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THE FOLLOWING IS SIMPLY INFORMATION. I DO RECOMMEND RESOURCES, BUT IN NO PLACE AM I RECOMMENDING UNCONVENTIONAL RESOURCES WITH THE INTENT OF PROMOTING SALES.
Who this is for: This guide is not for the casual CS taker that probably makes up at least 80% of US MD students obligated to take this exam. It's for the ones are probably struggling in one way or another. I say this with the best intent and not to scare you, but if you've:
1.) Failed this exam once.
2.) Have been diagnosed with learning disabilities and/or ADHD/Autism
3.) Suffer from performance anxiety as demonstrated by a marked difference on tasks when under pressure.
4.) Have deficits in certain areas (for example, good at written exams, bad at practical exams)
5.) Recently suffered from primary/secondary psychiatric ailments
you're more likely than others to fail this exam due to no fault of your own and you need to take additional steps I try to lay out in this post.
My Story: I took this exam very late for stupid mistakes related to delaying CK until the last possible moment and I needed to pass, worked very hard to, and did, but for all the struggling and even after all the prep, I thought I would kill it, but I still had two stars in the borderline section for ICE.
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A) How to fail:
1.) Meeting the above criteria which is unfortunately not in your control.
2.) Not practicing the real thing with a partner. There are just too many things you won't be able to do on the spot and will need deliberate practice beforehand to develop prior to the exam.
3.) Scheduling it to get it over with minimal study thinking that everyone else passes, you're not in the bottom 5% of your class, so you should be fine. Some people claim to pass by just doing this every year (and many may do so), but this test is NO LONGER JUST AN ENGLISH EXAM (make no mistake I still don't think it's a good exam).
4.) Kind of goes with point 4, but treating this like “any other clinical encounter”. It’s not. Your preceptors in M3/4 don't "fail" you for the day if you don't collect the pertinent information. They just give you soft-spoken constructive feedback. Step 2 CS will fail you. You have to pick up First Aid and see how they do a case and what rules/expectations are because if you're already borderline, every point matters.
B.) The Exam Broken Down by Section.
Intro: Make sure you get their name, write down the vitals/cc, knock, walk in, shake their hand, and introduce yourself as Dr. X and say you’re the physician in clinic today. Tell them that you’re sorry they’re not feeling well today (cheap CIS points) and then start with an open ended question (probably another CIS tick mark) by asking them if they can tell you more about their CC (chest pain). Keep the intro the same each time so it comes out as a reflex and you won't have to think under pressure and say something that's less appropriate. It won't be awkward because you have a different patient who won't know you're saying the same thing each time. While that's what you're expected to do, for those who suffer for performance anxiety, difficulty multi-tasking (ex. looking in someone's eyes and talking), I highly recommend you spend 30 seconds writing a differential on your piece of paper in an organized manner (in practice and the real thing on the same place of the page). What this does is give you free time where someone's not staring expectantly at you where you can anticipate and plan to ask certain things.
HPI #1: The first part of HPI is easy. Everyone has their FARCOLDER, OPQRSTAA, FORDPAPP, OLDHATS mnemonic(depending where you want to medical school), that basically gives some basic characterization of the chief complaint. My suggestion is to pick one mnemonic and STICK WITH IT. Don't keep changing mnemonics because the more you use one, the more you get used to it and you'll start to realize and anticipate it's weaknesses and learn to work around those.
HPI Part #2: This is one the the most difficult parts of any clinical encounter, not just CS. This is where, if you want to get technical with it, you ask targeted questions to narrow down the differential. An analogy I use is fishing. Each question is using a hook or or w/e, but it correctly placed, you score. This is the part that will require a lot of practice and will affect your ICE score. To get good, you need to practice to develop the experience to know when certain questions are relevant and not relevant. After practicing a million fever cases, you'll know to ask about N/V/D, Constitutional/Occult Malignancy, Headache/Light Sensitivity, SOB, Burning Urination from experience. I don't suggest making new acronyms for each potential differential here because there are just too many variations of fever (childhood cases, autoimmune, etc.) and using one mnemonic every time will may make you susceptible to missing the bigger picture. You need to work through as many cases. As you work through the questions, introspect on what you're getting wrong and just understand them why they're important and ask them in the appropriate situation next time. On top off the First Aid and UWORLD sources, the NBME has a PDF of many differentials they'll test and while you can't do a whole case off of them, you can think about the what questions may be pertinent to ask from the second part of the HPI. Another thing to get in a habit of doing is to always characterize a secondary symptoms. If they're coming in with a fever and have a cough, characterize is as productive, bloody, sputum color, etc and you will develop these habits through practice. Another tip is to help yourself out more, start anticipating HPI #2 questions you want to ask the patient so you're not on the spot during the actual encounter and write them down in a specific spot of your page.
ROS: Think of this as the safety net that catches whatever your HPI did not. My senseless mnemonic for this was: CHCRGGEMNS and I advise a mnemonic. The list below is just an example and is not really what I asked. Another unique tip is that you should customize your ROS to include things you realize you forget to ask in the HPI during practice sessions. When you realize you're missing weight loss which costs you a key differentials consistently, make it a habit to include it in your ROS.
Constitutional: Fever/chills, weight, fatigue, etc
HEENT: URI, Jaundice, ulcers, etc
CV: Chest pain, palpitations
Respiratory: SOB, cough,
GI: Pain, NVD, Reflux
Genitourinary: Changes in pee characterization
Endocrine: 3 Ps, hot/cold
MSK: weakness, pain, swelling
Neuro: LOC, weakness, SIGECAPS
Skin: rashes
I recommend you do a thorough ROS but you're probably not getting any points for doing this. This brings up one key point that gets in the way of success for many people. This is an objective exam and you're graded on accuracy of your answers, not going through the motions and you're not graded for the thoroughness of your ROS for example. There are certain things like counseling/being sympathetic where going through the motions will help, but when it comes to ICE, there's a few right answers, but otherwise you're wrong and it doesn't matter how many ROS questions you asked.
History:
Another easy section. Just use the tried and true PAMHITSFOSS. Past Medical, Allergies, Medications, Hospitalizations, Ill Contacts, Trauma, Surgical, Family, OB/GYN, Sexual, Social. Within Social, I use "TIA HOE" which is tobacco, illicit, alcohol, home, occupation/income, education and I suck at OB/GYN personally so I use RTV LMP PAP (google it). For Allergies, you don’t care unless it’s relevant drugs/exposures unless you get some case where the person tells you he or she is allergic to cats, and they get SOB and rashes after a dog exposure. Trauma can help with psych too. This is the most straight forward part. Keep it simple. Practice the same ways to ask things to maximize efficiency, but make sure they're not flawed ways of asking things. For example, "do you currently smoke" seemed to roll off the tip of my tongue during practice sessions and someone realized and said no. Sometimes real preceptors will make a face and say not currently, but don't rely on that. Ask if they have EtOH history, IVDU history, Tobacco usage history. An easy way to illicit family history is to ask if their what conditions run in their family like heart disease, diabetes, or kidney disease. Don't worry, this part isn't as hard as real patients where you have to coax it out of them. Then, when you run into substance abuse or bad habits, you COUNSEL immediately because you will forget at the end.
Physical Exam:
This is a medium difficulty section. If you're clumsy, you'll need to work on a bit otherwise, just a few pitfalls one of which is being nervous that your physical exam is inadequate when chances are it is (like everyone else) but the exam doesn't test for skill at listening to lungs. What you should be doing is at least going through the motions and you will find things and most times they are in your face. For example, I was rewarded for checking the lungs in a fever case by finding a painted bull's eye rash on the patient's upper back. There is no differentiation between an aortic stenosis or mitral regurgitation murmur. That said, I know someone who was handed an EKG by his patient who said the nurse told me to give this to you (it was sinus tach) so don't just forget all your technical details or panic if they for instance say they recorded their heart sound and play it on a tape recorder (no idea if they do this but this would be a way they could test you on that). Regardless, for the most part, be reasonable observant, don't rush, and you will run into things so don't panic with the physical exam. Other tips are to FIRST WASH YOUR HANDS. One appropriate thing to do is just get in the habit of washing them right when when you walk in because you're liable to forget on the pressure of the real thing. Don’t wear nails and clip them if they're long. Gloves just take longer and don't be the person who washes their hands, then changes their mind and tries to wear gloves, and then encounters the friction of wet hands, rips said gloves, has them drop on the floor, bends down to pick them up, which leads to your stethoscope falling off, which you pick up which prompts the patient to ask you to wash your hands again (true story from the sim lab at my school). Just wash your hands, dry them, and move on.
As for what to check, I suggest Heart, Lungs, Abdomen, Feet, BUT DON’T FORGET HEENT. There’s lots of things you can get by just quickly doing HEENT like thyromegaly, JVD, oral ulcers, exudates, jaundice, conjunctival pallor/injection, cervical lymphadenopathy, etc. These aren't going to be subtle which brings up the a major thing you need to get. Positive exam findings are meant to be pretty clear like I said. I could imaging whistling as a wheeze, kicking very hard with a reflex to demonstration hyperreflexia, weakness can be faked, hearing issues can, and don't forget like restlessness, pressured speech, and VITALS (which really put a setting and context to the whole encounter) which is why you're given them first. Chest pain in a patient with 80/50 BP, 120 HR is very different from 120/70, 80 HR. Another thing you should be doing on physical exam is to think of additional symptoms you may have forgotten to ask on the HPI/ROS to ask here. The Neuro exam is something that's time intensive so practice doing it many times and fast so you're not like, oh god! I have to do one now, what do I do. Also practice Weber/Rinne in case. Also, this is your last chance before you have to give your patient an answer into what's going on which to some is a kind of big deal so mentally prepare yourself and plan what you're going to say given that this is a relatively straight forward section otherwise.
Quick less emphasized ICE gems:
-Add Neuro exams for all headaches, suspected systemic disorders (HIV, Cancer).
-Hands, Mouth, Feet if they have one rash.
Easy CIS points:
-remember to use the pull out board to ensure comfort.
-don’t do exam maneuvers over the drape.
-don't reveal too much of the gown.
-wash your hands again if you touch their feet.
Closure: This section isn't hard. They will basically have a "challenge question". They range from easy to difficult with the easier ones asking you if "they will ever get better" to where you just say that you need to run tests, but you will take the best care of them, etc. It is important to also provide some plan to the patients. You don't have to tell them your top differentials (and I don't know if it counts against you if you give them wrong diagnoses). Regardless, your best bet is to be a little vague and describe a few possibilities. If you think they have a aspiration pneumonia, say they may have something going on in their lungs which may require a specific treatment with medication. That can cover a lot of things. If you're too vague, they'll ask a follow-up question because like any real person, they are trying to see what's going to happen to them and it's most important to at least provide them with some direction so if you have a bunch of differentials, it never hurts to give your top 2/3 (being a little vague), but saying we are going to take some blood and take some pictures to get a better idea of what's happening. Sometimes, the patient may press you for a diagnosis and if you have a diagnosis that you feel is serious, but are worried about stating because you don't want to be wrong and give a serious diagnosis, just say that I am concerned this may be a possibility, but you will be monitored here closely, and we need to do tests to confirm or rule out this possibility. This is mostly a CIS thing, but I've seen cases where someone has foot pain that seemed like stress fracture and they asked me if they should continue to walk on it tomorrow, and I had to be like, uh no...so bring your common sense to the exam too. Don't over inform them with technical details because it's going to open up the door to more questions.
Note-taking during the encounter: I encourage you to obviously take notes on ur clipboard, but at the same time make sure it's organized and you budget space appropriately and have the same lay out each time. Also, do not be a journalist and copy down what the patient is saying. If they say their mom has Mitral Valve Prolapse, just write down bad valve or MVP, you'll remember, the note is like 10 minutes away.
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I forget now if you get extra time for the note if you finish the encounter early, but I would never aim for this if I were you because you're going to feel stupid if you come out early and remember you forgot to ask something. ALSO DON'T WRITE DOWN STUFF YOU DIDN'T ASK OR DIDN'T DO. For example, if you're leading differential is a Migraine, don't lie that you asked about light sensitivity, it may seem small but who knows if you they go back, and I don't imagine it would work in your favor if they know you lied.
-The Note: This is basically the major part of ICE and the most stressful part and some may feel crunched for time here and may not finish. One trick you may want to try a few times to see if it works for you is to go right to the prize money which is the tests/imaging and the differential and supporting evidence. By doing this, you guarantee you don't miss this critical component before time runs out. Whether you choose to do this or not, get in the habit of doing it because otherwise your workflow will be messed up on the real thing and you'll maybe forget things.
For HPI #1: Bullet the mnemonic. You'll be surprised how many times you'll miss something if you try to write a paragraph in prose because grammar is limiting.
For HPI #2 and ROS: Pertinent +/-
Family History: Write out PAMHITSFOSS to spur memory but only write relevant details.
For Physical Exam: This can take a long time. If you haven't had a medicine rotation/been on a lighter rotation recently, get in the habit of typing a normal physical exam FAST (abdomen soft, contender to palpation, no masses, or hepatomegaly) on a word document as preparation.
For Labs/Imaging: Make sure you think of the basic stuff. They're not going to make you order a PET/MRI or stuff your academic center orders. It's going to be stuff like Complete Blood Count, Comprehensive Metabolic Panel (make sure these are NBME terms per their website). Ultrasounds and Pelvic exams are your friends for any OB/GYN problem as opposed to weird hormone tests and advanced imaging. Make sure you don't make a classic medical mistake in the heat of the moment like getting a CT scan for acute pancreatitis (even though the ED orders one) and first get the RUQ U/S because they're probably going to count that against you.
For Diagnosis/Supporting Info: Be as specific as you can, but it you forget something or are unsure, it's OK to be a little vague. For one case where it was kind a less common, but still classic medical disease, I had been out of study so long I forgot the name of the disease so I put "XYZ process" because I knew that was the pathophysiology. It's better to get partial points for that. On the flip side, I wouldn't write "Cancer" if it has to be a lung process and you're thinking lung cancer. Alternatively, if you see weight loss/night sweats/fatigue than neoplasm might be an appropriate diagnosis than Lung Cancer if you can list more supporting symptoms for just a general neoplasm. Also, I don't know where I heard this, but don't try to fill up the third space with an unlikely differential if there's truly no third differential or just make your other differentials more specific to fill up that space. If patient has fever, light sensitivity, focal neurological deficit, rigid neck, it might be better for your differentials to be 1.) Viral Meningitis 2.) Bacterial Meningitis instead of saying autoimmune disease or cancer and trying to make the symptoms fit.
C. Some extra pointers about preparation: Like I said about preparation, it is the most critical aspect and you need to do the best to simulate the real deal. You can’t just run through these in your head because it's already hard for you to make decisions on the spot. Don't place your faith in one practice partner who's lets say your good friend and won't give you great feedback. Pick a variety. I practiced with 4 different people and learnt something valuable from each. Draping/Physical exam technical skills are less important but I practiced knocking, introducing myself, washing my hands, closure, and writing notes and it helped on the real thing. For resources, First Aid is the best overall. I was concerned about my physical exam so I bought UWorld (because they supposedly had videos). Their videos are useless, but I think they do a slightly better job with explaining which physical exam maneuvers are necessary by indicating it in the answers for each practice case. Besides that though, First Aid cases are better because their HPI feedback is 100x better. They'll outline all the specific questions to ask and why it's important. If you need more sources, I’d recommend mixing some FA and UW, but FA alone is sufficient. I haven't looked into some of the more costly things, I imaging their good, but my hunch is that if you're struggling and have gone thru FA/UW, you are missing some basics. If you need to practice a case alone because no one is available on a day, make the most of it! First pretend you're standing outside a door and just look at the age, gender, vitals, and CC then make a differential and write what questions you want to ask. Then read their HPI and make note of what you didn't ask in red pen or something. Then write down what physical maneuvers you’d do and then check yourself again. Finally, write down your diagnoses/supporting evidence and work up and check yourself a final time. This way you learn actively instead of passively reading. I do remember FA makes it harder to do this as physical findings are on the page with closure, etc. so it requires some discipline to not look at things .
D. My Philosophy on Mnemonics:
Step 2 CS requires a lot of repetition of the same questions without missing things. Some websites out there have a million mnemonics out there. I think the Past Medical History is where the mnemonics are the most helpful and the initial HPI is a good place to use the mnemonic your school taught you. Mine taught me OPQRSTAA but it’s very tailored to pain, as opposed to something like a cough, fever, heart failure, etc. I think FORDPAPP is the best for general complaints (see links below). Also, ROS is a good place to use mnemonics for the order of the systems only you need to ask. For the HPI #2 though, conceptually but you need to be actively thinking and give yourself the flexibility to change your line of questioning if a game changer emerges (you're working up a fever and they tell you they have HIV). Mnemonics make that harder.
Who this is for: This guide is not for the casual CS taker that probably makes up at least 80% of US MD students obligated to take this exam. It's for the ones are probably struggling in one way or another. I say this with the best intent and not to scare you, but if you've:
1.) Failed this exam once.
2.) Have been diagnosed with learning disabilities and/or ADHD/Autism
3.) Suffer from performance anxiety as demonstrated by a marked difference on tasks when under pressure.
4.) Have deficits in certain areas (for example, good at written exams, bad at practical exams)
5.) Recently suffered from primary/secondary psychiatric ailments
you're more likely than others to fail this exam due to no fault of your own and you need to take additional steps I try to lay out in this post.
My Story: I took this exam very late for stupid mistakes related to delaying CK until the last possible moment and I needed to pass, worked very hard to, and did, but for all the struggling and even after all the prep, I thought I would kill it, but I still had two stars in the borderline section for ICE.
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A) How to fail:
1.) Meeting the above criteria which is unfortunately not in your control.
2.) Not practicing the real thing with a partner. There are just too many things you won't be able to do on the spot and will need deliberate practice beforehand to develop prior to the exam.
3.) Scheduling it to get it over with minimal study thinking that everyone else passes, you're not in the bottom 5% of your class, so you should be fine. Some people claim to pass by just doing this every year (and many may do so), but this test is NO LONGER JUST AN ENGLISH EXAM (make no mistake I still don't think it's a good exam).
4.) Kind of goes with point 4, but treating this like “any other clinical encounter”. It’s not. Your preceptors in M3/4 don't "fail" you for the day if you don't collect the pertinent information. They just give you soft-spoken constructive feedback. Step 2 CS will fail you. You have to pick up First Aid and see how they do a case and what rules/expectations are because if you're already borderline, every point matters.
B.) The Exam Broken Down by Section.
Intro: Make sure you get their name, write down the vitals/cc, knock, walk in, shake their hand, and introduce yourself as Dr. X and say you’re the physician in clinic today. Tell them that you’re sorry they’re not feeling well today (cheap CIS points) and then start with an open ended question (probably another CIS tick mark) by asking them if they can tell you more about their CC (chest pain). Keep the intro the same each time so it comes out as a reflex and you won't have to think under pressure and say something that's less appropriate. It won't be awkward because you have a different patient who won't know you're saying the same thing each time. While that's what you're expected to do, for those who suffer for performance anxiety, difficulty multi-tasking (ex. looking in someone's eyes and talking), I highly recommend you spend 30 seconds writing a differential on your piece of paper in an organized manner (in practice and the real thing on the same place of the page). What this does is give you free time where someone's not staring expectantly at you where you can anticipate and plan to ask certain things.
HPI #1: The first part of HPI is easy. Everyone has their FARCOLDER, OPQRSTAA, FORDPAPP, OLDHATS mnemonic(depending where you want to medical school), that basically gives some basic characterization of the chief complaint. My suggestion is to pick one mnemonic and STICK WITH IT. Don't keep changing mnemonics because the more you use one, the more you get used to it and you'll start to realize and anticipate it's weaknesses and learn to work around those.
HPI Part #2: This is one the the most difficult parts of any clinical encounter, not just CS. This is where, if you want to get technical with it, you ask targeted questions to narrow down the differential. An analogy I use is fishing. Each question is using a hook or or w/e, but it correctly placed, you score. This is the part that will require a lot of practice and will affect your ICE score. To get good, you need to practice to develop the experience to know when certain questions are relevant and not relevant. After practicing a million fever cases, you'll know to ask about N/V/D, Constitutional/Occult Malignancy, Headache/Light Sensitivity, SOB, Burning Urination from experience. I don't suggest making new acronyms for each potential differential here because there are just too many variations of fever (childhood cases, autoimmune, etc.) and using one mnemonic every time will may make you susceptible to missing the bigger picture. You need to work through as many cases. As you work through the questions, introspect on what you're getting wrong and just understand them why they're important and ask them in the appropriate situation next time. On top off the First Aid and UWORLD sources, the NBME has a PDF of many differentials they'll test and while you can't do a whole case off of them, you can think about the what questions may be pertinent to ask from the second part of the HPI. Another thing to get in a habit of doing is to always characterize a secondary symptoms. If they're coming in with a fever and have a cough, characterize is as productive, bloody, sputum color, etc and you will develop these habits through practice. Another tip is to help yourself out more, start anticipating HPI #2 questions you want to ask the patient so you're not on the spot during the actual encounter and write them down in a specific spot of your page.
ROS: Think of this as the safety net that catches whatever your HPI did not. My senseless mnemonic for this was: CHCRGGEMNS and I advise a mnemonic. The list below is just an example and is not really what I asked. Another unique tip is that you should customize your ROS to include things you realize you forget to ask in the HPI during practice sessions. When you realize you're missing weight loss which costs you a key differentials consistently, make it a habit to include it in your ROS.
Constitutional: Fever/chills, weight, fatigue, etc
HEENT: URI, Jaundice, ulcers, etc
CV: Chest pain, palpitations
Respiratory: SOB, cough,
GI: Pain, NVD, Reflux
Genitourinary: Changes in pee characterization
Endocrine: 3 Ps, hot/cold
MSK: weakness, pain, swelling
Neuro: LOC, weakness, SIGECAPS
Skin: rashes
I recommend you do a thorough ROS but you're probably not getting any points for doing this. This brings up one key point that gets in the way of success for many people. This is an objective exam and you're graded on accuracy of your answers, not going through the motions and you're not graded for the thoroughness of your ROS for example. There are certain things like counseling/being sympathetic where going through the motions will help, but when it comes to ICE, there's a few right answers, but otherwise you're wrong and it doesn't matter how many ROS questions you asked.
History:
Another easy section. Just use the tried and true PAMHITSFOSS. Past Medical, Allergies, Medications, Hospitalizations, Ill Contacts, Trauma, Surgical, Family, OB/GYN, Sexual, Social. Within Social, I use "TIA HOE" which is tobacco, illicit, alcohol, home, occupation/income, education and I suck at OB/GYN personally so I use RTV LMP PAP (google it). For Allergies, you don’t care unless it’s relevant drugs/exposures unless you get some case where the person tells you he or she is allergic to cats, and they get SOB and rashes after a dog exposure. Trauma can help with psych too. This is the most straight forward part. Keep it simple. Practice the same ways to ask things to maximize efficiency, but make sure they're not flawed ways of asking things. For example, "do you currently smoke" seemed to roll off the tip of my tongue during practice sessions and someone realized and said no. Sometimes real preceptors will make a face and say not currently, but don't rely on that. Ask if they have EtOH history, IVDU history, Tobacco usage history. An easy way to illicit family history is to ask if their what conditions run in their family like heart disease, diabetes, or kidney disease. Don't worry, this part isn't as hard as real patients where you have to coax it out of them. Then, when you run into substance abuse or bad habits, you COUNSEL immediately because you will forget at the end.
Physical Exam:
This is a medium difficulty section. If you're clumsy, you'll need to work on a bit otherwise, just a few pitfalls one of which is being nervous that your physical exam is inadequate when chances are it is (like everyone else) but the exam doesn't test for skill at listening to lungs. What you should be doing is at least going through the motions and you will find things and most times they are in your face. For example, I was rewarded for checking the lungs in a fever case by finding a painted bull's eye rash on the patient's upper back. There is no differentiation between an aortic stenosis or mitral regurgitation murmur. That said, I know someone who was handed an EKG by his patient who said the nurse told me to give this to you (it was sinus tach) so don't just forget all your technical details or panic if they for instance say they recorded their heart sound and play it on a tape recorder (no idea if they do this but this would be a way they could test you on that). Regardless, for the most part, be reasonable observant, don't rush, and you will run into things so don't panic with the physical exam. Other tips are to FIRST WASH YOUR HANDS. One appropriate thing to do is just get in the habit of washing them right when when you walk in because you're liable to forget on the pressure of the real thing. Don’t wear nails and clip them if they're long. Gloves just take longer and don't be the person who washes their hands, then changes their mind and tries to wear gloves, and then encounters the friction of wet hands, rips said gloves, has them drop on the floor, bends down to pick them up, which leads to your stethoscope falling off, which you pick up which prompts the patient to ask you to wash your hands again (true story from the sim lab at my school). Just wash your hands, dry them, and move on.
As for what to check, I suggest Heart, Lungs, Abdomen, Feet, BUT DON’T FORGET HEENT. There’s lots of things you can get by just quickly doing HEENT like thyromegaly, JVD, oral ulcers, exudates, jaundice, conjunctival pallor/injection, cervical lymphadenopathy, etc. These aren't going to be subtle which brings up the a major thing you need to get. Positive exam findings are meant to be pretty clear like I said. I could imaging whistling as a wheeze, kicking very hard with a reflex to demonstration hyperreflexia, weakness can be faked, hearing issues can, and don't forget like restlessness, pressured speech, and VITALS (which really put a setting and context to the whole encounter) which is why you're given them first. Chest pain in a patient with 80/50 BP, 120 HR is very different from 120/70, 80 HR. Another thing you should be doing on physical exam is to think of additional symptoms you may have forgotten to ask on the HPI/ROS to ask here. The Neuro exam is something that's time intensive so practice doing it many times and fast so you're not like, oh god! I have to do one now, what do I do. Also practice Weber/Rinne in case. Also, this is your last chance before you have to give your patient an answer into what's going on which to some is a kind of big deal so mentally prepare yourself and plan what you're going to say given that this is a relatively straight forward section otherwise.
Quick less emphasized ICE gems:
-Add Neuro exams for all headaches, suspected systemic disorders (HIV, Cancer).
-Hands, Mouth, Feet if they have one rash.
Easy CIS points:
-remember to use the pull out board to ensure comfort.
-don’t do exam maneuvers over the drape.
-don't reveal too much of the gown.
-wash your hands again if you touch their feet.
Closure: This section isn't hard. They will basically have a "challenge question". They range from easy to difficult with the easier ones asking you if "they will ever get better" to where you just say that you need to run tests, but you will take the best care of them, etc. It is important to also provide some plan to the patients. You don't have to tell them your top differentials (and I don't know if it counts against you if you give them wrong diagnoses). Regardless, your best bet is to be a little vague and describe a few possibilities. If you think they have a aspiration pneumonia, say they may have something going on in their lungs which may require a specific treatment with medication. That can cover a lot of things. If you're too vague, they'll ask a follow-up question because like any real person, they are trying to see what's going to happen to them and it's most important to at least provide them with some direction so if you have a bunch of differentials, it never hurts to give your top 2/3 (being a little vague), but saying we are going to take some blood and take some pictures to get a better idea of what's happening. Sometimes, the patient may press you for a diagnosis and if you have a diagnosis that you feel is serious, but are worried about stating because you don't want to be wrong and give a serious diagnosis, just say that I am concerned this may be a possibility, but you will be monitored here closely, and we need to do tests to confirm or rule out this possibility. This is mostly a CIS thing, but I've seen cases where someone has foot pain that seemed like stress fracture and they asked me if they should continue to walk on it tomorrow, and I had to be like, uh no...so bring your common sense to the exam too. Don't over inform them with technical details because it's going to open up the door to more questions.
Note-taking during the encounter: I encourage you to obviously take notes on ur clipboard, but at the same time make sure it's organized and you budget space appropriately and have the same lay out each time. Also, do not be a journalist and copy down what the patient is saying. If they say their mom has Mitral Valve Prolapse, just write down bad valve or MVP, you'll remember, the note is like 10 minutes away.
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I forget now if you get extra time for the note if you finish the encounter early, but I would never aim for this if I were you because you're going to feel stupid if you come out early and remember you forgot to ask something. ALSO DON'T WRITE DOWN STUFF YOU DIDN'T ASK OR DIDN'T DO. For example, if you're leading differential is a Migraine, don't lie that you asked about light sensitivity, it may seem small but who knows if you they go back, and I don't imagine it would work in your favor if they know you lied.
-The Note: This is basically the major part of ICE and the most stressful part and some may feel crunched for time here and may not finish. One trick you may want to try a few times to see if it works for you is to go right to the prize money which is the tests/imaging and the differential and supporting evidence. By doing this, you guarantee you don't miss this critical component before time runs out. Whether you choose to do this or not, get in the habit of doing it because otherwise your workflow will be messed up on the real thing and you'll maybe forget things.
For HPI #1: Bullet the mnemonic. You'll be surprised how many times you'll miss something if you try to write a paragraph in prose because grammar is limiting.
For HPI #2 and ROS: Pertinent +/-
Family History: Write out PAMHITSFOSS to spur memory but only write relevant details.
For Physical Exam: This can take a long time. If you haven't had a medicine rotation/been on a lighter rotation recently, get in the habit of typing a normal physical exam FAST (abdomen soft, contender to palpation, no masses, or hepatomegaly) on a word document as preparation.
For Labs/Imaging: Make sure you think of the basic stuff. They're not going to make you order a PET/MRI or stuff your academic center orders. It's going to be stuff like Complete Blood Count, Comprehensive Metabolic Panel (make sure these are NBME terms per their website). Ultrasounds and Pelvic exams are your friends for any OB/GYN problem as opposed to weird hormone tests and advanced imaging. Make sure you don't make a classic medical mistake in the heat of the moment like getting a CT scan for acute pancreatitis (even though the ED orders one) and first get the RUQ U/S because they're probably going to count that against you.
For Diagnosis/Supporting Info: Be as specific as you can, but it you forget something or are unsure, it's OK to be a little vague. For one case where it was kind a less common, but still classic medical disease, I had been out of study so long I forgot the name of the disease so I put "XYZ process" because I knew that was the pathophysiology. It's better to get partial points for that. On the flip side, I wouldn't write "Cancer" if it has to be a lung process and you're thinking lung cancer. Alternatively, if you see weight loss/night sweats/fatigue than neoplasm might be an appropriate diagnosis than Lung Cancer if you can list more supporting symptoms for just a general neoplasm. Also, I don't know where I heard this, but don't try to fill up the third space with an unlikely differential if there's truly no third differential or just make your other differentials more specific to fill up that space. If patient has fever, light sensitivity, focal neurological deficit, rigid neck, it might be better for your differentials to be 1.) Viral Meningitis 2.) Bacterial Meningitis instead of saying autoimmune disease or cancer and trying to make the symptoms fit.
C. Some extra pointers about preparation: Like I said about preparation, it is the most critical aspect and you need to do the best to simulate the real deal. You can’t just run through these in your head because it's already hard for you to make decisions on the spot. Don't place your faith in one practice partner who's lets say your good friend and won't give you great feedback. Pick a variety. I practiced with 4 different people and learnt something valuable from each. Draping/Physical exam technical skills are less important but I practiced knocking, introducing myself, washing my hands, closure, and writing notes and it helped on the real thing. For resources, First Aid is the best overall. I was concerned about my physical exam so I bought UWorld (because they supposedly had videos). Their videos are useless, but I think they do a slightly better job with explaining which physical exam maneuvers are necessary by indicating it in the answers for each practice case. Besides that though, First Aid cases are better because their HPI feedback is 100x better. They'll outline all the specific questions to ask and why it's important. If you need more sources, I’d recommend mixing some FA and UW, but FA alone is sufficient. I haven't looked into some of the more costly things, I imaging their good, but my hunch is that if you're struggling and have gone thru FA/UW, you are missing some basics. If you need to practice a case alone because no one is available on a day, make the most of it! First pretend you're standing outside a door and just look at the age, gender, vitals, and CC then make a differential and write what questions you want to ask. Then read their HPI and make note of what you didn't ask in red pen or something. Then write down what physical maneuvers you’d do and then check yourself again. Finally, write down your diagnoses/supporting evidence and work up and check yourself a final time. This way you learn actively instead of passively reading. I do remember FA makes it harder to do this as physical findings are on the page with closure, etc. so it requires some discipline to not look at things .
D. My Philosophy on Mnemonics:
Step 2 CS requires a lot of repetition of the same questions without missing things. Some websites out there have a million mnemonics out there. I think the Past Medical History is where the mnemonics are the most helpful and the initial HPI is a good place to use the mnemonic your school taught you. Mine taught me OPQRSTAA but it’s very tailored to pain, as opposed to something like a cough, fever, heart failure, etc. I think FORDPAPP is the best for general complaints (see links below). Also, ROS is a good place to use mnemonics for the order of the systems only you need to ask. For the HPI #2 though, conceptually but you need to be actively thinking and give yourself the flexibility to change your line of questioning if a game changer emerges (you're working up a fever and they tell you they have HIV). Mnemonics make that harder.
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