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Step 2 CS Concern

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PickleRick19

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I don't want this to turn into another Step 2 CS freak-out post (I took it a few weeks ago), but I have a general question about Step 2 CS. I'm NOT posting anything specific about it as I don't want to violate any rules.

My question: are we or are we not supposed to do a physical exam on patients in street clothes? I was confused about this from the Step 2 CS orientation video. I was under the impression that patients in street clothes didn't require a physical exam (especially if you can't really do an exam for what they are there for), so I didn't do it in one instance (like at all, and wrote nothing in the physical exam section). And by extension since I didn't do a physical i didn't wash hands for it. I feel kinda stupid for doing this now, and am worried it would affect the overall outcome of my test in a big way.

I'm already kinda worried that I may have failed CS on the ICE part given the countless mistakes I made (straight up wrong diagnosis on 3 cases, bad differentials that I shouldn't have put for a few other cases, vague closure on at least 4-5 cases because I wasn't exactly sure what they had or what to do, didn't ask a lot of questions that I should have for a few cases, not sure if I made enough eye contact on some cases near the end because I was writing or just so tired, forgot to write some physical exams I did in the note, used layman terms in the note sometimes instead of medical jargon, did incomplete exams on all patients due to time constraints, etc).

I know no one can say for sure if I passed, but it would somewhat ease my anxiety during this extremely long waiting period knowing that the whole "no physical if in street clothes" thing is legit or not.
 

MSTP18

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I honestly don't remember CS rules exactly, but my school does its own mini CS that was way harder than the real one and we also had the "street clothes = no exam" rule. I highly doubt they would have that rule if it wasn't the same for CS.
 
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Crayola227

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my understanding is that not washing your hands for a station = autofail of the station

it just sounds like you didn't do even the most basic of CS Prep

all you have to do is get FA for Step 2 CS and read for like 15 minutes to avoid most of the reasons to autofail

it won't mean you pass for sure but it's a great way not to fail for dumb reasons

for example you would know that you should ALWAYS do some sort of exam related to the CC
 
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Crayola227

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it's not that hard to avoid the autofails

the problem is that people worry too much about how good their ddxs are when that's not the point of CS, that's what intern yr is for

CS is more about seeing that you have the basic approach to any patient even in your ignorance down, like handwashing, basic PE skills, and certain things to ask in your history and include in your notes

for example you don't want to leave any sections blank is more important than how good each section is, skipping a section = autofail

skipping PE = autofail

skipping writing something in subj, PE, and ddx = autofail

the part where knowledge counts is that certain complaints should trigger certain questions in your history, certain PE manuevers, and certain ddx inclusions - under ddx it's more about being able to generate a reasonable number of them, and most importantly not forgetting certain ones, for example with teenage athlete that has syncope it's not so much that you are sure to include eating disorder vs dehydration vs any number of things, or one over the next, but that you don't leave off HCM

you don't have to include every cause of CP for a CP cc, but you do need to do a CP exam, ask about SOB, and include a life threatening dx like MI on your ddx
 
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Crayola227

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with Step 2 CS there is more to it than avoiding autofails, since people do manage to fail it despite not triggering autofails

that said, plenty of failures are due to things like not washing hands, not writing anything in all sections of the note, not asking permission to touch the patient, etc etc

so therefore the first and easiest and highest yield approach is initially to avoid all autofails

what's the point of obsessing over how good your ddx is when you fail half the stations not washing your hands or doing any PE at all?
 
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Crayola227

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possibly the idea is that for some patients in street clothes you should be dissuaded from some PE manuvers given the time constraints of the exam, and that's a legit thing to consider in your CS Exam approach, but that it means a blanket rule that you don't do a PE and that you don't record anything for PE is WRONG

you should learn too that any patient that you lay eyes on you have some PE data you can record
 
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Crayola227

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well shyte son guess it's been too long since I did it and I read the FA CS

everyone says how you don't need it or any CS prep, but I didn't see any reason not to buy it used on Amazon for like $20. I didn't really end up reading it beyond what it said were the highest yield things to do and how to avoid the autofails

plus for the most common CCs you'll see it has a list of ddxs that you can review and will already know, plus the like 1 or 2 points for each type of case that would be an autofail

I still don't understand how people fail to wash their hands knowing that it's an autofail

the test is really a big exercise in not failing over doing a great job

I know they made the damn thing harder since my time, which only serves in my mind as more reason to just use a surefire method to avoid surefire ways of failing
 
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Crayola227

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I walked about feeling like what the actual **** like everyone else, except that I heeded the advice that it was more important to follow strict guidelines on what to do/not to do than anything else
 
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PickleRick19

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my understanding is that not washing your hands for a station = autofail of the station

it just sounds like you didn't do even the most basic of CS Prep

all you have to do is get FA for Step 2 CS and read for like 15 minutes to avoid most of the reasons to autofail

it won't mean you pass for sure but it's a great way not to fail for dumb reasons

for example you would know that you should ALWAYS do some sort of exam related to the CC

For the record, I did review FA and went through the whole book once so it wasn't a preparation thing. I only did what I said for one patient and did the usual gloves, physical, etc for all others.

I walked about feeling like what the actual **** like everyone else, except that I heeded the advice that it was more important to follow strict guidelines on what to do/not to do than anything else

I definitely followed the common advice and whatever the strict guidelines were for all other cases. The confusion is from the Step 2 CS video at the beginning of the exam (it's posted on the USMLE website too). I don't know if it's new in the past few years but I'm 99% sure the video said that some patients may appear in street clothes and be there to discuss something like management or another concern and a physical would not be necessary and that part of the note would be blank. I took it to mean "street clothes = no physical required" and it seems like so did many others, so that's what I did during the exam. It would seem that some schools teach that for their mock Step 2 CS too.

I just took it as well, didn't have any patients in street clothes but 99.9% sure it said NOT to do an exam if the patient is in street clothes (or if it's a phone encounter, obviously) and just put nothing in the PE section of the note.

Our proctors said in the orientation that we would not be able to do a complete history and physical on every patient, and the video said FOCUSED history and physical like 4 times, so I don't think not having done a complete exam on everybody is a big deal. Like if you had a patient with a non-HEENT complaint, it's fine to not do a HEENT exam (at least that's what I'm hoping...lol).

If it's any consolation, I am equally freaking out and running over things I did wrong over and over again in my head. SDN is full of threads with people doing the same thing, and then they come back and say they passed. >95% of US MD students pass...so the question is do you think your performance was in the bottom 5% of all med students? I'm guessing not. I guess the best we can do at this point is try not to think about it lol.

Okay I'm glad to hear I'm not the only one who got that impression lol. I definitely thought it was weird because I never heard that before but it made sense given the situation. Plus, can't really do even a basic heart and lungs exam since the patient can't lower their shirt enough for you to listen against skin.

It does make me feel better that I'm not the only one who feels bleh after this "test". I definitely don't think my performance was bottom 5% but who knows what I missed exactly. I kinda set myself up for this anxiety because I made the mistake of reading the CS failure posts before my exam and now I'm comparing my mistakes. That was pretty dumb of me. Hopefully the fact that we're hyper aware of our mistakes means we actually did fine. The wait is just the worst part.
 
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Crayola227

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Fair enough. All I got from SDN is it's a shytty test and you have to just do what you did to prepare and just ignore the horror stories.

I felt confident I had done all the "you're supposed to" things like washing hands, showing empathy, etc, and was more unsure if my notes came off right or said all the right things, but that's just how it is and all you can do. Which is fine 95% of the time. So you have to make peace that all you can do is try to avoid failure while having no idea of what was "right" or success, which is what makes this test different than all the others and so rotten feeling.
 

PickleRick19

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Fair enough. All I got from SDN is it's a shytty test and you have to just do what you did to prepare and just ignore the horror stories.

I felt confident I had done all the "you're supposed to" things like washing hands, showing empathy, etc, and was more unsure if my notes came off right or said all the right things, but that's just how it is and all you can do. Which is fine 95% of the time. So you have to make peace that all you can do is try to avoid failure while having no idea of what was "right" or success, which is what makes this test different than all the others and so rotten feeling.

Yeah it's a crappy test. I feel like it doesn't really reflect real life, no one can do a full workup and know exactly what to do in 15-25 minutes time and with no labs to look at. I know I made mistakes on every patient (as does everyone) but it wasn't consistent across the board so hopefully my performance is good enough to fall in that 95%.

Yeah, my school gives us literally dozens of practice OSCE cases that are supposed to closely mimic the CS format throughout M1-M3 - I always did fine and I'm STILL crapping my pants haha. I listened to hearts through the gown for every single patient lol, didn't do some PE stuff I for sure should have done in a few cases, had some cases where I had extra time and could have easily like looked in their mouth or felt their thyroid real quick just for thoroughness, felt super awkward/disorganized in a few of my closures, got some really weird/difficult challenge questions I feel like I fumbled, etc. But I have yet to talk to a single med student that was like "that went great!" after finishing and somehow most of us pass lol. The wait is awful - October, seriously?? - but I'm doing my best to just focus on my rotations and residency applications and put it out of my mind until then.

I felt like my school prepared us pretty well and I always did well on OSCEs, and yet this somehow still felt different (more vague). And oh I for sure did all of those things you said. I was so flustered because I didn't sleep well the night before. I did pieces and parts of different physicals, didn't do or ask a lot of things that I should have for some cases, accidentally interrupted sometimes or they had trouble hearing me, eye contact was iffy at times because I write a lot, never did a thorough PE for any given organ system due to time, forgot things in my notes, put the wrong/unlikely differentials for a few. Many of my closures were awkward and I couldn't even give them a concrete differential/plan because I needed more time to think about it. I don't get why it takes so long to grade. I'm pretty sure the patients grade you after you leave the room (they can't remember everything everyone did to them at the end of a day, and I don't think the video recordings are used for anything besides quality control), so really the note grading is what we're waiting on.

All we can do now is just wait and make sure we put all our energy into applying for residency and not give this exam any more of our head-space than it deserves (which is none). It'll be so nice once it's all behind us.
 
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PickleRick19

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Definitely realizing a lot more things I did wrong on the ICE part as the days go on and I study for CK: completely wrong and zebra-like primary (and probably 2nd/3rd) diagnoses on 2 cases because I literally had no clue, uncertain but justified primary diagnosis on 1 or 2 other cases, 4 other cases IN ADDITION to all of those that I thought went well but the 2nd and/or 3rd diagnoses were pretty unlikely (or poor/wrong justification) that I probably just shouldn't have put to begin with. Probably doesn't constitute an auto-fail in ICE in those cases and just points off. But that's like 7-8 cases, and FA makes the whole "likely diagnosis" thing seem big for ICE. Praying I didn't sink myself for the ICE component because of differentials. Kicking myself but thought I'd post for any others perusing these types of threads who are looking for some sort of comparison or relief. If anyone can comment, would be great. Will definitely update with my results once the time comes.
 
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pv12

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I am in the same boat. I think i forgot to wash I my hands on one of my cases, I have weird documentation notes because of the word limit, my diagnosis were way off.. list goes on and on
I am really nervous and scores come out October 10th.. -____-
 
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PickleRick19

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I am in the same boat. I think i forgot to wash I my hands on one of my cases, I have weird documentation notes because of the word limit, my diagnosis were way off.. list goes on and on
I am really nervous and scores come out October 10th.. -____-

I think you're okay on the hand-washing, people have passed and forgot to do it on multiple patients. For me, the biggest things are crappy closures on half of the cases, crappy primary/secondary differentials on half the cases, unsure of my eye contact because of so much writing, plus the huge list of other stuff I mentioned. Hopefully the two they drop happen to be my bad cases.

It's gonna be a fun wait :unsure: but somehow it's comforting knowing I'm not the only one who thought it was rough
 

Redpancreas

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my understanding is that not washing your hands for a station = autofail of the station

it just sounds like you didn't do even the most basic of CS Prep

all you have to do is get FA for Step 2 CS and read for like 15 minutes to avoid most of the reasons to autofail

Nobody knows how its scored but probably not true
 
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pv12

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I think you're okay on the hand-washing, people have passed and forgot to do it on multiple patients. For me, the biggest things are crappy closures on half of the cases, crappy primary/secondary differentials on half the cases, unsure of my eye contact because of so much writing, plus the huge list of other stuff I mentioned. Hopefully the two they drop happen to be my bad cases.

It's gonna be a fun wait :unsure: but somehow it's comforting knowing I'm not the only one who thought it was rough




yes yes.. long 2 months wait but I guess we will be waiting together.:)
 
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W19

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At least you guys have time to retake the damn thing (If you fail). I know at least two people in my class who matched with no CS--one IM and the other EM.
 
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PickleRick19

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At least you guys have time to retake the damn thing (If you fail). I know at least two people in my class who matched with no CS--one IM and the other EM.

That's true. Hopefully it doesn't come to that though because I feel like many (if not all) of the FM programs I'm applying to have a "pass step 2 cs on the first attempt" requirement. Not sure if it's a hard requirement or not but at the very least would affect ranking despite my otherwise solid application.
 
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W19

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That's true. Hopefully it doesn't come to that though because I feel like many (if not all) of the FM programs I'm applying to have a "pass step 2 cs on the first attempt" requirement. Not sure if it's a hard requirement or not but at the very least would affect ranking despite my otherwise solid application.
I would be surprised if a FM program passes on a good applicant because of a CS retake.
 
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ryanr

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You DO NOT do a physical exam on patients at Step 2 CS who are in street clothes
Source - Step 2 CS orientation video

Also if you read the door sign completely, you will notice "physical exam" is omitted from the list of things required of that encounter
 
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Crayola227

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I'll admit I was wrong on that exception. It's been a while. The point is really that it's made quite clear certain fairly clear cut rules for success on CS, which is a good place to start.
 
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I will also confirm from personal experience that it is possible to pass CS (without any borderline subscores) even after forgetting to wash hands 2-3 times.
 
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PickleRick19

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I will also confirm from personal experience that it is possible to pass CS (without any borderline subscores) even after forgetting to wash hands 2-3 times.

Any anecdotal stories on whether 2-3 completely wrong primary diagnoses and 3 cases with iffy/bad 2nd/3rd diagnoses can result in a pass? Asking for a friend lol.
 

PickleRick19

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Hey guys, so I ran into one of our clinical skills teachers today who grades OSCEs, individually tutors students struggling with OSCEs/clinical skills, and is an all around wonderful doctor/person. I mentioned I was freaking out about CS and he gave me some great advice I wanted to share - hopefully it will be as helpful to you guys as it was to me.

1) If you are aware/knowledgeable enough that you can think of multiple things that you could have done better, you probably have good enough clinical skills to pass this exam. And honestly, if you look at some of the posts on this forum...the people who panicked afterward and posted lists of 20+ things they did wrong usually come back and say they passed, and the people who are asking what to do after they failed say stuff like "I don't know how this happened," "I don't know what I can improve for next time," "I'm so surprised/shocked," etc. So that seems to follow the pattern.
2) You do not have to do everything perfectly to pass this exam. We are medical students, not residents or attendings who are expected to be able to handle things relatively independently and do everything exactly right. There is plenty of wiggle room for errors, missed diagnoses, forgetting stuff, etc.

Also, I talked to a classmate of mine who took it earlier and recently found out they passed...they straight up forgot to do the physical exam on one patient lol. Like took the history, counseled/closed, and walked out of the room. And they said they still scored really well on the ICE component, not even close to failing.

So, I hope that gives you guys some reassurance. Good luck with the loooooong wait til October haha.

This does make me feel a bit better. I'm pretty sure I've run through all of the things I did wrong and diagnoses I missed a million times in the past few weeks lol, hopefully that's actually a good sign.
 
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PickleRick19

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Wanted to stay true to my word and update this thread for all future CS takers. You know, all those who are biting their nails and $***ing their pants after taking the exam. Now, despite all my mistakes listed above, I PASSED.

There's another thread out there (think it's titled "feeling after cs") where I listed out all my mistakes for someone. And there were A LOT (and more I didn't list). No joke, I straight up told 2 patients they probably had cancer. Another told me something I didn't know how to react to, so me being me I just awkwardly laughed and said "okay" like a *****. Another standardized patient was really attractive and I was tongue tied every time I tried to say something coherent to her. None of it mattered, and none of my x's were anywhere close to the borderline.

To all those reading who are lurking the web for CS experiences like a crazy person, just to validate their anxiety: you will most likely be okay. I did the same thing for a few weeks after the exam, and I've never been type A or worried about an exam in my life. It's just another cash grab made by people who have probably never had to take their own useless, expensive acting exam. That being said, no amount of people telling you "you're fine", "most people pass", etc will make you feel better or make you stop worrying. But I'm here to say, spend your time on the things that matter. Go for a run, eat a full pack of oreos, work on your ERAS app, kill your interviews, have fun with friends/family/boyfriends/girlfriends/imaginary friends. Literally do anything else. But know you're not alone in your worry and you'll most likely be okay (like 95-98% chance. Because that's how many people pass).
 
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DrKoala27

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Wanted to stay true to my word and update this thread for all future CS takers. You know, all those who are biting their nails and $***ing their pants after taking the exam. Now, despite all my mistakes listed above, I PASSED.

There's another thread out there (think it's titled "feeling after cs") where I listed out all my mistakes for someone. And there were A LOT (and more I didn't list). No joke, I straight up told 2 patients they probably had cancer. Another told me something I didn't know how to react to, so me being me I just awkwardly laughed and said "okay" like a *****. Another standardized patient was really attractive and I was tongue tied every time I tried to say something coherent to her. None of it mattered, and none of my x's were anywhere close to the borderline.

To all those reading who are lurking the web for CS experiences like a crazy person, just to validate their anxiety: you will most likely be okay. I did the same thing for a few weeks after the exam, and I've never been type A or worried about an exam in my life. It's just another cash grab made by people who have probably never had to take their own useless, expensive acting exam. That being said, no amount of people telling you "you're fine", "most people pass", etc will make you feel better or make you stop worrying. But I'm here to say, spend your time on the things that matter. Go for a run, eat a full pack of oreos, work on your ERAS app, kill your interviews, have fun with friends/family/boyfriends/girlfriends/imaginary friends. Literally do anything else. But know you're not alone in your worry and you'll most likely be okay (like 95-98% chance. Because that's how many people pass).


Hey! I recently took my step 2 CS, and I think my first patient was in street clothes, but I did an exam on them anyways because I totally spaced. Is this terrible?? Also I did not counsel any patients on lifestyle (smoking, alcohol etc) -did you do much of this?
 

PickleRick19

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Hey! I recently took my step 2 CS, and I think my first patient was in street clothes, but I did an exam on them anyways because I totally spaced. Is this terrible?? Also I did not counsel any patients on lifestyle (smoking, alcohol etc) -did you do much of this?

I don't think it's a big deal if you do a physical on someone in street clothes, especially if it's just one patient. I'm still not entirely sure about that rule though. My friend did a physical on someone in street clothes and he passed. Also, I probably only counseled 6-7 of my patients on diet, smoking, alcohol, etc. Sometimes they just don't have anything to counsel. If that's the only thing you didn't do I'd think you're probably fine. Hang in there!
 

NYCdude

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Wanted to stay true to my word and update this thread for all future CS takers. You know, all those who are biting their nails and $***ing their pants after taking the exam. Now, despite all my mistakes listed above, I PASSED.

There's another thread out there (think it's titled "feeling after cs") where I listed out all my mistakes for someone. And there were A LOT (and more I didn't list). No joke, I straight up told 2 patients they probably had cancer. Another told me something I didn't know how to react to, so me being me I just awkwardly laughed and said "okay" like a *****. Another standardized patient was really attractive and I was tongue tied every time I tried to say something coherent to her. None of it mattered, and none of my x's were anywhere close to the borderline.

To all those reading who are lurking the web for CS experiences like a crazy person, just to validate their anxiety: you will most likely be okay. I did the same thing for a few weeks after the exam, and I've never been type A or worried about an exam in my life. It's just another cash grab made by people who have probably never had to take their own useless, expensive acting exam. That being said, no amount of people telling you "you're fine", "most people pass", etc will make you feel better or make you stop worrying. But I'm here to say, spend your time on the things that matter. Go for a run, eat a full pack of oreos, work on your ERAS app, kill your interviews, have fun with friends/family/boyfriends/girlfriends/imaginary friends. Literally do anything else. But know you're not alone in your worry and you'll most likely be okay (like 95-98% chance. Because that's how many people pass).
Hey, what was your prep like? I have about 8 days to study for this thing. I was hoping to get through a one time pass of First Aid in that time. Do you think that's adequate?
 
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PickleRick19

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Hey, what was your prep like? I have about 8 days to study for this thing. I was hoping to get through a one time pass of First Aid in that time. Do you think that's adequate?

Yeah that should be more than adequate, especially if you've done well on school OSCEs. I used about 5-6 days and went through first aid once (some cases more than once if I was uncomfortable), but regrettably wasted half the days on the mini cases in first aid. Some people like them but I personally think they're useless, so many stupid/uncommon/off-the-wall differentials. I would try to go through as many of the full-length cases as possible and get those down. If you have someone to practice some of the full-length cases with, that would be good too. Also, practice typing a few notes on the CS website until you've got the timing where you want it, and it'll help make you more comfortable for the exam. The section in the beginning with challenge questions and answers is also pretty helpful. Good luck!
 

NYCdude

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Yeah that should be more than adequate, especially if you've done well on school OSCEs. I used about 5-6 days and went through first aid once (some cases more than once if I was uncomfortable), but regrettably wasted half the days on the mini cases in first aid. Some people like them but I personally think they're useless, so many stupid/uncommon/off-the-wall differentials. I would try to go through as many of the full-length cases as possible and get those down. If you have someone to practice some of the full-length cases with, that would be good too. Also, practice typing a few notes on the CS website until you've got the timing where you want it, and it'll help make you more comfortable for the exam. The section in the beginning with challenge questions and answers is also pretty helpful. Good luck!
Thanks man!
 
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Nf50

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I don't want this to turn into another Step 2 CS freak-out post (I took it a few weeks ago), but I have a general question about Step 2 CS. I'm NOT posting anything specific about it as I don't want to violate any rules.

My question: are we or are we not supposed to do a physical exam on patients in street clothes? I was confused about this from the Step 2 CS orientation video. I was under the impression that patients in street clothes didn't require a physical exam (especially if you can't really do an exam for what they are there for), so I didn't do it in one instance (like at all, and wrote nothing in the physical exam section). And by extension since I didn't do a physical i didn't wash hands for it. I feel kinda stupid for doing this now, and am worried it would affect the overall outcome of my test in a big way.

I'm already kinda worried that I may have failed CS on the ICE part given the countless mistakes I made (straight up wrong diagnosis on 3 cases, bad differentials that I shouldn't have put for a few other cases, vague closure on at least 4-5 cases because I wasn't exactly sure what they had or what to do, didn't ask a lot of questions that I should have for a few cases, not sure if I made enough eye contact on some cases near the end because I was writing or just so tired, forgot to write some physical exams I did in the note, used layman terms in the note sometimes instead of medical jargon, did incomplete exams on all patients due to time constraints, etc).

I know no one can say for sure if I passed, but it would somewhat ease my anxiety during this extremely long waiting period knowing that the whole "no physical if in street clothes" thing is legit or not.
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