Step 2 CS questions

[bowlofmushypeas]

Hey guys,

Test is approaching and glancing through FA, I have a few questions.

1. FA recommends rectal exam for basically anything abdominal..which in real life, is not at all what I'd do. GI bleeds, sure. But for cholecystitis, classic PUD or appendicitis, kidney stones.. meh. What should we be putting down on the exam?
2. Can someone clarify what really goes in the "workup" section? It seems vague and VERY confusing to me. Are we suppose to just list what we'd do initially? Are we putting down what we'd like to order to rule in/out each of our 3 differentials? Often times, I might have 3 diagnoses on the differential for the purposes of the exam, but we really all know it's most likely only one of the three so in real life, I'm not going to order everything to rule out the other 2...for instance, if it's classic migraine, you wouldn't do additional workup, but you might order something if cluster headache is 2nd on your list (even if you don't really think that's what it is). Similarly, for peds, when you can't do an exam and the baby just has a "rash," would you put down LP if it's only a possibility (which you have no idea because you don't know what the rash looks like)? Also, should we put down tests we'd run because it's what you should do for screening purposes? For instance, if someone's coming in with pregnancy, I would order the whole gamut (Rh, Hep B, etc etc) but on the test, are we just suppose to rule it in or out (i.e., only put down HCG?)

3. How important is it to counsel everyone about sex/drugs/diet/exercise? It seems really inappropriate sometimes..like I'm not going to counsel a sexual assault victim on her exercise habits.
4. Abbreviations -- based on the site, it sounds like more or less any common abbreviation including those not on the list are fine, right? What about CMP/BMP, LFTs? FA says no, but the official site doesn't seem to say.
5. I know we're not supposed to do breast exams, but for cardiac auscultation on bare skin, I assume it's OK to listen at the tricuspid and mitral areas even though this is going to be a bit invasive?
6. Finally anyone have tips/experiences with time management? I've been off rotations for over a year now so am a bit nervous about getting through exams and notes quickly enough. It seems impossible to take a history and physical in 15 min if you get a neuro case since you'd have to do exams for CV, Resp, neuro, heent, etc.

Sorry this ended up being so long-winded. I'm nervous!

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[shiftingmirage]

Let me preface this by saying, I don't have any special insight to how the exam is graded; these are just my opinions.

1) I think FA tries to be all inclusive. Sometimes that means overkill. You don't have to hit each thing listed in FA, but I have no idea how many you do have to hit to pass.
2) Any exam maneuvers that you aren't to do on a patient (breast exam, rectal), but would do on a real one. This does not include things you forgot to do. Then, the first line of tests you would order. For pregnancy, I would do the HCG, maybe a pelvic and then exams to address other differentials. But maybe the graders want the whole gamut.
3) Counsel when appropriate.
4) At the testing center, there was actually a list of acceptable abbreviations at each computer. I believe I read somewhere, if they can figure out what you mean, they will give you credit, but they may not be able to figure it out. In the case of LFTs, I think you should itemize what tests you want.
5) Yes, just make sure to ask permission to loosen the gown, but do listen on bare skin.
6) I did heart, lung, and then focused exam. If they were complaining about a HA, I did not touch their belly. Advice for time management - for me if I heard the 2 min warning, I wanted to be wrapping it up. I knew I would be a little slow with notes. Also, you don't have to start writing the HPI. You can skip to ddx, tests, then fill in HPI.

 

[bowlofmushypeas]

Thanks, appreciate the feedback! Would love additional thoughts on #2. I've always heard to list 3 differentials even if you really think it's obviously one. So then, what to do for the workup and how far do you go?

 

[bowlofmushypeas]

bump. test is quickly approaching..what'd you guys do for workup?

 

[bowlofmushypeas]

Aw.. no love guys! What'd you all do for the workup section? E.g. Guy with classic IBS (but IBD and celiac in the differential for the purposes of the test, no red flags) -- in real life, EBM says you would not order tests but in FA, it lists rectal, scope, CBC, etc etc