Step 2 CS: heavily weighted towards ROS

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medblazer21

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After pondering my failure on this test, I bought Blueprints Step 2 CS, and looked at their case scenarios, and now I understand why I failed (I failed the ICE portion, which is split into data gathering and patient note; data gathering is further split into history taking and physical exam).

I asked all of the PAMHUGSFOSS stuff with no problems. I did all the basic physical exam stuff that they have listed too. On CS, it doesnt split up the score between PE and History, but from looking at First Aid and Blueprints, its clear that I failed the history portion and not the physical exam part.

But the way CS is scored, you dont get points for asking that stuff UNLESS ITS SPECIFICALLY RELEVANT TO THE CASE. So if a pt comes in with cough, and you ask about PMH and they say they had an appendectomy 10 years ago, then it doesnt count for anything and its not on their checklist. If however, you ask about PMH and they say they had lung cancer then you do get points.

I know that seems obvious to you guys, but it totally skews the scoring system over to complaint-specific ROS, and I believe thats what determines whether you pass or fail that case. Since they arent giving you automatic points for all the PAMHUGSFOSS stuff unless its particularly relevant, that means your score on the data gathering is very heavily weighted towards specific ROS questions.

Looking at the blueprints guide, I messed up in a major way with my questions about provocative/palliative factors. In all my cases, I just threw out the broad/vague "does anything make it better or worse?" I think that the SPs wont give you credit for that, you have to ask SPECIFIC THINGS. For example, suppose a pt comes in with dizziness. You have to ask them specifically whether its made worse by standing up, or by reaching overhead, or by turning their head, etc. They wont give you credit if you just ask what makes it better or worse.

Another example in blueprints was a lady with chronic abd pain and diarrhea. One of the suggested questions was "do you consume large amounts of diet soda or sorbitol." I never woulda thought to ask that in a million years. I dont think a general question about diet woulda got you those points either.

Also, on the PMH part I'm wondering how specific you have to be. In Blueprints, for a guy with chest pain they want you to ask SPECIFICALLY if the pt has a history of DM or HTN, not just a vague "do you have any other medical problems" question.

Next time I'm going to use PAMHUGSFOSS, LIQORAAA, and TOADDES as a base of questioning, but I'm also going to memorize the specific ROS questions associated with each complaint.

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I never ran into a problem with something that needed an extremely specific ROS. If it is a lung case you ask about cough, sputum production, bloody cough, SOB, DOE, etc. But those are still pretty basic questions. After that just make sure you hit on all systems in a ROS: any change in vision/hearing, any difficulty swallowing/pain with swallowing, any palpatations, CP, dizziness, abdominal pain, GI complaints, urinary changes, muscle aches or weakness, joint pains/redness/swelling, skin changes/rash, paresthesias, headaches. Expect all negatives except for the system with a represented lesion. ROS usually takes 1-2 minutes with these fake patients because they just say "no" to everything. In the real world you would get 10 yes/maybes with stories about each one ("10 years ago I got the flu and had horrible abdominal pains.", "14 years ago I fell off a ladder and my shoulder really hurt.", "4 years ago I got a rash after mowing the lawn and getting into poison ivy.").
 
I never ran into a problem with something that needed an extremely specific ROS. If it is a lung case you ask about cough, sputum production, bloody cough, SOB, DOE, etc.

Well its not "extremely specific" but I asked all those questions you cited and still failed. What I DIDNT ask was stuff about PPD, TB exposure, etc and that was a major reason I failed.
 
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