Screwed up big and still passed CS???

[HappyMS]

Hi All,

Like a lot of fellow MS I think I did poorly on step 2 cs and was wondering if you guys that passed (or failed) can calm my nerves and share laughs at things that you did and still passed (whether comfortably or just barely). I found some funny and helpful stories in some other threads but thought it would be nice to have them in one place. Sorry if this annoys some...

Here is what I did (or didn't do) that makes me nervous:
1. Pt with a neuro complaint - forgot CN exam and reflexes entirely. Will miss points on exam and note.
2. Pt with a resp complaint - did not do Head and Neck exam at all, no lymph nodes. Just listened to heart and lungs. Again will miss points on hx and note.
3. Did not offer to comfort patients when I should have...
4. Did not ask about fevers, weight loss, etc. when the case called for it
5. Did not ask about smoking or alcohol use at all when I should have... nor did I document in my note.
6. For a few pts, didnt ask about allergies or family history.
7. Did not ask about sexual hx in a patient with risk factors.
8. did not document some dx tests or differentials

After writing this, I wouldn't be surprised if I failed.

Thank you all for your time,

Not so HappyMS

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[Proverbs31]

Hey Proverbs, disregard my PM requesting advice...looks like you laid it out very nicely right here. Awesome post!

Very welcome! Good Luck!!!

 

[Proverbs31]

Did it and passed. Don't know if you are supposed to or not.
That said, I would pause and ask them ie, before doing abdominal exam realize I did not ask abdominal ROS. I did not ask WHILE palpating, and as I would do in real life. And I did not do it THAT often. Again, its just a check box and if you do it, it gets checked but it is probably best to keep a nice separation between the history and the physical.

And never talk while auscultating
Good luck

THANKS again for all your great advice. I actually took to heart a lot and I also counseled my patients during the exam on smoking or whatever...so that worked great! I took it yesterday and God Willing I passed! Will let yal know come 2 months from now! Overall I can't say thanks enough to all who give advice. It was really helpful and great! ALSO WATCH the websites videos and read the exam content info the USMLE supplies. I mean I cant tell you how much that answers most things you need to know from the horse's mouth! Good luck all who are yet to take it!
One more step on your path to becoming a DOCTOR!

 

[Proverbs31]

Just wanted to add:

1. I wrote out my notes. Because I knew I would need to insert extra things here or there that I would forget to put in the HPI by the time I was writing the Work-up and I knew I would want to be able to go back and draw the little : ^ and write legibly and very tiny, whatever I wanted to add. I figured I needed more space and for me writing is better.

2. I also asked all the patients if it would be ok with them if I wrote while they told me their problems, so that I wouldnt forget anything important they told me so we could help try and figure out what was bothering them and get them to feeling better soon...Something like that...But I did ask permission to write while in the room with them. I tried not to write while they talked to me and I tried not to talk to them at all if I was writing. I made sure to use eye contact and not to write too often, but also not to leave things out because I def would have forgotten certain things had I not written them down. (Realized this during note time!)

3. I ALWAYS asked if they had any questions or concerns, AND told them I would be back to discuss the results with them and we would figure out our best treatment plan together at that time.

Ok- sorry to overload yal with info. Hope this may help relax some and give good insight into how you want to engage with your patients on test day. I highly recommend trying to find a pattern or method that you use to introduce yourself to the patient, collect info, do the exam and close AND doing this the same way with every patient, so you dont leave something out.

Good Luck!

Ok, so I just took my USMLE Step 2 CS today! I now have officially taken both COMLEX PE and USMLE CS...

SO....to give back, because all of you helped me a lot. Some advice:

FA for step 2 CS is still the best review book I know. USE IT!
I practiced with my brother as the patient for 6 cases out of the FA book and I reviewed the minicases the night before and the day of and felt very prepared for today's test.
Honestly, I felt good walking out of it.....Ironically so. I took the exam in ATL and felt the staff were very friendly and helpful and believe it or not, I enjoyed the food too! SO that was a bonus. If youre a vegetarian, they have food options which is nice. I took the afternoon session starting at 3pm and was completely finished and sitting in my car texting my family I was done by 10:10pm. So we finished a little earlier than 8 hours. I truly believe that if you review FA for the CS, you should be prepared to handle any "case presentation" they throw your way. I am not going to guess reasons why great people fail, but in terms of being able to determine a good work-up and differential, FA will absolutely prepare you for that. I'll keep you guys posted when I recieve my score in a few months. Best of luck to you all and thanks for helping answer my questions prior to my exam today!

Im sure I made silly mistakes, but overall felt like nothing was out of left field. AGAIN - STUDY FA CS step 2. I also reviewed the online video on USMLE website about what to expect for test day and it is IDENTICAL to the real test day. So I felt comfortable with no surprises.
I also took the first 30sec to 1 -1/2 minutes at the initial "OK to begin" announcement and I wrote on my own scrap paper, "The given Name, Age, and CC, and thought of 3-6 differentials to think about for whatever the CC was and wrote them on my scrap paper. This helped guide my questions and reminded me at the end during the actual write up of my note. I also scribbled down quickly - "LOPQRST" - just to remind me to ask the simple "location, onset, etc " questions and I quickly just wrote the headings:" PMedHX: ; Meds; Surg HX; Allergies; Social; Fam HX; Summarize: Conclusion".

THAT IS THE BEST ADVICE I can give! It took no more than a minute and a half MAX to write all that and then I would enter my patients room and begin. This helped me remember to ask everything and to try and "summarize" the patients CC and HPI with them prior to my conclusion of the differential and work-up to them. (Something not required of COMLEX PE and something I wasnt used to doing.) I only forgot to ask some of these things on 1 patient for these pertinent easy points, all because my initial 30second to 1 minute writing at the exam start!! I DIDNT EVEN DO THIS FOR MY COMLEX PE and I wish I had. From practicing with my Brother, I found out that I always had about 4min left over from the exam, from our timed 15min, and I always caught myself forgetting to ask easy allergy or Fam Hx questions. So, I decided to write these headings on my scrap paper, along with a few quick first thoughts as to what could cause ...Blank "CC", once I was allowed to start. It really did help and reminded me to ask. I highly recommend it! Best of luck guys!

I do have a few questions for those that have taken and PASSED it already:

1. Did anyone list MORE than 5 differentials and/or work-ups on a patient? Im curious is that is counted against you or okay to do? I didnt see an answer for this online.

Thanks again to everyone for all your great advice!

 

[Captopril]

How do you avoid writing the Hx down while the patient talks? Would you wait for them to finish answering each question and then write it? Isn't that awkward with the long pauses between them finishing answering and you asking the next question?

Just wanted to add:

1. I wrote out my notes. Because I knew I would need to insert extra things here or there that I would forget to put in the HPI by the time I was writing the Work-up and I knew I would want to be able to go back and draw the little : ^ and write legibly and very tiny, whatever I wanted to add. I figured I needed more space and for me writing is better.

2. I also asked all the patients if it would be ok with them if I wrote while they told me their problems, so that I wouldnt forget anything important they told me so we could help try and figure out what was bothering them and get them to feeling better soon...Something like that...But I did ask permission to write while in the room with them. I tried not to write while they talked to me and I tried not to talk to them at all if I was writing. I made sure to use eye contact and not to write too often, but also not to leave things out because I def would have forgotten certain things had I not written them down. (Realized this during note time!)

3. I ALWAYS asked if they had any questions or concerns, AND told them I would be back to discuss the results with them and we would figure out our best treatment plan together at that time.

Ok- sorry to overload yal with info. Hope this may help relax some and give good insight into how you want to engage with your patients on test day. I highly recommend trying to find a pattern or method that you use to introduce yourself to the patient, collect info, do the exam and close AND doing this the same way with every patient, so you dont leave something out.

Good Luck!

 

[Benign Teratoma]

Like to give the forum something back.

I felt like I failed the exam. but turns out I passed with NO borderline scores.

Things I did wrong:

1) Forgot to wash my hand one station! Ouch….
2) Definitely didn’t finish all the PE
3) My ptn notes were horrible. and I mean horrible. Mostly my writing [recommend typing instead of writing at least for me]

The things I did correct:

1) Always asked if the ptn had any questions in the end.
2) Showed tons of empathy [oh boy it might have looked and sounded fake but you gotta act!!!]
3) I would always leave 2 mins where I will tell the SPs what was happening with them and what the history and PE showed.

So what I did to pass?

-I am a US MD student. Taking a year off for research. My school emphasizes on clinical exposures, so I have had lots of practice with SPs previously. But then again I was a year out from the clinics.

-USED USMLE STEP 2 CK 2005 version that you can get free on google [type "USMLE STEP 2 CK PDF torrent" on google]

-Went through each case only once with my girlfriend [whos also in medical school]. We took turns being SPs and clinicians. The book is really good...and I say 10 out of 12 cases where indirectly from the book.

 

[Proverbs31]

Captopril:

I would "scratch" write really quick things, like NEG: N/V/D/HA/ for nausea, vomitting, dizziness, Headache, etc so it didnt take me but a sec to note things that were said. My scratch paper looked ridiculous. Plus a few times I would say "Ok, so you have noticed some....whatever, " as I wrote quick note or abbreviation, and then looked up and asked something else...I dont know..There wasnt a whole lot of pauses to be honest...It just kinda flowed. I write quick, sloppy and fast, and sometimes would jot something down while I was looking at the patient with the clipboard in my lap...Does that make sense? On some of the summaries, I would say , "Ok I want to make sure I understand everything that youve told me, So you have been having .....blank.... for the past 3days...and...blah blah.,..." --As I would kinda read off the clipboard looking up at the patient as they would nod or agree with what I said....Then Id put the clipboard down and say my initial impressions and ask if they had any questions or concerns for me before we went ahead with the Physical exam. Then Id drape them and wash my hands...usually throwing in some small talk while I washed my hands - because thats what Id do anyway in real life....
I didnt write all the time, but I did ask if it was okay always and then tried to write quickly and in small abbreviations that Id understand...were there a few small pauses in between..Probably, but nothing felt weird or awkward. YOURE GONNA DO GREAT!! I KNOW IT! Good luck!

 

[PlutoBoy]

My turn

1) Didn´t check gait on a patient complaining of dizziness... I also forgot to ask him about hearing issues.

2) Didn´t check thyroid/neck on 2 patients complaining of fatigue.

3) Forgot to drape a patient...

4) Didnt counsel a patient on condom use

On the other hand, i managed to "connect" real well with most patients and I think my notes are good. Always asked ROS and questions about weight, appetite, etc...

I did really well on STEP 1 and CK, I hope this thing doesnt ruins my record!

 

[34140]

i always told the pt that im going to be taking notes while i write so i dont forget anything important that they tell me, and then i would ask if thats ok, they always said yes.

on my exam, i did counsel for smoking, but forgot to counsel for cessation of drug use! i hope that didnt cost me big. i also forgot the names of pts and ended up not using their name through out the exam, i did def say it on entering and most of the time when leaving. i also hope that didnt cost me time will tell!

i also only used the computer on 3-4 notes, and they were easier notes with not a lot in the HPI. i found that i could fit in more if i wrote it out by hand, i didnt use cursive since my writing was small to fit everything in. i think writing the note is much easier.

 

[PlutoBoy]

I just hope I passed...

 

[Nellyakgo]

I just took the exam in LA. I was so nervous to begin with, the night before and morning off. Then it wore off once the exam started. It went by faster than I though and when it was over it was a big anti-climax.

I didn't finish the closure on 2 cases and I think I'll lose the most points on those. On the others I may lose some points on emphaty statements and perhaps some key "associated symptoms" which I may have overlooked. I think I forgot social history on 2 cases. My note writing is not that stong either. Otherwise, I'm still hopeful. Fingers crossed.

I spent at least 1 minute at the door with each case, writing mnemonics and thinking possible diagnosis. I think I was always the last student to enter. But I do feel this time is well worth spending. When I was practing I found that if I left the history to my own memory I would always without fail forget something - like allergies, or tobacco, alcohol use etc.

Good luck to all who still have to take it and keep your positive karma flowing my way too.

 

[ChessMess]

I brought a small carry on sized overnight bag. Are they gonna freak out if I bring it in? Are the lockers those micro-lockers that are like 1 foot cubed? Or an open cubby where I could just put it down and it would be fine?
Thanks

 

[Nellyakgo]

The locker "cubicles" are too small for a carry sized bag (assuming they are standard accross all centers) but the cubicles are inside a room whose door gets locked. If the staff are nice perhaps they will let you do that. But the web site says definetly no. So rather than taking a chance I would leave it somewhere else if I were you.

 

[ShyRem]

Many hotels will let you do a late check out, or barring that they often have a bellhop's closet near the front desk that you can store stuff in after check-out time but before you need to leave the area (i.e. for meetings or .. an exam).

 

[radiodoc99]

Excellent list. I would also add to the list OMM. Many students forget to do OMT on the PE exam as much as they should. Its a tough balance. See my blog post.

 

[Pontifex Maximus]

You can definitely screw up a lot and pass. I ended up forgetting a LOT of physical exam stuff, including crucial neuro stuff, did a completely made up "straight leg raise" test, forgot to ask a bunch of questions, and missed some really clearcut stuff on my differential. The format is definitely intimidating and easy to miss stuff you obviously know.

 

[kemper6036]

How do you avoid writing the Hx down while the patient talks? Would you wait for them to finish answering each question and then write it? Isn't that awkward with the long pauses between them finishing answering and you asking the next question?

you can take notes on the history, just ask the pt if they mind if you write some notes. not a big deal

 

[kluverbusy]

Just took it n well...i don't know, what do you think:
1. Didn't finish closing on 2-3 px. I worry about this prob the most. I would start...based on your Hx and PE i think it's xyz..and the voice would say this px encounter is over. I talk alot and think i gathered most info but w no complete closure not sure how much that will hurt me.
2. If i thought it was a depression case i asked about depression, how things were w the wife and kids at home, buuut forgot to ask about suicidal ideation (Ha, u kiddin me im a tad suicidal after that, ridiculous).
3. If i thought it was back pain i did one horrible job of a PE. Didn't assess gait, didn't test ROM, i think i clubbed her knees and ankles for reflexes..i think, didn't assess muscle strength LE or UE.
4. If i thought it was fatigue i clumsly explained how a thyroid gland works and why hypOthy might be causing fatigue..info sharing def not gettin checked there
5. Typed my notes, they were ok except i only put 3 DDX on some..based on Hx and Findings i r/o others..but FA would have about 6 for each case. I think i remember missing one or two important tests to run. And i didn't structure any sentence in a nice poetic form like FA either. Not sure why we need to, no Dr's notes ever are.

I'm sure there are plenty more mistakes. I did score points for playing Dr. Empathy...well ma'am 2wks is too long to have xyz, i'm sorry to hear that (insert concerned face), i'm going to get you help as soon as i can.
Whatever i'm sure some clever guy will say at least u took it early..always time to repeat! yaya
Anyways, thoughts?

 

[Nellyakgo]

If all your other parts (data gathering, information sharing, communication, pt notes, etc) were sufficient, and good enough on the majority of cases, I don't think 2-3 failures to close won't cost you to fail the test. Same for the failiure to do required complete PE on 1 or 2 cases. It's a balance

I didn't finish on time for 2 cases.

I got my result 3 days ago. Thumbs up.

 

[kluverbusy]

Thanks for the reply nelly. Now that i've gotten further from the exam i realized the thing i missed a handfull of times was "do u have any questions?" Bc i didn't get to fully close. But i know that part of closing is summarizing and i always did that rt after the HPI so at least i got those pts. So basically i missed, some of the time, the Dx i thought it might be at the time; and a handfull of times "do u have any questions?" Simply bc i ran out of time. Man my history taking was good everytime at least. How much will missing those things hurt, will that fail me? Has anyone else experienced that?

 

[dinkey]

Honestly I believe if you were courteous to the patients, attended to their needs, and did a proper history and closing most of the time, you don't need to worry.

I got my result last week and I passed. I didn't close on two patients. Didn do a proper physical on three patients and two of my ptnt notes only had two differentials and two diagnostic work ups. Just be confident, courteous, practice the ptnt note before hand, and do the FA book front to back as many times as you can and you will do fine.