks. Perhaps its because I took it the second time and so much is at stake for passing this exam.. but I can't even think..

I think I am significantly PTSDed from my first failure, esp since I had no doubt that I passed my first try..

So without giving away any cases, here are the mistakes that I remember:

- didn't wash hand for one case (got off rhythm)

- didn't do one MMSE and neuro exam that may have been required, although i don't know how critical it was since i don't think the pt had seizures

- flustered and may have rushed one case, answered the difficult question but added more detail to the difficult question

- didn't know the exact ddx for 2 cases, had 2-3 ddx for all cases except 2 where i only had 1, one of the 2 cases was really vague, had very little idea what was going

- missed atleast one hx question if not multiple for each case to r/o a ddx

- feel like missed one PE maneuver per case

- missed couple diagnostic tests per case, including rectal/pelvic exam for 1, on average had about 4-5 tests, few i had up to 7... but I still missed some critical diagnostic test which I slapped my head for when I left the exam

- since I was writing the note all shorthand to maintain eye contact, it was pretty messy and I had to decipher it while writing the PN. I remembered few ROS questions that I might have asked during the encounter, but wasn't sure but the note was mostly done from my blue sheet

- some I forgot to ask 1-2 components of the onset duration, frequency, progression since I was committed to asking open ended questions.

- didn't ask some relevant social history questions such as exercise, diet, lifestyle, living conditions, safety, although i don't think I had any abuse cases

- might have not counseled on few pt, esp smoking

- forgot to do gait for some who may have required it

- missed out some counseling on the end with regard to lifestyle (exercise and diet)

- finished pt note but ran out of character space so had to delete some ROS to fill in other things

- missed documenting few PE I did

- didn't document vital signs unless they were abnormal or could be supporting the ddx

- didn't ask how the illness was affecting the pt's life and what the pt thought the illness was for any case

- forgot Ob/Gyn q for one case although i don't think it was relevant to the CC

- didn't use medical terminology in the PN when it could have been used (e.g emesis instead of vomiting)

- overall had about 10+ ROS questions that I probably asked to the CC to either rule in or rule out a diagnosis..

- had about 3 CC that I didn't expect/wasn't on FA, so I don't think I asked enough relevant ROS questions for those (maybe around 8)

What i did right:

- was generally empathetic, whenever doing the abdominal exam, I always asked the pt if he/she felt comfortable lying on the exam table, pulled out the extension, and when helped the pt sit back up.

- draped the pt appropriately, exposing only the minimal skin of exposure, untied and tied the gown back appropriately and folded the gown to expose the back and the chest with minimal exposure for ascultation

- washed hands for all cases except 1, always knocked and introduced/ smiled/ shaked hands/ always asked 3-4 open ended questions and maintained eye contact while pt talked, used transition statements when switching from HPI to ROS to rest of the hx such as "well Mr/Mrs, I want to now ask you few questions about your general health, would that be okay?", also told the pt "Mr/Mrs so and so, I wanted to let you know that everything we talk is going to remain confidential, but i wanted to ask you few questions about your sexual practices" before asking about sexual hx

- counseled pt when I could, asked CAGE for all drinkers (may have been unnecessary) but I said it in the way of "so, Mrs/Mr so and so, here are few questions we ask all pt who drink.. do you mind if I ask those questions?"

- smiled when leaving the room if the pt encounter was good, always left saying "Thank you for letting me serve you today, I hope you feel better soon"

- did LIQRAAA ODFP for all pain pts

- asked for more details every time I finished closed ended-questions, summarized after finishing history, always told the pt what physical exam I was going to do

- I told the pt what I was doing while I was doing the physical exam, auscultated heart and lungs for all patient including the PMI for female pt by asking the pt to lift her left breast

- palpated thyroid when appropriate, did abdominal exam (inspection, auscultation, palpation, percussion) when appropriate with additional manuevers, checked CVA tenderness when appropriate, murphy's sign, etc.

- did additional MSK maneuvers along with ROM, sensation, pulses, strength, DTRs for 2 MSK cases I think

- always finished closure with what I thought the concerning ddx were for the CC, the diagnostic tests I was going to order, and left the room with about a min (average) to spare

- always finished pmhx, pshx, shx, fhx, meds, allergies along with the HPI

- answered challenging questions appropriately

- explained all things in layman terms even after using the medical terms

- pretty certain i got main diagnosis and few ddx for 10/12 but not certain for the other 2..

 

[Psyche Estrelle]

At risk of sounding insensitive, I always wonder what people are looking for by making posts like the one above. You already took the test. It's done. Just wait for the results. Literally nothing is going to change between now and then. Is it worth taking all this time to write a long post about everything you THINK you did right or wrong when you don't even know if you passed or not and all that effort might be (and probably is) all for nothing? You may think it's making you feel better but it definitely seems to be doing the opposite for most of you (especially if people don't reply telling you what you want to hear!)