Failed Step 2 CS

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Although I will not want to write here any more, I will tell you guys something. I don't think you guys read my note carefully. As I wrote the first part of my note, I use mnemonics just for help when I run out of questions suggested by Dr. & Prof. Swartz, C3NY & New York Univ. School of Medicine. Now I am practicing for the exam with my English tutor using "The ultimate guide and review for Step 2 CS exam by Mark H. Swartz." She pretends a patient. As you know, I can't ask these questions following the order of my note. I ask questions following her talk. I just use mnemonics when I run out of questions. I wrote "Be flexible. You don't need to follow the order of my note." in my note. I also wrote "You can't ask all questions for the 15 minute-time limit. Follow the patient's leads, not yours." I take a part of history and do physical exam at the same time to save my time suggested personally by Dr. & Prof. Wolfe, Kaplan 5-day course & Stanford Univ. School fo Medicine. The first part of my note to show empathy is from Kaplan 5-day course. Although I don't think I can use the same phrase in all cases, when I used this technique in C3NY in front of the director and Dr. & Prof. Swartz, New York Univ. School of Medicine, they were really impressed. But I think the most important thing is to take care of them with empathy like your real patients as you did. I tried this way in Kaplan 5-day course. My CIS score jumped up to 77-90 %. My only problem is I can't speak clearly. Now I am working on this very hard. I am hiring English tutor, reviewing ESL materials, listening to NPR, repeating phrases in NPR and TV, reading my note loudly & recording my voice & listening to my voice, and singing English songs almost every day. But it will take at least 3 months to improve SEP.
Anyway I may have mislead someone just using these mnemonics. For me, the phrases in my note I took from several books deserve to remember them because I am not an English speaker. I read these sentences, record them, listen to them and check if I pronounce them correctly every day so that I can use them in the exam.
Any comments?
I was mad and deleted my note. I will put my note here and bold the sentences I mentioned for persons who can't read carefully.

• This exam is about communication and being with the patient. It is about satisfying the patient. It is about making the patient talk. Treat them like real patients with empathy. CIS≥70%?, SEP≥90%
• On Step 2CS, it is very likely that you will not be able to ask all these questions because of the 15-minute time limit. Just listen to your patient and follow their leads. Go with their directions-not yours! The patient's initial responses to your open - ended questions will steer you toward those questions you need to ask. A word about mnemonics - use them sparingly! If you run out of things to ask, look at the mnemonic for help. Speak slowly, pronounce clearly, and be strong but not overpowering. - From Dr. Swartz. Eye contact!!! Don't write mnemonics to keep eye contact. If you run out of questions, jot them down and ask them. Watch red flags!
• The regular mnemonics [SIQO(FDC)R A3, HEEDS CNN JR, FFAW, PAM HITS RUGS FOS SODAS TIME], the pediatrics specific one [SIQO(FDC)R A3, HEEDaycareSorethroat&Shaking CNNose JR, FFAW, PAM HITS RUGS FSmoke/SupportT, PBN FDR BEEFS], the adolescent (12-18 years old) specific one [SIQO(FDC)R A3, HEEDS CNN JR, FFAW, PAM HITS RUGS FOS SODAS TIME, BEEFS], or the psychiatric specific one [SIQO(FDC)R A3, SIGEM CAP STIR, FFAW, PAM HITS RUGS FOS SODAS TIME, MMSE].
• Get dressed neatly and use moderate deodorant. Take breath mints and brush your teeth before the beginning and after lunch.
• Write LAST NAME, age, CC, abnormal vitals.
• Breathe slowly and deeply three times. Knock on the door three times; open the door; "Are you ready, Mr. XYZ?" (OBSERVE! OBSERVE! OBSERVE!) ; Close the door.
• Smile (Remember a funny thing that makes you laugh). "Hello. My name is Dr. (pause) your name. I'm a physician in this hospital. Mr. XYZ, nice to meet you. (Shake hands if the patient is not in acute distress or in pain of his arm). Did I pronounce your name correctly?"
• "I will cover you with this cloth to make you a bit more comfortable."
• "Do you mind if I sit down?"
• "Mr. XYZ, I'll be writing down some notes while we talk. Is that Okay?"
• Write 6+the time=finish history, 11+the time=finish PE.
• Never write anything while the SP is speaking! In my experience, amazingly you remember everything the patient talked to you about. Just write mnemonics when you run out of questions.
• "We start with talking about your problem. Then I'll do a physical exam and then we'll go over possible tests to treat this. Sounds OK?"
• "I see from your chart that you have.…and your ….. is somewhat high, which concerns me."
• * For follow-up cases, medication refills, and pre-employment physical, and health fair seeming to have no symptoms or abnormal vital signs from the doorway information, "I see from your chart that you come here for diabetes follow-up or need a refill of your blood pressure medicine. Are you having any other concerns I can help with?" Because they may have problems related to their diseases.
• "When did it start?"
• "When were you in perfectly good health?"
• "Did anything change in your life around the time of complaint?"
• "How is this impacting your life?" (GESTURE)
• Touch the arm or shoulder. "I am sorry to hear that. That must be difficult for you. I shall try my best to help you."
Other reassurance:
"I will do everything I can to make you feel better."
"I know how you feel because I have a brother/mother/father with the same problem."
"I have a child of my own."
"It is very difficult to watch a child suffer."

• "Now let's go back to the problem. Could you tell me more about it?"
• Use reflections and continuers like "Uh huh," "I see." "Go on." "Tell me more." vertical head shaking, engaged listening posture. When you agree with them, say "I understand."
• When patients use vague terms such as "often," "somewhat," "a little," "fair," "reasonably well," "sometimes," "rarely," or "average," you must always ask for clarification.
• After asking the patient about the Chief Complaint in detail, repeat what the patient told to you. Paraphrasing concentrates on only a particular symptom. Do this thing at least twice. For example, "You told me you have had 3 days of cough and 1 day of shortness of breath. Is that correct?"
• "What are you worried about most?"
• When you run out of questions, tell the patients "I need a moment to think" before silence, or escape to PMH/FH/SxH/SH/the summary!
• Dr. Wolfe from Kaplan said you can do history taking and a physical exam at the same time if you have tendency to run out of time. You can also summarize before PMH/FH/SxH/SH. Be flexible! You don't need to follow the order of my note.

SIQO(FDC)R A3
• Site: "Please show me exactly where it is."
• Intensity/Quantity/Quality: "How is the pain affecting your life style? How severe is your shortness of breath? DEATH? How many pads or tampons do you use a day? How much sputum do you have? Are your bowel movements watery?"
• Quality of symptoms: "Tell me what it feels like."
• Onset/Frequency/Duration/Change: "Are you aware of anything that might have brought this on? What were you doing when it started? Does it start suddenly or gradually? Does it come and go? How often do you have this? Is the pain there all the time? For how long does the pain last? Is it getting better or worse?"
• Radiation: "Do you have pain anywhere else at the same time? Show me where."
• Aggravating factors: "Does anything make your pain worse?"
• Alleviating factors: "Does anything make your pain better?"
• Associated manifestations (symptoms that commonly occur in the diagnoses you are considering): "In addition to your headache, have you noticed anything else?

Associated manifestations - HEEDS CNN JR FFAW

• Headache: "Do you get headaches?"
• Eye: "Has your eyesight changed in any way?"
• Ear: "Did you notice any change in your hearing?" For pediatrics, "Is he pulling at his ears?"
• Dizziness: "Do you ever feel dizzy? Did you lose consciousness?" For pediatrics, Daycare: "Does your child go to the daycare? Did he/she contact sick children in the daycare? Are there any sick persons at home?"
• Sore throat/Swallow: "Do you have sore throat? Do you have difficulty swallowing?" For pediatrics, Shaking: "Did he/she have shaking?"

• Cough/Chest pain: "Do you have a cough? When you cough, does anything come up? How much phlegm comes up? What color is it? Is there any blood in it? Do you get short of breath? Have you been wheezing? Do you have chest pain? Do you have palpitations? Leg swelling? Shortness of breath when sleeping?"
• Nausea: "Did or do you feel nauseated? Did you vomit? What was in it? What color was it? Was there any blood in it? How much was there?"
• Numbness: "Do you notice any numbness or weakness? Do you notice any tingling?" For pediatrics, Nose: "Does he/she have a runny nose?"

• Joint pain: "Do you have joint pain anywhere in your body? Is there any redness or swelling of the joint?"
• Rash: "Have you noticed any rash? Have you noticed any yellowing of the skin?"

• Fever: "Have you been running a fever? Do you sweat a lot during the night?"
• Fatigue: "Do you feel tired?"
• Appetite: "How is your appetite?"
• Weight changes: "Has your weight changed any? How much? Over what period of time? Was it intentional?"

Ask height and weight for pre-employment physicals, pediatric cases, and other cases in which patients will want help with managing their diabetes, hypertension, or obesity.

"What does your blood pressure normally run?" "Have you ever been immobilized?" "How often do you test your blood sugar? How high have your sugars been?" Don't forget to ask about rash and fever in joint-pain cases.
For overweight patients, "Does she have excessive bodily and facial hair? Does she have excessive acne?"
Thyroid function 5 (BS HiTS) ("Have you noticed any change in your bowel habits? Constipation? Diarrhea? ; Has your skin been very dry/very moist lately? ; Have you been losing your hair? ; Do you find yourself having trouble adjusting to cold or hot temperature recently? ; Do you have trouble sleeping?")

SAFE for domestic violence,
• Safe: "Are you concerned about your safety or the safety of your children?"
• Afraid: "Do you feel afraid?"
• Friends/Family: "Do you have friends and family support"
• Emergency plan: "Do you have an emergency plan?" If say no, consult as below.

DEATH & SHAFT for dementia,
• Dressing: "Are you having any problems getting dressed?"
• Eating: "Are you able to prepare your own food and eat it?"
• Ambulating: "Are you having any falls?"
• Toilet: "Any problems getting off and on the toilet?"
• Hygiene: "Are you able to bathe or shower by yourself?"

• Shopping: "Do you need any help shopping?"
• Housekeeping: " Do you need any help cleaning your house?"
• Accounting: "Do you need any help managing money?"
• Food preparation: "Do you need any help preparing food?"
• Transportation: "Do you need any help getting from place to place?"

• After finishing, go to standard questions. "Mr. XYZ, now I am going to ask you about your health?" (PAM HITS RUGS FOS SODAS TIME)

• Previous episodes of chief complaint: "Have you ever had this or a similar experience before? Have you ever had ……?" (Name diseases or conditions related to chief complaint and history findings.)
• Allergies: "Do you have any allergies?"
• Medications: "Are you taking any medications? Prescriptions? Over-the-counter pills? Vitamins? Herbs?"

• Hospitalizations: "Have you ever had to stay in the hospital?"
• Illness: "Have you had any other major illnesses before? Have you ever had high blood sugar? Have you ever had high blood pressure? How about high cholesterol?"
• Trauma: "Have you had any recent injuries or accidents?"
• Surgery: "Have you ever had any surgeries?"

• Review of symptoms (urinary, GIT, sleep)
• Urinary problem: "Have you had any changes in your urinary habits?
FINISHED PUBS
Frequency: "How often do you urinate?"
Incontinence: "Have you lost control of your urination?"
Nocturia: "How many times do you get up at night to urinate?"
Incomplete emptying: "Do you feel that you haven't completely emptied your bladder after urination?"
Stream: "Is the stream weak?"
HEmaturia: "Have you noticed any changes in the color of your urine? Any blood?"
HEsitancy: "Do you have difficulty initiating or stopping urination?"
Dysuria: "Do you have any pain during urination?"

Pyuria: "Have you suffered a penile discharge?"
Urgency: "Do you have the need to urinate immediately?"
Burning: "Do you have any burning with urination?"
Strain: "Do you need to strain during urinating?"
• GIT problems: "Have you had any changes in your bowel habits? When you go to the bathroom, what does your stool look like? What color is it? Was it very foul smelling? Does it float? Have you been having diarrhea? How long have you had the diarrhea? Have you been constipated? How many bowel movements do you have per day? Do you get stomach cramps? Did you notice any blood? Is there any mucus in it? Do you feel as though you strain to go to the bathroom and then very little feces or none at all come out? Have you lost control of your bowels?"
• Sleep problems: "Has your sleep pattern changed in any way?"

• Before taking a family history, say "Mr. XYZ, I am going to ask you about your family." Empathy for bad news.

• Family health: "Does anyone in your family have this or a similar problem? Is there any history of the following in your family? High blood pressure? Diabetes? High cholesterol? Any other serious illnesses?"

• Before taking OB & GYN and sexual history, say "Now I am going to ask you about your gynecological and sexual health.

• OB & GYN: Ask "When was your last menstrual period?" with all women past the age of menarche. Ask more detailed Ob/Gyn history to only women with complications of abdominal pain, abnormal vaginal bleeding, dysuria, discharge. " How old were you when you had your first period? Do you have a period every month? When was your last menstrual period? How many days are in your cycle? How long does it last? Has your period changed in any way? On a heavy day, how many pads or tampons do you use? Do you ever have any spotting between periods? Do you have any problems with PMS? Have you ever been pregnant? How many times? What is the outcome? In what trimester?"
• Sexual history: Needed only if they are relevant to the case. "Are you currently sexually active? Do you use condoms consistently? Other contraceptives? Are your sexual partners male, female, or both? Have you ever had a sexually transmitted disease? Have you ever been tested for HIV? Do you have any problems with sexual function?" For adolescent, "Have you talked to your child about sex? Is your child sexually active? Have you asked your child if he is sexually active? Have you discussed contraception? Has your daughter had the new shot that prevents cervical cancer?"

• Before taking SODAS TIME, say "Now I am going to ask you about your lifestyle."

• Smoking: "Have you ever used tobacco in any form? How many packs for smoking a day and for how many years?"
• Occupation: "What type of work do you do? Tell me about your work situation. Is there physical strain? Are you exposed to hazardous materials? Is it stressful? Tell me about your home life."
• Diet: "What is your diet like? Have your eating habits changed in any way?"
• Alcohol & Coffee: "Do you drink alcohol? How much and how often? How's your caffeine intake?"
CAGE: "Have you ever felt the need to cut down on your drinking?; Have you ever felt annoyed by criticism of your drinking? ; Have you ever felt guilty about your drinking? ; Have you ever had to take a morning eye opener?"
• Support system: "Whom do you live with? Do you have anyone you can talk to? Does anyone support you?"

• Travel Hx: "Have you been traveling anywhere lately?"
• Illicit Drugs: "Have you ever used recreational drugs? Which ones? How often? Do you inject any drugs? When did you take it?"
• Marriage: Don't ask about marriage unless they talk.
• Exercise: "Do you do regular exercise?"

• Do the counseling after you ask about it. The key here is to have the patient see the counselor.
• For Smoking: "Your health will improve if you stop smoking. I'd like you to attend nonsmoking classes run by our counselor."
• For Alcohol: "For your health, it is important that you stop drinking. I'd like you to speak with our alcohol counselor. I will bring you her number."
• For Recreational Drugs: "Please stop using drugs. They are hurting your health. I know it can be difficult, so I'd like you to speak to our drug counselor."
• For the sexually promiscuous patient: "I understand that you may not like to use condoms, but I am concerned that you may be putting yourself at risk for STDs. You could contract HIV, herpes, chlamydia, or any of a number of other STDs. The complications of these diseases include infertility, painful infections, or even death. If anyone with whom you have sexual contact has an STD, you could share it among all of them, including your girlfriend. I hope you will consider using a condom in the future."
• For Sexual Transmitted Diseases: "Do not have sex until all your treatment is finished and your partners are treated as well. Then I want you to use a condom every time to prevent infection in the future."
• For Diabetes Control: "Not controlling blood sugar, eating fatty foods, not doing regular exercise and not watching your feet regularly puts you at a higher risk of getting complications of diabetes. I must advise you to observe strict blood sugar control, eat less fat, do regular exercise and observe your feet. I'd like you to speak to our nutrition expert, who can help to plan out a diet and exercise program with you."
• For Hypertension: "Not controlling blood pressure, eating salty foods and not doing regular exercise puts you at a higher risk of getting complications of high blood pressure. I must advise you to observe strict blood pressure control, eat less salt, and do regular exercise. I'd like you to speak with our nutrition expert, who can help to plan out a diet and exercise program with you."

• For patients who denied all workup plans: "I understand that it is very difficult to quit an old habit, but taking cocaine damages your body a lot and it might be one of the causes of your condition. There are a few professional support groups also available that would be happy to help you. Please let me know if I can be of some help to you."

• For domestic violence: "Ms. ….., many women are victims of domestic violence. If anyone is hurting you, I can help keep you safe. I know it is difficult to talk about. Remember I am here to help you. I'd like you to see our counselor to help. Also I want to be sure you have a safe place to go when you feel you are in danger. I'll bring you a list of shelters that you can use."

• For depression: "You answered yes to many of my questions. I believe that you might have the diagnosis of depression. Depression is a common disease. Fortunately, we have medications that can help. However, these medications work best when they are combined with counseling. I can write you a prescription and also give you a referral to see a therapist. Is this something you are interested in?"

• For challenging questions: "I understand your problem/concerns that …………… But right now it is difficult for me to say for sure as I need to run some tests and once the results come back, I will be in a better position to tell you what we are dealing with. I will keep you informed. Is there anything I can do to make you feel more comfortable? Please bear with me. I will very much appreciate your patience."

• For the patients upset waiting for a long time, "I'm sorry for keeping you waiting. I'm here now and you have my full attention."

Specific mnemonic for Ped Hx, PBN FDR BEEFS.
"I'm going to ask you about your pregnancy of him/her."
• Prenatal History: "How was the mother's health during pregnancy? Were there any problems during pregnancy? Did the mother have routine prenatal checkups? How often? Was an ultrasound performed during pregnancy? What was the result? Did the mother take medications during the pregnancy? smoke? drink alcohol? use recreational drugs?"
• Birth History: "Was the pregnancy full term? What was the type of delivery? Neonatal History: Did the child have any medical problems when he or she was born? How long did mother and child stay in the hospital after delivery?"
"I am going to ask you about his/her diet."
• Feeding History: "Was the child breastfed or given formula? When did the child start eating solid food (3-4 mo)? Has there been any change in your child's diet? What foods does the child eat and like now? How is the child's appetite? Does the child take daily pediatric multiple vitamins? Does the child have any food allergies?"
"I'm going to ask you about his/her growth and development."
• Developmental History: "Has the child gained weight appropriate to the growth chart? Has there been any sudden gain or loss of physical growth? Has the child met developmental milestones? -When did your child smile (2 mo)? When did your child first sit up (6 mo)? When did your child start putting things in his mouth (6 mo)? When did your child start crawling (9 mo)? When did your child start talking (9 mo)? When did your child start walking (12 mo)? When did your child learn to tie his shoes? When did your child start using short sentences (2 yr)? When was he toilet-trained?"
"I'm going to ask you about his/her routine care."
• Routine Care: "What is the name of pediatrician and clinic where child is routinely seen? Are the child's immunizations up to date? What is the date of child's last routine checkup?"

• Body Image: "How is your child's body image?"
• Eating Disorders: "Has your teen's weight changed? How much does your child exercise? Does he frequently go to the bathroom during dinner?"
• Education: "Has there been any change in your child's grades? Is your child interested in school?"
• Friends and Activities: "Do you know your child's friends? Is your child secretive about his friends? Does your child have friends and activities?"
• Suicide/Depression: "Does your child seem sad or hopeless? Does your child seem to want to harm himself? Does your child seem uninterested in activities?"

8 causes of enuresis
1. Genetic (family history)
2. Constipation (dietary history)
3. Sleep-disordered breathing (snoring)
4. Neurogenic bladder (gait)
5. Seizure (fainting)
6. Thyroid disease
7. Diabetes
8. Psychological stress

Specific mnemonic for Psychiatric Hx, SIGEM CAP STIR.
• Stress: "Do you have any problem in your job? Have you had any recent emotional or financial problems?"
• Interest: "Have you lost interest in activities you enjoy?"
• Guilt: "Do you feel guilty?"
• Energy: "How is your energy level?"
• Mood: "How is your mood? Do you have any plans for the future? Do you have hope for the future? Do you feel hopeless?"

• Concentration: "How's your concentration? Do you have any memory problems?"
• Abuse: "Are you in any danger from anyone in your personal life?
• Psychomotor agitation: "Sometimes when people are under a lot of stress, they see or hear things that others don't. Does this ever happen to you? (Hallucination) Do people ever say they think you have extremely unrealistic ideas about yourself or about life in general? (Delusions) Do you ever feel like hurting anyone? (Harming others)"

• Suicide: "Do you ever consider taking your own life? Do you actually have a plan? Would you be willing to tell me what it is? Do you already have the gun or pills?
• Traumatic event: "Have you had any recent traumatic event in your life?"
• Insight: "What do you think about your symptoms?"
• Routine: "Has your daily routine changed any?"

• Summarize. "Let me see if I have it straight. …………………… Is that correct? Do you have any other things to tell me before I start your physical?"

• "Okay, Mr. XYZ. Now I am going to do a physical exam."
• "Alright then, excuse me for a moment here so that I can put on gloves."
• Wipe your stethoscope with an alcohol pad, put on gloves, and make it warm by a hand.
• Pull out the leg extension when the patient is reclined. "Let me fix the bed to make it comfortable."
• Pull out the footstool when you ask the patient to walk. "Let me pull out the foot stool."
• Never undress patients. When the patients can't do, you say "Shall I assist you?"
• Read phrases of physical exam in Kaplan notes.
• JVD is not necessary.
• Heavy drinker, smoker - check the tongue & floor in the mouth.
• Headache - check with ophthalmoscope.
• Joint exam: Inspection; Palpation; ROM; MRS; Distal pulse. Sensory exam: Back & Hip & Knee & Ankle/Foot - just above patella (L4), lateral lower leg (L5), lateral foot (S1); Shoulder & Elbow & Hand - 5th finger pad (ulnar nerve), 3rd finger pads (median nerve), dorsum of hand at web space between thumb and second fingers (radial nerve).
• Brief torso exam is indicated when back pain, rash, depression, mental status change, fatigue, extremity problem. "I'm going to take a look at your back. Would you untie your gown? Please lower your gown." "Now I'll listen to your lungs. Please breathe in and out through your mouth." Listen at 4 places on the back. "Now I'll listen to your heart." Listen to 4 places. Say "You may tie your gown." "Now I'm going to look at your stomach area. Let me fix the bed to make it comfortable. Can you please lie back? Please raise your gown." "Now I'll listen to your stomach area." One place for 3 seconds. "I need to press on your stomach area now." Palpate 4 quadrants.
• Brief neurological exam is indicated when headache, mental status change, dementia, or head trauma. If the patient is not oriented to person, place, and time, do the rest of the mental status exam. Cranial nerves: Do the 5th nerve last. Say, "Clench your teeth," and then check the 5th sensory with cotton balls (all three branches). Sensory exam: Check just the tip of the third finger and the top of the foot where the great toe and second toe meet (only use cotton balls). Check both sides at once. Motor strength: "Squeeze my fingers; pull me in; kick out, kick out." Test the upper extremities at the same time but test leg strength one leg at a time. Deep tendon reflexes: Check brachial and patella only. Cerebellar: Gait.

Psychiatric exam.
MMSE: "I am going to check your memory and concentration by asking you to do a few things now."
• Orientation-person, time, and place "Can you tell me the date? Can you tell me where we are? Please tell me your full name." Ask everyone older than 65 years old.
• Memory-"car, tulip, black"
• Attention & concentration-spell "earth" backward.
• Language-name "pen, clock"; repeat "No ifs, ands or buts."
• Obey commands-"Write your name on this paper, fold it in half, and throw it on the floor."

• If the patient complains of any pain, say "I am sorry, I need to do this test to know what is actually the cause of your problem. Next time I will be gentle." But don't repeat.
• Never talk at the back of the patient. If you have to do that, say "Now I am going to examine your back. I may give some instructions from the back. Please follow them." When you examine the back, put your hand on the patient's shoulder if possible.

• "Mr. XYZ, I have finished your physical exam."

• Summary: Very important to share information with patients. "Thanks for your cooperation, Mr. XYZ. Now I will sit and talk over what I am considering so far. You told me that you have had this problem since ….. and it is progressively getting worse and on physical exam, I was not able to find anything significant/I was able to find that you have ………….. Based on this, there are a few diagnostic possibilities like …… and …….But there are other possibilities as well and what I am going to do now is to run a few tests like some blood tests and some imaging studies such as ….. on you. Do you agree to have them? Once the results come back, we will sit together again and discuss your problem in more detail." For Pediatrics cases, tell them "Bring a child here today."

• "Have you understood everything that I have told you today?"
• "Do you have any questions?"
• "Okay then, Mr. XYZ. I am glad that I was able to work with you and I assure you that I am always here to help you. Thanks for your cooperation and it was nice meeting you. Bye for now and take care."

• Don't leave early. You will lose your points. Say "Let me check if I have got all my facts right."
• When you have to go because of final announcement, say "I've just been called away. I've got to go. I'll be right back to talk more."

You don't need to apologize. You just might have misunderstood I focused only on my mnemonics because you might not have read the beginning of my note. The mnemonics is help just in case as I mentioned in my note. I just organized the sentences I need to use in the exam. I appreciated your kindness & energy to help me pass the exam. But you used your energy toward the wrong direction because you misunderstood I was just focusing on them. It is likely that my writing way makes you misunderstand me because I am not an English writer. I understand your saying because I took a course in C3NY and learned not to use them except that I just run out of questions. Hope you will not feel bad. I will be pleased to hear further suggestions from you.

Best,

GATO.

2 minor corrections.

Do you get shortness of breath?

Does she have excessive body or facial hair?

Thanks, Irongal.
As I told before, now I am working with an English tutor. She pretends a patient. She is a good actress and corrects my English. When I speak fast, she can't understand me sometimes. I miss some words occasionaly in sentences. She pointed out silence when I was thinking about next questions. After I come home, I practice to write patient notes. I study with her for an hour twice a week. It costs, but is worth.
Today when I practice by myself, I record my voice using a free software "audio recorder" in my computer. Then I listen to my voice to check if I can understand my English, there are missing words, and there is silence. I think this is a good way when I study by myself. Even though I think I speak well, I can find out something wrong.
This is just for IMG.

I think the book she mentioned is "USMLE Step 2 CS: complex cases, 35 cases you are likely to see in the exam" by Kaplan medical. I have it. You can buy it from Amazon. Send a personal message to Irongal and ask what the Kaplan book is.

I learned a tip from Kaplan course.
Draw a vertical line and divide in half in History and Physical examination. You can use the space efficiently.
Hope this will be helpful.

GATO.

I have a question. I am anxious and scared of taking this exam.
In addition to the exam, the paper I had been worked for 6 years after the journal requested to revise the paper was rejected because my previous boss was slow and asked me to do more experiments for 1 year. Usually by 3 months to resubmit. He messes up my paper. This triggered my depression. I don't like my present boss at work. I want to get out of here as soon as possible. My plan was I would pass the exam and get out of my present work. But Step 2CS totally messed up my plan. I want to change my job. But not easy to find a new job. If I had passed Step 2 CS, I should have gone into the residency. But I failed. So I must wait for 1 year. I saw a primary care doctor today and he gave me Alprazolam. Now I feel better. My sadness is gone so far. He also referred a psychiatrist to me. I hope this will work. Sorry I am writing a lot of things because I am on the medication. My question is if there are any good medications to treat nervousness. I am extremely nervous to see new people. I think this is the reason I can't smile well to encounters in the exam. This is absolutely demerit.

I was in a psychiatric hospital for 6 days as a patient. The staffs are generally nice. Meals are good. But a lot of classes. I felt I was pretty normal there. I enjoyed watching WWE with a well-treated Schizophrenia female elderly although I don't like it so much, but she loves it. She is a nice woman. My psychiatrist prescribed me temazepam 30 mg plus lorazepam 1 mg at bed time and budeprion XL 150 mg every morning. But my brain is a little bit cloudy. He said this doesn't affect mental activity. Does this affect taking Step 2 CS?

I changed some part of my note. Yesterday I saw my English teacher. She said the following sentences are too complicated.

"Sometimes when people are under a lot of stress, they see or hear things that others don't. Does this ever happen to you? (Hallucination) Do people ever say they think you have extremely unrealistic ideas about yourself or about life in general? (Delusions)

She corrected like this. "Are you hearing voices or seeing images? (Hallucination) Have people been telling you are acting strangely or thinking strange thoughts? (Delusions)

She also said usually in here that physicians ask about pain like this. "What is your level of pain on a scale of 1 to 10? 10 being the most intense, 1 being the least intense.

She also said that for the adolescent, tell him/her at the beginning so he/she will tell you more about himself/herself as follows: "I want to assure that everything we talk about is private/confidential. It is important that you tell me everything so that I can help you feel better."

I think if she took this exam after learning a little bit medicine, I am sure she would be able to pass this exam.

Last night Budeprion XL gave me a big ****. During the day time, I found tremor in my left hand and was irritated by high-pitch sounds and voices. When I was eating dinner, watching TV, and talking to my roommate, suddenly I felt nauseated, restless, almost panicked. My roommate doesn't know I was hospitalized because he was in Finland for business. I lied to him that I was my friend's house in LA. Anyway I told him that I had to study in my room, I called the hospital. They asked me if I wanted to go back. During the talk, my symptoms were going down. I felt like I was going crazy. Finally I caught my doc at noon today. Now I take Budeprion XL 150 mg & Lorazepan 1 mg at 10 am, and temazepam 30 mg at bed time. I was very scared. Today I told my boss that I was scared that I might be confused at work, then I would stay at home to check if I will be OK or not. If it is OK, I will go to work. I can't believe this one is used to quit smoking. So scarely drug. I hope I will get out of Budeprion soon.

They are all prescription medications. Sorry I can't understand what you want to say. My anxiety and depression (sadness) are not only from failure of CS. But several other factors are associated with my disease. There is a long story I told to my psychiatrist. One thing (but trivial thing) triggered my sadness and led me to see my primary care doc and psychiatrist,

I was hospitalized in danger to commit a suicide and possibility to harm persons. I sent e-mail about my feeling to my previous boss who is a good guy and called me if I am OK. I also wrote I need to see my primary care doctor and ask him to refer a psychiatrist because I really needed help. My primary care doc prescribed anti-anxiety medication and I made an appointment with a psychiatrist. I think that my previous boss thought I was in pretty danger and he called police. Policemen and one specialist? came to my place and took me to a psychiatric hospital. I don't make up anything. I own a 2-br condo. I am leasing one room to him. I don't want him to be scared and leave my place. He is a good guy. Off course also money. These side effects might not be written in the textbook. The information about the medications was given to me by a pharmacy where I bought them. Are there any psychiatrists around? Ask psychiatrists in your school. These side effects are true. I don't know the reason why I am writing here. Life is not easy. I met patients in the ward. You bet there are no dangerous people in my ward. I feel sorry to someone and someone messed up their lives because of drugs & alcohol, trying to get over. Families and significant ones still come to see most of them. But one teen was screaming that nobody cares of him and walking around. Sad. I have no relative here and called my friends. One of my friend who is my ex-roommate, knows me for 10 years, and a professor of organic chemistry in a famous research institute (actually I work there, too) brought underwear to me because I have none of them and was brought there by police for no time. Now I am back to work. My boss is so stressful. My friend called him and now he is a little bit milder to me because people say my friend is a superstar in the institute and my boss is weak to influential persons. One of the reasons to want to go to residency is get out of my boss. I am so depressed when I failed Step 2 CS because I have to work with him one more year. He is so stressful and drives me crazy. Then another trigger made me see a psychiatrist. My NIH training will be expired in March. Hope I will get out of him, pass the exam, and go into the residency (pathology) next year. Pathology is less stressful, isn't it? My friend, a cardiologist recommended me to be.
You bet I created my note after I failed. It is from experience of Kaplan 5-day course and C3NY, several CS books, and my English tutor's suggestion. I am confident that my note covers most of the cases.

Correction in my note from my English tutor.

"Did he/she contact sick children in the daycare?" is wrong.

Instead,
"Has he/she been in contact with any sick children in the daycare lately?"

I disclosed to my co-workers why I was absent and where I was for 6 days.
I told them my boss is perfect fit in the hospital. They laughed a lot. You can imagine how he is.

Now my medication is only mirtazapine 15mg at bedtime. I feel like I am floating in the air.