Step 2 CS Grading Questions

[Got Em]

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Had a few questions if anyone can answer:

1) Medications - if a patient gives you a list of 6-7 meds, do you only have to list the names or are the strength, dosing, route required as well?

2) Ordering tests - are you counted off if you take a shot gun approach? For example, if a scenario is pretty classic for lumbar strain, but I order x-ray and MRI, would I get points taken off or will it not matter?

3) Washing hands - we have been told to wash hands before shaking hands with the patient and this is what I've been doing. However, every resource I've gone over have stated to wash hands right before the physical exam. Does this matter?

4) Draping - FA CS states to drape the patient to cover legs and to only remove as little draping as possible when doing examinations. I'm very confused. Does this mean that the patient is already draped and has gown that only covers the upper body? Wouldn't it waste time if we have to wait for patients to change? For our exams, we have always just examined patients with their shirts on. Somebody please explain this to me.

 

[cbrons]

2) Ordering tests - are you counted off if you take a shot gun approach? For example, if a scenario is pretty classic for lumbar strain, but I order x-ray and MRI, would I get points taken off or will it not matter?

I had the same question about this one. On our school's practice OSCE, I didn't order any imaging at all since the history and PE findings did not suggest any serious underlying systemic illness and the patient's story was essentially one about bending sideways while doing something mechanical under a car and had only been going on for 8 hours.

From my understanding most patients complaining of low back pain should not get any imaging unless you have a solid reason.

 

[lymphocyte]

Had a few questions if anyone can answer:

1) Medications - if a patient gives you a list of 6-7 meds, do you only have to list the names or are the strength, dosing, route required as well?

2) Ordering tests - are you counted off if you take a shot gun approach? For example, if a scenario is pretty classic for lumbar strain, but I order x-ray and MRI, would I get points taken off or will it not matter?

3) Washing hands - we have been told to wash hands before shaking hands with the patient and this is what I've been doing. However, every resource I've gone over have stated to wash hands right before the physical exam. Does this matter?

4) Draping - FA CS states to drape the patient to cover legs and to only remove as little draping as possible when doing examinations. I'm very confused. Does this mean that the patient is already draped and has gown that only covers the upper body? Wouldn't it waste time if we have to wait for patients to change? For our exams, we have always just examined patients with their shirts on. Somebody please explain this to me.

1. You're not going to get 6-7 medications. You'll get none to a few very common ones. Don't worry about doses.

2. You lose points if you shotgun. Check out the Step 2CS manual which specifically addresses this point (using the example of back pain!) Just do what a reasonable and safe doctor would do. And no doctor should be ordering an MRI (or even a XR) for clear-cut lumbosacral strain without red flags. *This is where FA is incredibly misleading.* They sometimes suggest some pretty crazy tests that no one would perform on an initial encounter. You have to use your judgement.

3. Do it before the physical. It's a nice transition. They also have hand sanitizer.

4. This is a question that seems to keep coming up and provoke unnecessary anxiety.

Watch the Step 2CS orientation video to get a sense of what the patients will look like. Most of them will already be in a gown and wearing a drape. The goal is to provide modesty and courtesy. When you need to pull up the gown to exam the abdomen, for example, make sure the drape covers their pelvis. It's honestly pretty intuitive.

Also, I suggest having a practised strategy for listening to the MV and TV in women. I said something like, "I need to listen to your heart under your left breast. Is that okay? Okay, I'm going to pull up your gown. Could you kindly hold up your breast for me? Okay, now I'm just going to feel for your heart beat (for PMI)." etc.

As a general strategy, I recommend talking through your physical; explain what you're doing in simple terms. This gets you points in multiple domains (information sharing, SEP etc.).