Step 2 CS clarifications

[Bbon]

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Hi all,

Taking Step 2 CS in less than a week and recently started working through First Aid for Step 2 CS. Couple points that I thought merited clarification.

1) FA lists every conceivable diagnostic test for the chief complaint. I imagine you shouldn't actually list all of them on the real test and certainly not in clinical practice. Does anyone have any insight into whether you should err on the side of being conservative or just order the full gamut of tests? Examples: order a head CT on a patient with classic presentation of migraine or tension headache? Order a lumbar spine film or MRI on someone with obvious sciatica or lumbar strain and absolutely no red flag symptoms?

2) They mention not to list treatments, but I imagine scenarios where a treatment would be part of the initial work-up. For instance, for an older patient with headache, jaw pain, and blurred vision, I'd fear a malpractice lawsuit if I didn't give high dose prednisone. Am I really going to put temporal artery biopsy and just wait for the results from path? Or even something more minor, like a patient with classic GERD - who is really going to order a 24 hour pH probe instead of prescribing a PPI first?

Anyhow, I realize there's unlikely to be a step 2cs scorer on here, but I figure I'd hear what your thoughts are. Thanks for the input.

 

[tco]

Hope this isn't too late for you. I just started studying for my CS exam the other day (taking it Thursday). I'm a bit more familiar with the format now. Here's what I think:

Hi all,

Taking Step 2 CS in less than a week and recently started working through First Aid for Step 2 CS. Couple points that I thought merited clarification.

1) FA lists every conceivable diagnostic test for the chief complaint. I imagine you shouldn't actually list all of them on the real test and certainly not in clinical practice. Does anyone have any insight into whether you should err on the side of being conservative or just order the full gamut of tests? Examples: order a head CT on a patient with classic presentation of migraine or tension headache? Order a lumbar spine film or MRI on someone with obvious sciatica or lumbar strain and absolutely no red flag symptoms?

FA is ridiculous. They have me wondering 1. Will I be able to get the SP to answer all of my questions during the allotted 15 minutes? 2. Did I learn anything about taking the history and physical exam? I say you use FA as a review and a loose guide and do your own thing. I think as long as you hit the correct diagnosis and a few DDx that are relatively close with an acceptable workup, you're okay.

2) They mention not to list treatments, but I imagine scenarios where a treatment would be part of the initial work-up. For instance, for an older patient with headache, jaw pain, and blurred vision, I'd fear a malpractice lawsuit if I didn't give high dose prednisone. Am I really going to put temporal artery biopsy and just wait for the results from path? Or even something more minor, like a patient with classic GERD - who is really going to order a 24 hour pH probe instead of prescribing a PPI first?

Anyhow, I realize there's unlikely to be a step 2cs scorer on here, but I figure I'd hear what your thoughts are. Thanks for the input.

Yep, no treatments should be listed. You have someone that clearly has temporal arteritis, you list ESR, temporal artery biopsy, CBC with differential, electrolytes, CT head (if you want to rule out malignancy...Blah, first aid...) Make no note about prednisone. Same with the guy with GERD, no PPI.


I have a question about formatting. I used a case in First Aid and typed it out on the Patient Note form on the NBME website. Here's what works best for me...My question: is this acceptable? I'm asking because I obviously did not make new lines for new sections...

HPI:74 year old male presents after a fall in the garden onto outstretched right hand three days ago. Now has constant right middle and upper arm pain that is nonrelenting and severe. Not moving the arm and tylenol have improved the pain; movement worsens the pain. He denies additional symptoms of numbness or weakness. PMH: Asthma PSH: Prostatectomy without cancer detected via path. Allergies: Aspirin Medications: Albuterol inhaler, tylenol. FH: non-contributory SH: Denies tobacco use, alcohol use, illicit drugs. Lives at home with son and three grandchildren. Feels safe. Retired schoolteacher.