Scared sick about CS last week

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Nov 19, 2018
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I'm a US med student at a top 20 school and I took CS last week; I thought it went well at first. Then looking back I'm scared that I didn't pass. Most of my encounters went fine although I didn't get asked all that many questions even though I did ask each patient whether they had any. Basically my closure consisted of me summing up the history and physical and talking about which tests we would do next to get a better idea about what is going on, followed by "what questions do you have." I only mentioned differentials to the patient about half the time and the rest I just mentioned what the next steps would be (e.g. EKG to check and make sure your heart is ok)---is this a huge problem? The other main issue is I really only counseled a few patients on lifestyle changes. Maybe 3. That makes me so worried; I can't believe myself. I really don't want to fail because I will be applying for one of the most competitive fields and don't want this to limit me in any way. It would be a nightmare if this caused my downfall because I got 260+ on both Step 1 and CK and have honors in all but one clerkship.

Another issue was that when I walked into the room, I put on the alcohol soap before shaking hands. Several of the patients made faces when their hands got wet. Is this a big problem? It must have happened several times until I stopped putting it on in the beginning and waited until the PE to wash. Overall I felt like I developed pretty good relationships with patients, but I'm worried about passing still. I do think my notes where fine, although there where a few differentials that weren't the best.

What do you guys think? This is going to be a rough 2 months. Would a fail limit my options for a super competitive field? Sorry for ranting I'm just so nervous.

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This sounds exactly like my experience and I passed without anything in the borderline. I stressed a ton about whether I passed and it was completely wasted time.
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To whoever is reading this thread: I feel obligated to write up my tips considering I stressed about this test WAY too much over the past two months. I was most worried about CIS but ended up with a star to the right (top performance). I actually almost changed my residency plans because I was so sure that didn't pass, but it ended up going great. There are plenty of ICE tips on SDN so I won't go through that, but I feel there is a lot of misleading and unnecessary info about CIS online, so I wanted to provide my own personal advice. Here's what I did:

Knock on door. Put on Purell. "Hello firstname lastname, I'm NewYorker100, a senior medical student working here today. How would you prefer to be addressed?" Let them answer. Shake hands: "Nice to meet you." "OK Mr./Ms. XXX. What brings you in today?" They tell you what's bothering them. "I'm sorry to hear that this is going on; I'm glad you came in to get this checked out" (say this again later on if there's awkward silence). Then ask them one open ended question e.g. "how would you describe your pain?" Then ask the usual questions based on your favorite mnemonic (when did this all start? does the pain spread anywhere else? any other symptoms? any xxxx/xxxx/xxxx (ROS)). Every once in a while say something to the effect of "that sounds terrible"---do this in a genuine way without being fake. Before moving on to PMH etc, ask them how their problem is affecting their life (if appropriate to ask this). Before social history, preface by saying "there are a few more questions that I need to ask you which are a little bit personal. I ask all my patients these questions. Is that ok with you?" Be non-judgemental when asking social history. CAGE only if >14 drinks/week for a man or >7 per week for a woman (or if the patient gives a vague answer about how much alcohol they drink).

Personally I DID NOT counsel people unless their chief complaint was directly related to a lifestyle issue (e.g. if respiratory problem tell them to quit smoking). This only happened a few times. I know the SDN mantra is to counsel everyone, which I didn't do. I just thought it would sound patronizing and judgmental if it wasn't directly related to the chief complaint. Do so in a casual way: "Have you thought of quitting? We have resources here to help you if you're interested." Congratulate the patient if they quit already or are trying.

After taking entire history: "Now I'm going to summarize to make sure we're on the same page and that I'm understanding everything correctly." SUMMARIZE for literally 15-20 seconds. No more. "Is there anything that I've missed or that you'd like to add? Any questions for me now? Any particular concerns you might have?" Next: "OK, now that I have an idea about what's been going on, I'm going to wash my hands and do a quick physical exam. Is that ok with you?" Then wash quickly. For PE, BE QUICK rather than too thorough. Ask before you do each move, e.g. "now I'm going to listen to your heart. Is that ok with you?" Ask their permission to untie the gown. I didn't retie it even once (I told them they could put it back on). Pull out the leg rest before abdominal exam. If they cough, offer water (I didn't do this but it's probably a good idea). Warn them before you do anything, especially something painful. Tell the patient to let you know if something hurts too much and then apologize.

After PE: summarize briefly PE findings. "I noticed that you had xxxxxxxx on physical exam. Based on what you told me before and what I saw on exam, I'm concerned about several different things. I want to order some labs and studies to help me get a better idea about what's been going on. How does that sound to you?" Let them answer. You may or may not get a challenge question now. Don't worry if they don't ask you a question/concern; I stressed too much when I didn't get asked anything.

NEXT (based on what I did, but others may disagree with me here): if the patient has an obvious diagnosis---"Mr. xxxxxx, I'm concerned that you might have xxxxxx (in lay person talk; only gave one diagnosis max). Have you heard of this before?" let them answer. "I want to order xxxxxxxxx labs/imaging to evaluate further. I'm going to put in the orders and you can get these done down the hall. We'll meet back here to discuss the results as soon as I have them. How does this sound to you?" "OK thank you so much Mr. xxxxxx. It was nice to meet you in spite of these circumstances. I'll be back within an hour to discuss the results with you and your next steps moving forward." Shake hands and leave the room. I left consistently 2 minutes early to give myself extra time for the note.

For closing, if the patient did not have an obvious diagnosis, rather than giving differentials I just said that I wanted to order labs/imaging to look at heart, hormone levels, brain, etc (whatever I put in my workup). I DID NOT give them a diagnosis every single time since I thought it would be bad to scare them unnecessarily. I was worried about this, but still ended up doing great on CIS. So no worries about the closure part; I only took about a minute (maybe 1.5 min max).

I hope this helps! LMK if anyone has questions. I was so scared of failing because I spent too much time on SDN after the exam realizing that I didn't do everything that others did; it sounds like many people went overboard with the counseling/explaining/wrapping up. First Aid is wayyyyy too detailed. If you basically memorize this style you will be more than fine for CIS and can concentrate on ICE. Don't go overboard with CIS stuff or you'll lose points on ICE and may not finish in time. Just act like a human, put yourself in the role of a doctor, and remember to put in some of the niceties that I wrote above.
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The **** man - You changed your whole residency plans over anxiety? Oh sorry I didnt see the "almost" infront : ) Thanks for your advice - Doing my exam on Wednesday next week ;P