My CS experience, mistakes, HELP!

[Meesky]

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[Meesky]

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[Phloston]

Now i know, no one can tell me if i passed, failed, etc. Just need to vent anonymously a little.
Took CS a few weeks ago, I had prepared for a few months with another med student who was also taking it around the same time. I felt pretty prepared going into it(not cocky, but felt like I had done everything I could have).
Here are some of my mistakes
Case 1 was very nervous and went WAY too slow - did everything up to the BEGINNING of closure and time ran out- did NO CLOSURE - everything except closure was good I think.
Case 2 went fine
Case 3 think i ran out of time near the end of closure, but did miss one part of focused exam, otherwise went okay.
case 4 could not figure out what was wrong with this patient - ran out of time during closure - asked every question under the sun - forgot thyroids existed and didnt do PE for it. - ended up with 1 sub-par diagnosis, but could justify it.
case 5 went well
case 6 Went well
Case 7 messed up diagnosis/case in general - got main diagnosis, but missed an OBVIOUS second diagnosis - ran out of time during closure.
case 8 ran out of time during closure (did summarize and was in process of explaining tests) didnt check THYROID when i needed to.
case 9 stumbled on the challenge question, but figured it out in the end.
case 10 vague case. asked every question - didn't figure out one diagnosis until the end. was uanble to counsel on important aspect of case. ran out of time near end of closure
case 11 went well
case 12 went well

**I always did my summarizing before doing the PE, so at least when I ran out of time during closure, i had already summarized.
My biggest concern is my sub-par PEs (feel like i missed a LOT of basic PE for most patients because i was so focused on NOT running out of time, not finishing (not doing in 1 case) closure in some (3-4) cases.
MY PNs were complete for the most part (i definitely left out some stuff that I asked/did, but not too much i hope).
I had 1 DDx for 2 cases because there just wasnt anything else I could justify, but I felt those diagnoses were correct.

My history taking was good (probably a little too detailed), did all the saying hello, shaking hands, washing hands, foot rest, empathy, smile, comfort, etc.

I would appreciate anyone's thoughts/ideas.

I'm finding your post essentially humorous because I took the 2CS a few days ago and feel as though I screwed up way worse than you did. The fact that you even think most of your cases "went well" means you should probably just relax. I've been "realizing" things I could have done differently pretty much every day since the exam.

I think most of the uncertainty (at least for me) came down to genuine confusion about what the USMLE even wanted. I could come up with DDx during the exam, but I knew they just weren't correct so I didn't bother listing them. Regarding negative findings, I didn't know if we were supposed to list them only if they supported the diagnosis, because that was exceedingly rare. For example, if a guy had issues swallowing but the Dx was clearly esophageal cancer and the Hx didn't support Zenker or achalasia, I didn't bother listing the latter two because there was nothing to support them. I mean, what would I write: "achalasia" then "fever, night sweats, weight loss" under the findings? It just didn't make sense. So I left the exam not sure whether I was supposed to put more DDx even if I felt they weren't right. I really feel the DDx portion of the note should be amended to just be a large text box (like the Hx and PE ones) to write why you think that Dx is vs is not supported.

Oh and btw, my P/Es were also hyper-cursory and I didn't do tons of maneuvres, but there was literally no time. I gave priority to the closure for every patient because I had heard tons of points were in this component. So whenever I got the 5-minute warning I basically just stopped the exam and gave an extended impression/counsel with PEARLS.

 

[rodmichael82]

I'm finding your post essentially humorous because I took the 2CS a few days ago and feel as though I screwed up way worse than you did. The fact that you even think most of your cases "went well" means you should probably just relax. I've been "realizing" things I could have done differently pretty much every day since the exam.

I think most of the uncertainty (at least for me) came down to genuine confusion about what the USMLE even wanted. I could come up with DDx during the exam, but I knew they just weren't correct so I didn't bother listing them. Regarding negative findings, I didn't know if we were supposed to list them only if they supported the diagnosis, because that was exceedingly rare. For example, if a guy had issues swallowing but the Dx was clearly esophageal cancer and the Hx didn't support Zenker or achalasia, I didn't bother listing the latter two because there was nothing to support them. I mean, what would I write: "achalasia" then "fever, night sweats, weight loss" under the findings? It just didn't make sense. So I left the exam not sure whether I was supposed to put more DDx even if I felt they weren't right. I really feel the DDx portion of the note should be amended to just be a large text box (like the Hx and PE ones) to write why you think that Dx is vs is not supported.

Oh and btw, my P/Es were also hyper-cursory and I didn't do tons of maneuvres, but there was literally no time. I gave priority to the closure for every patient because I had heard tons of points were in this component. So whenever I got the 5-minute warning I basically just stopped the exam and gave an extended impression/counsel with PEARLS.

What did you mainly talk about in the closure?
Summary of everything in the history and physical? what your DDx was? and what labs/tests you wanted to order and counseling on any tobacco, alcohol, depression etc,,
Was that mainly the focus of your closures?

Thanks in advance.

 

[Phloston]

What did you mainly talk about in the closure?
Summary of everything in the history and physical? what your DDx was? and what labs/tests you wanted to order and counseling on any tobacco, alcohol, depression etc,,
Was that mainly the focus of your closures?

Thanks in advance.

For all patients, I ended the P/E by saying "Now Mr. Smith, if it's okay with you I'd like to just sit with you and give you my impression." Or "Mr. Smith, I'd like to sit with you and give you my impression. Is that okay?"

Then I'd say something like "Now I now you've come in today with [e.g., back pain]. I know this is really frustrating and annoying and I'm sorry that you're having to deal with this. Just know that we'll do everything we can to get to the bottom of this as soon as possible. There are lots of things that can cause back pain and at this point in time we can't make any definitive conclusions about what is causing this. However based on what we've talked about and the brief physical exam, I suspect it may be __. And once again, I don't want to scare or alarm you in any way because we can't confirm that at this point in time, but doing some tests will help us figure things out and get things sorted. We might be able to do some imaging, such as X-ray, and even more advanced imaging like MRI. We can also draw your bloods to look for signs of infection and see how your red cells and white cells are doing, which can give us an even better idea of certain things we can rule in or out. It might also be beneficial to take a urine sample to look for things like sugar and proteins. Do you have any concerns or questions for me?

And they'd ALWAYS say yes. Which was good actually because it gave yet another opportunity to reinforce PEARLS. Then I'd say again how I know it's frustrating/annoying for them and I'm sorry they're having to go through this, but I'm there for them 100%.

So in short, my closure/counsel, followed by the SP voicing his or her concern, followed by my second round of counsel, summed to ~4 minutes.

--------

Honestly, all of this is complete speculation and no one knows for sure how the grading scheme works, but from the posts I've read in the past it seems that people who don't close the encounters run into trouble. And that's not saying if you forget to close a couple cases you're ruined, but whenever the 5-minute warning was given and I was mid-P/E, I pretty much just stopped whatever I was doing and just closed/counselled. As I said though, my exams SUCKED. There are tons of things you practice or think you'll have time for that you just straight up don't. I found that doing a couple minutes for a targeted exam left another minute to auscultate the heart and lungs. But there really wasn't any time for anything else.

 

[rodmichael82]

For all patients, I ended the P/E by saying "Now Mr. Smith, if it's okay with you I'd like to just sit with you and give you my impression." Or "Mr. Smith, I'd like to sit with you and give you my impression. Is that okay?"

Then I'd say something like "Now I now you've come in today with [e.g., back pain]. I know this is really frustrating and annoying and I'm sorry that you're having to deal with this. Just know that we'll do everything we can to get to the bottom of this as soon as possible. There are lots of things that can cause back pain and at this point in time we can't make any definitive conclusions about what is causing this. However based on what we've talked about and the brief physical exam, I suspect it may be __. And once again, I don't want to scare or alarm you in any way because we can't confirm that at this point in time, but doing some tests will help us figure things out and get things sorted. We might be able to do some imaging, such as X-ray, and even more advanced imaging like MRI. We can also draw your bloods to look for signs of infection and see how your red cells and white cells are doing, which can give us an even better idea of certain things we can rule in or out. It might also be beneficial to take a urine sample to look for things like sugar and proteins. Do you have any concerns or questions for me?

And they'd ALWAYS say yes. Which was good actually because it gave yet another opportunity to reinforce PEARLS. Then I'd say again how I know it's frustrating/annoying for them and I'm sorry they're having to go through this, but I'm there for them 100%.

So in short, my closure/counsel, followed by the SP voicing his or her concern, followed by my second round of counsel, summed to ~4 minutes.

--------

Honestly, all of this is complete speculation and no one knows for sure how the grading scheme works, but from the posts I've read in the past it seems that people who don't close the encounters run into trouble. And that's not saying if you forget to close a couple cases you're ruined, but whenever the 5-minute warning was given and I was mid-P/E, I pretty much just stopped whatever I was doing and just closed/counselled. As I said though, my exams SUCKED. There are tons of things you practice or think you'll have time for that you just straight up don't. I found that doing a couple minutes for a targeted exam left another minute to auscultate the heart and lungs. But there really wasn't any time for anything else.

Hey Pholston that was an amazing close dude. I can't imagine you not passing with flying colors. Thank you so much for sharing this, I am sure this will be extremely helpful to others too. You're a champ man! Keep up the good work.

 

[rodmichael82]

For all patients, I ended the P/E by saying "Now Mr. Smith, if it's okay with you I'd like to just sit with you and give you my impression." Or "Mr. Smith, I'd like to sit with you and give you my impression. Is that okay?"

Then I'd say something like "Now I now you've come in today with [e.g., back pain]. I know this is really frustrating and annoying and I'm sorry that you're having to deal with this. Just know that we'll do everything we can to get to the bottom of this as soon as possible. There are lots of things that can cause back pain and at this point in time we can't make any definitive conclusions about what is causing this. However based on what we've talked about and the brief physical exam, I suspect it may be __. And once again, I don't want to scare or alarm you in any way because we can't confirm that at this point in time, but doing some tests will help us figure things out and get things sorted. We might be able to do some imaging, such as X-ray, and even more advanced imaging like MRI. We can also draw your bloods to look for signs of infection and see how your red cells and white cells are doing, which can give us an even better idea of certain things we can rule in or out. It might also be beneficial to take a urine sample to look for things like sugar and proteins. Do you have any concerns or questions for me?

And they'd ALWAYS say yes. Which was good actually because it gave yet another opportunity to reinforce PEARLS. Then I'd say again how I know it's frustrating/annoying for them and I'm sorry they're having to go through this, but I'm there for them 100%.

So in short, my closure/counsel, followed by the SP voicing his or her concern, followed by my second round of counsel, summed to ~4 minutes.

--------

Honestly, all of this is complete speculation and no one knows for sure how the grading scheme works, but from the posts I've read in the past it seems that people who don't close the encounters run into trouble. And that's not saying if you forget to close a couple cases you're ruined, but whenever the 5-minute warning was given and I was mid-P/E, I pretty much just stopped whatever I was doing and just closed/counselled. As I said though, my exams SUCKED. There are tons of things you practice or think you'll have time for that you just straight up don't. I found that doing a couple minutes for a targeted exam left another minute to auscultate the heart and lungs. But there really wasn't any time for anything else.

Hey man I just had a few quick questions. I just read that on the step 2 CS you only have 15 mins in the encounter. Assuming last 5 are spent on summarizing, coming up with differential, explaining the next step/labs and answering any questions/concerns that means there's 10 minutes for the history and physical encounter. 10 minutes for history and physician sounds insane. How do you rush through HPI, medications, allergies, PMH, FH, SH and all of the physical exam that quickly especially if you ask "open ended questions".

What was your strategy of moving fast and did you ask closed ended questions in your HPI. Also how were you able to monitor the time because I know analog or digital watches are not allowed.

Thanks in advance Pholston. You've been an amazing support system for all of us here on SDN and I want to sincerely thank you for that.

 

[Phloston]

Hey man I just had a few quick questions. I just read that on the step 2 CS you only have 15 mins in the encounter. Assuming last 5 are spent on summarizing, coming up with differential, explaining the next step/labs and answering any questions/concerns that means there's 10 minutes for the history and physical encounter. 10 minutes for history and physician sounds insane. How do you rush through HPI, medications, allergies, PMH, FH, SH and all of the physical exam that quickly especially if you ask "open ended questions".

What was your strategy of moving fast and did you ask closed ended questions in your HPI. Also how were you able to monitor the time because I know analog or digital watches are not allowed.

Thanks in advance Pholston. You've been an amazing support system for all of us here on SDN and I want to sincerely thank you for that.

I would generally spend ~7-8 minutes on the Hx, ~2-3 minutes on the P/E (yes, that's it), then ~4-5 minutes closing.

Once the 5-minute warning sounded and I was mid-P/E, I'd wrap it up within 60 seconds the absolute max. Often times this meant I would finish auscultating the lung bases and heart. One time I examined the abdomen after the warning was sounded, but my P/E for that literally was a diffuse palpation lasting a few seconds followed by ostensibly listening to bowel sounds. But if you can knock off a cursory abdomen, that allows you to write "SNT, non-distended, BS++, no HSM" in the note, which is a nice bonus. Because you can only write things you actually do.

But yeah, I spent a lot of time closing/counselling. I always made sure to reiterate numerous times that we can't make any conclusions at this point in time but that we'd do some tests and get to the bottom of it as soon as possible. I tended to give thorough explanations of disease mechanisms in layman terms during the counselling (e.g., if I thought the patient might have type-II diabetes, I'd talk about the body's regulation of sugars, how there's an organ called the pancreas that has cells that make a hormone called insulin, and sometimes other parts of our body can stop responding to insulin, and that the progression is in the patient's control and he or she can grab it by the horns... you get the point). But most importantly, the closing/counselling is a really good time to implement PEARLS. I always made sure to tell the patients ~twice during the closing that I'm sorry they had to deal with this and that I knew it must be frustrating/annoying. And I always asked if they had concerns and questions, and they ALWAYS SAID YES. Sometimes this helped with the DDx (e.g., "Yes, I do actually. Idk, do you think this could be anxiety related?"). Then after you PEARL/allay that concern by talking them through it, you end by again asking "do you have any more concerns or questions?" Then when they finally said no/they were happy, I ended the encounter. But on average it took two "rounds" of counselling+PEARLS to finish up (i.e., counsel/PEARL --> ask if they had concerns/questions --> counsel/PEARL again --> ask again if they had concerns/questions --> thank them for their time and leave). I usually finished right at the end or with ~1 minute left. At the end, you go out in the hallway to type the note, and any extra time you have is added onto your 10 minutes for the write up. I noticed most of the time it seemed as though the majority of the examinees were already typing when I exited the room. Because everyone was on the same clock, that means my typical 14-15 minutes for each encounter was longer than most people's. I think the only people who run out of time are those who try to go overboard on the P/E without effectively closing.

 

[Meesky]

In case anyone was waiting with bated breathe....I passed! Yes haw!