Hey guys,
I wanted to share with you on how I got through Step 2 CS. I passed all portions with high marks.
I'm sure I left stuff out in this write up, so I'll keep updating as questions come up.
1. Nothing substitutes being in current rotations -- my advice is to squeeze in a family med or emergency med rotation right before you take CS. EM is quite good because you have a ton of patients and you have to do a quick focused H&P which is what CS is all about.
2. If you aren't in rotations -- no sweat -- but get a partner and work out First Aid or usmleworld. If you don't have a partner then make sure you are talking out loud and going through every motion as you practice -- don't just sit there.
3. Create a template for the H & P and stick to it. On exam day you need to be on auto pilot. It flies by. That means get your dialogue down pat.*
4. What helped me the most actually was studying for CK prior to taking CS. The reason being that I have no issues with spoken English nor the empathy/compassion portion -- but was nervous with coming up with differentials and supporting them from my H&P and then the diagnostic w/u.
5. So the mnemonics I used:*
FOR HPI: For PAIN the standard LIQQORAAA (location, intensity, quality/quantity, onset, radiation, aggravating/alleviating/associated) For everything else: DOCFP (duration, onset, course, frequency, precipitation factors).*
FOR HX: PAMHUGSExFOSS (previous, allergies, medications, hospitalizations (past medical/surgery/illnessnes/etc), urinary sx, GI sx, sleep, exercise, family hx, obgyn hx, sexual hx, social hx -- for social this includes occupation/tobacco/EtOH (CAGE)/rec drugs/other stressors/living conditions/etc
Now this is a very loose skeleton -- I included extra ROS as needed -- for instance appetite, travel hx, diarrhea/constipation/nausea/vomiting in the GI sx -- obviously CP/SOB/orthopnea/etc for chest/breathing cases -- you'll have to fill in the details.
Also before OBGYN & SEXUAL/SOCIAL hx I always said "Thank you for answering my questions. Now the next set of questions are a bit personal but I wanted to remind you and assure you that everything we talk about is confidential and that these are standard questions that I ask all my patients in order to get a complete history so I can provide the best possible care.
6. For PE: I was very conflicted. On one hand I had everyone telling me to be very focused and do relevant organ system and I had other buddies do more. What I did was I came up with a template from head to toe. I touched a bit on everything from HEENT -- NECK (including thyroid) -- CHEST -- LUNGS -- ABD -- EXTREMITIES. I could do this in about a 1 minute. The reason being was it allowed me time to think about what my focused exam would be without looking like I have no idea what to do. Once I figured out what I wanted to do I would do a more focused exam on the relevant organ system.
Now of course if it is a NEURO or MUSCULOSKELETAL case I would just dive right into that exam because they were lengthy and there is no time to do other stuff. If I had extra time I'd jump back into my 1 minute template.
Now USMLE makes it clear that you will not be graded on irrelevant exams and some people think my method is a waste of time -- but it worked for me. Now from my general template I could come up with a template patient note for a benign/normal exam.
GEN: AAOx3; NAD
HEENT: EOMI; PERRLA; moist mucus membrances; -ve scleral icterus; -ve conjunctival pallor; -ve tonsillar erythema, enlargements, exudates
NECK: supple; -ve LAD
CVS: RRR; normal S1 S2; no M/R/G
LUNGS: CTA B/L; no W/C/R
ABD: + BS in all 4 Qs; tympanic to percussion; soft/NT/ND/-ve HSM/no palpable masses
EXTREMITIES: 2+ pulses throughout; no edema; no cyanosis, clubbing
Now I wouldn't use all of this -- only relevant ones but I wanted to have them in my toolbox to throw out there if I needed them. Of course neuro I used Mini Mental -- Cranial Nerves -- MRS (motor strength, reflexes, sensations) -- as well as RAM; heel to shin; gait; romberg.
Musculoskeletal I used "I PROM MRSP" (inspection, palpation, ROM, MRS, pulses). Always beginning with the unaffected side then moving to the affected side. Starting with distal joints moving towards affected joint as well as proximal joint moving towards affected joint.
7. Now on my sheet before going in the room I wrote down my mnemonics, studied the doorway info, as well as added the words 'SUMMARIZE' and 'COUNSEL' to remind myself of these 2 tasks for every encounter.
8. So here is a sample encounter: Write my mnemonics. Knock on door. Hi Mr/Ms Smith -- I'm Dr. Jones and I'll be taking care of you today. So what brings you in?*
USE MY LIQQORAAA, PAMHUGSExFOSS -- Finish history.
Well thank you Mr/Ms Smith for answering my questions. Do you mind if we begin the physical exam? Please excuse me while I wash my hands.
GO INTO MY TEMPLATE -- Finish PE
Then I usually sat down and said "Ok Mr/Ms Smith. I just wanted to SUMMARIZE everything you told me -- this allows you to get the history organized as well as have the patient correct any parts that you've blanked out on.
Then I said something like this: "So Mr/Ms Smith I wanted to let you know what I'm thinking so far from what you told me as well as from the PE….."
At this point give some kind of differential along with some back up. If you're clueless -- keep it vague and remind them that you'll need to run some tests to really get a handle on what is going on. Keep stressing the fact that without labs/imaging you can't give a definitive diagnosis.
Now at this point I would say something like this: "Besides starting on your lab work there are some things that I'd like to discuss with you -- have you thought about quitting smoking/etc…" COUNSEL!!!!!
So for every patient I had this template during the close.
1. Do you understand my diagnosis?
2. Do you agree with my treatment plan?
3. Do you have any questions for me? ANSWER challenge question
4. Well Mr/Ms Smith, regardless of the final diagnosis I just want to make sure you know that I am here for you and that we will work together as a team to figure out what's going on with you and how we can make you feeling better. It was an absolute pleasure meeting you and I'll call in the nurse to begin the lab work up.
I always left the room with 2 minutes to spare. This allowed me extra time for my patient note.
Now make sure you fill out the whole PATIENT NOTE. The very first encounter that I had since the computer screen doesn't show the whole length of the note, I filled everything out perfectly and sat there with extra 2 minutes and when they said to submit I realized I had forgotten to write down any diagnostic w/u. I guess it was my nerves or whatever but I didn't realize I left it blank until I scrolled the computer down and to submit. So please practice on the usmle website and use their patient note to practice typing and such.
So for one of my notes I had left out the whole diagnostic w/u, but I still scored high marks on ICE because the rest of my notes were good (I'm assuming).
I wanted to share with you on how I got through Step 2 CS. I passed all portions with high marks.
I'm sure I left stuff out in this write up, so I'll keep updating as questions come up.
1. Nothing substitutes being in current rotations -- my advice is to squeeze in a family med or emergency med rotation right before you take CS. EM is quite good because you have a ton of patients and you have to do a quick focused H&P which is what CS is all about.
2. If you aren't in rotations -- no sweat -- but get a partner and work out First Aid or usmleworld. If you don't have a partner then make sure you are talking out loud and going through every motion as you practice -- don't just sit there.
3. Create a template for the H & P and stick to it. On exam day you need to be on auto pilot. It flies by. That means get your dialogue down pat.*
4. What helped me the most actually was studying for CK prior to taking CS. The reason being that I have no issues with spoken English nor the empathy/compassion portion -- but was nervous with coming up with differentials and supporting them from my H&P and then the diagnostic w/u.
5. So the mnemonics I used:*
FOR HPI: For PAIN the standard LIQQORAAA (location, intensity, quality/quantity, onset, radiation, aggravating/alleviating/associated) For everything else: DOCFP (duration, onset, course, frequency, precipitation factors).*
FOR HX: PAMHUGSExFOSS (previous, allergies, medications, hospitalizations (past medical/surgery/illnessnes/etc), urinary sx, GI sx, sleep, exercise, family hx, obgyn hx, sexual hx, social hx -- for social this includes occupation/tobacco/EtOH (CAGE)/rec drugs/other stressors/living conditions/etc
Now this is a very loose skeleton -- I included extra ROS as needed -- for instance appetite, travel hx, diarrhea/constipation/nausea/vomiting in the GI sx -- obviously CP/SOB/orthopnea/etc for chest/breathing cases -- you'll have to fill in the details.
Also before OBGYN & SEXUAL/SOCIAL hx I always said "Thank you for answering my questions. Now the next set of questions are a bit personal but I wanted to remind you and assure you that everything we talk about is confidential and that these are standard questions that I ask all my patients in order to get a complete history so I can provide the best possible care.
6. For PE: I was very conflicted. On one hand I had everyone telling me to be very focused and do relevant organ system and I had other buddies do more. What I did was I came up with a template from head to toe. I touched a bit on everything from HEENT -- NECK (including thyroid) -- CHEST -- LUNGS -- ABD -- EXTREMITIES. I could do this in about a 1 minute. The reason being was it allowed me time to think about what my focused exam would be without looking like I have no idea what to do. Once I figured out what I wanted to do I would do a more focused exam on the relevant organ system.
Now of course if it is a NEURO or MUSCULOSKELETAL case I would just dive right into that exam because they were lengthy and there is no time to do other stuff. If I had extra time I'd jump back into my 1 minute template.
Now USMLE makes it clear that you will not be graded on irrelevant exams and some people think my method is a waste of time -- but it worked for me. Now from my general template I could come up with a template patient note for a benign/normal exam.
GEN: AAOx3; NAD
HEENT: EOMI; PERRLA; moist mucus membrances; -ve scleral icterus; -ve conjunctival pallor; -ve tonsillar erythema, enlargements, exudates
NECK: supple; -ve LAD
CVS: RRR; normal S1 S2; no M/R/G
LUNGS: CTA B/L; no W/C/R
ABD: + BS in all 4 Qs; tympanic to percussion; soft/NT/ND/-ve HSM/no palpable masses
EXTREMITIES: 2+ pulses throughout; no edema; no cyanosis, clubbing
Now I wouldn't use all of this -- only relevant ones but I wanted to have them in my toolbox to throw out there if I needed them. Of course neuro I used Mini Mental -- Cranial Nerves -- MRS (motor strength, reflexes, sensations) -- as well as RAM; heel to shin; gait; romberg.
Musculoskeletal I used "I PROM MRSP" (inspection, palpation, ROM, MRS, pulses). Always beginning with the unaffected side then moving to the affected side. Starting with distal joints moving towards affected joint as well as proximal joint moving towards affected joint.
7. Now on my sheet before going in the room I wrote down my mnemonics, studied the doorway info, as well as added the words 'SUMMARIZE' and 'COUNSEL' to remind myself of these 2 tasks for every encounter.
8. So here is a sample encounter: Write my mnemonics. Knock on door. Hi Mr/Ms Smith -- I'm Dr. Jones and I'll be taking care of you today. So what brings you in?*
USE MY LIQQORAAA, PAMHUGSExFOSS -- Finish history.
Well thank you Mr/Ms Smith for answering my questions. Do you mind if we begin the physical exam? Please excuse me while I wash my hands.
GO INTO MY TEMPLATE -- Finish PE
Then I usually sat down and said "Ok Mr/Ms Smith. I just wanted to SUMMARIZE everything you told me -- this allows you to get the history organized as well as have the patient correct any parts that you've blanked out on.
Then I said something like this: "So Mr/Ms Smith I wanted to let you know what I'm thinking so far from what you told me as well as from the PE….."
At this point give some kind of differential along with some back up. If you're clueless -- keep it vague and remind them that you'll need to run some tests to really get a handle on what is going on. Keep stressing the fact that without labs/imaging you can't give a definitive diagnosis.
Now at this point I would say something like this: "Besides starting on your lab work there are some things that I'd like to discuss with you -- have you thought about quitting smoking/etc…" COUNSEL!!!!!
So for every patient I had this template during the close.
1. Do you understand my diagnosis?
2. Do you agree with my treatment plan?
3. Do you have any questions for me? ANSWER challenge question
4. Well Mr/Ms Smith, regardless of the final diagnosis I just want to make sure you know that I am here for you and that we will work together as a team to figure out what's going on with you and how we can make you feeling better. It was an absolute pleasure meeting you and I'll call in the nurse to begin the lab work up.
I always left the room with 2 minutes to spare. This allowed me extra time for my patient note.
Now make sure you fill out the whole PATIENT NOTE. The very first encounter that I had since the computer screen doesn't show the whole length of the note, I filled everything out perfectly and sat there with extra 2 minutes and when they said to submit I realized I had forgotten to write down any diagnostic w/u. I guess it was my nerves or whatever but I didn't realize I left it blank until I scrolled the computer down and to submit. So please practice on the usmle website and use their patient note to practice typing and such.
So for one of my notes I had left out the whole diagnostic w/u, but I still scored high marks on ICE because the rest of my notes were good (I'm assuming).
