Step 2 CS - Third Attempt

[superoxide]

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Hi there,

I am preparing for my third attempt at CS. The first time I failed the CIS section, the second time I failed the ICE section. I passed the SEP section both times.

I have some questions after going through the First Aid cases. Some might seem rather simple/stupid, but I really can't afford to fail this test a third time.

Please help if you can. Thanks

1) Can we shake the patient's hand without washing them? I mean when you enter the room and introduce yourself, do you shake their hands and say "Hello, I am Dr. Superoxide. Nice to meet you". Do you lose a check mark if you don't shake hands? Can I just introduce myself without touching the patient and wash my hands before I start the physical? That's what I did both times.

2) When you wash your hands, do you have to use soap? For both my previous attempts I just washed hands with water.

3) When asked about sexual activity, if the SP replies "with husband/wife only" do you ask about Hx of STDs, HIV test, contraception etc. If the case is something related to STDs (lets say woman comes in with vaginal discharge, then I know I would ask those deeper questions), but what about a case which has nothing to do with STDs? I also noticed in FA that when the SP is not married (has a girlfriend/boyfriend) they almost always ask about hx of STDs, protection etc etc.

4) While going through the different cases, I really couldn't see a pattern as far as CAGE questioning is indicated. There were some cases where the reply was "just a few beers a week" and CAGE was asked, but in other cases the SP probably had the same amount, but CAGE was not asked.

5) Do you counsel as you go, or you counsel right at the very end. What I mean is while I am getting the Hx and if I ask about smoking, and the SP is a heavy smoker, do I counsel to stop smoking right then, or do I make a note to remind myself to counsel her about quitting smoking at the end of the encounter. I always counseled along the way, because I was afraid I'd forget to do it at the end.

6) Lab testing - Do you get points taken off if you list more tests than are necessary? I always put "CBC/electrolytes" or "CT/MRI", even if I wasn't sure electrolytes or MRI were indicated. My theory was that it is better to be safe and put more. Do you lose points for unnecessary tests? I'm not going to order totally unnecessary tests like ordering an head CT for someone with abd pain, but what about always putting "CT/MRI" or "CBC/electrolytes"?

7) Patient note - I always typed my notes, because my writing is terrible. Is it OK to put everything in one line, or separate lines for each catergory. For example:

Allergies: NKDA, Meds: Aspirin, PMH: Hypertension, PSH: none

OR

Allergies: NKDA
Meds: Aspirin
PMH: Hypertension
PSH: none

I always wrote my patient notes all in one line. According to the score report, my patient notes was "borderline". Do you think it makes a difference?

8) In case # 4 in First Aid, the Patient Note example has "WNL" written in the PE section. I was always told never to write WNL and instead write the whole think out. I always wrote it all out (example: "no exudates, no erythema or discharge etc etc")

9) While doing the physical, do I have to explain what I am doing? While I am listening to the heart, do I have to say out loud "OK, Mr. D. I am going to listen to your heart for any irregular heart beats or murmurs"? or "I am now inspecting your joints for ROM, any redness, swelling or pain" etc etc? I didn't do that previously. Do you think that hurt me? For both my attempts my data gathering section (which includes the physical was weak) I think not explaining what I was doing hurt my score.

10) If the SP mentions a disease/condition when I ask her about PMH which is unrelated to the CC, do I have to dig deeper? Lets say someone comes in with joint pain, but when I ask about the PMH, the SP says she has diabetes, do I ask about blood sugar readings, last HbA1c, diet?

11) Is it OK to touch the patient to show empathy or is that getting "too close"? Is it OK to touch the patient on the shoulder when saying "I'm really sorry about your condition, but I am here to help you etc etc"? I showed empathy and support, but never touched the patient. Does it matter?

12) To rule out depression, do you have to go through the whole SIG EM CAPS? What if after two or three questions (lets say I ask the SP the SIG questions) and they are all negative, should I skip the EM CAPS? or do I have to ask every single one? Same thing if the SP answers positive to the SIG questions, do i continue to ask the rest, or can I say that the SP has depression because he answered positively to the SIG questions?

13) Do I have to ask *all* women about OB/Gyn hx? Age of menarche, LMP, Last pap smear, Hx of abnormal pap smear, pregnancy hx etc etc. If the CC is something related to OB/Gyn, then yes, but what about some woman who comes in with ,lets say, chest pain? I asked Ob/Gyn hx for *all* women SPs. Is that a waste of time?

14) Finally, is it OK to stand outside the room for 30-45 seconds once the encounter starts so that I can come up with a differential before I enter the room? I never did that before and I think that hurt my history, because I didn't have a strong differential. Is the SP/staff going to think something is wrong??

Once again, I know some of these questions are fairly trivial, but I want to make sure that I am not doing anything wrong this time.

You can either reply here or PM me.

Thanks.

 

[Law2Doc]

Hi there,

I am preparing for my third attempt at CS. The first time I failed the CIS section, the second time I failed the ICE section. I passed the SEP section both times.

I have some questions after going through the First Aid cases. Some might seem rather simple/stupid, but I really can't afford to fail this test a third time.

Please help if you can. Thanks

1) Can we shake the patient's hand without washing them? I mean when you enter the room and introduce yourself, do you shake their hands and say "Hello, I am Dr. Superoxide. Nice to meet you". Do you lose a check mark if you don't shake hands? Can I just introduce yourself without touching the patient and wash my hands before I start the physical?

2) When you wash your hands, do you have to use soap? For both my previous attempts I just washed hands with water.

3) When asked about sexual activity, if the SP replies "with husband/wife only" do you ask about Hx of STDs, HIV test, contraception etc. If the case is something related to STDs (lets say woman comes in with vaginal discharge, then I know I would ask those deeper questions), but what about a case which has nothing to do with STDs?

4) While going through the different cases, I really couldn't see a pattern as far as CAGE questioning is indicated. There were some cases where the reply was "just a few beers a week" and CAGE was asked, but in other cases the SP probably had the same amount, but CAGE was not asked.

5) Do you counsel as you go, or you counsel right at the very end. What I mean is while I am getting the Hx and if I ask about smoking, and the SP is a heavy smoker, do I counsel to stop smoking right then, or do I make a note to remind myself to counsel her about quitting smoking at the end of the encounter. I always counseled along the way, because I was afraid I'd forget to do it at the end.

6) Lab testing - Do you get points taken off if you list more tests than are necessary? I always put "CBC/electrolytes" or "CT/MRI", even if I wasn't sure electrolytes or MRI were indicated. My theory was that it is better to be safe and put more. Do you lose points for unnecessary tests? I'm not going to order totally unnecessary tests like ordering an head CT for someone with abd pain, but what about always putting "CT/MRI" or "CBC/electrolytes"?

7) Patient note - I always typed my notes, because my writing is terrible. Is it OK to put everything in one line, or separate lines for each catergory. For example:

Allergies: NKDA, Meds: Aspirin, PMH: Hypertension, PSH: none

OR

Allergies: NKDA
Meds: Aspirin
PMH: Hypertension
PSH: none

I always wrote my patient notes all in one line. According to the score report, my patient notes was "borderline". Do you think it makes a difference?

8) In case # 4 in First Aid, the Patient Note example has "WNL" written in the PE section. I was always told never to write WNL and instead write the whole think out. I always wrote it all out (example: "no exudates, no erythema or discharge etc etc")

9) While doing the physical, do I have to explain what I am doing? While I am listening to the heart, do I have to say out loud "OK, Mr. D. I am going to listen to your heart for any irregular heart beats or murmurs"? or "I am now inspecting your joints for ROM, any redness, swelling or pain" etc etc? I didn't do that previously. Do you think that hurt me? For both my attempts my data gathering section (which includes the physical was weak) I think not explaining what I was doing hurt my score.

10) If the SP mentions a disease/condition when I ask her about PMH which is unrelated to the CC, do I have to dig deeper? Lets say someone comes in with joint pain, but when I ask about the PMH, the SP says she has diabetes, do I ask about blood sugar readings, last HbA1c, diet?

11) Is it OK to touch the patient to show empathy or is that getting "too close"? Is it OK to touch the patient on the shoulder when saying "I'm really sorry about your condition, but I am here to help you etc etc"? I showed empathy and support, but never touched the patient. Does it matter?

12) To rule out depression, do you have to go through the whole SIG EM CAPS? What if after two or three questions (lets say I ask the SP the SIG questions) and they are all negative, should I skip the EM CAPS? or do I have to ask every single one? Same thing if the SP answers positive to the SIG questions, do i continue to ask the rest, or can I say that the SP has depression because he answered positively to the SIG questions?
...
14) Finally, is it OK to stand outside the room for 30-45 seconds once the encounter starts so that I can come up with a differential before I enter the room? I never did that before and I think that hurt my history, because I didn't have a strong differential. Is the SP/staff going to think something is wrong??

Once again, I know some of these questions are fairly trivial, but I want to make sure that I am not doing anything wrong this time.

You can either reply here or PM me.

Thanks.

Here's my take:
1 - yes, shake hands right as you enter the room, no washing required yet.

2 - yes use soap. Always. Just as you hopefully do in real life. And dry them.

3 - Ask questions you deem important, just like real life. If your differential might include STDs, ask about it. If your differential might include the patient being pregnant, ask about contraceptive use. If the patient is monogomous and is presenting with sinus issues, don't worry about it. They aren't testing to see if you ask all questions -- they are testing to see if you ask the kinds of questions you would ask if you were working at a family health clinic.

4 - If someone says they drink a couple of drinks a week or more, than CAGE is fair game. I don't know that you are graded on CAGE, but for sure ask it of folks who might be alcoholics, and counsel them on considering quitting.

5 - I think counseling as you go is fine. eg. "Do you smoke? How much? Do you know smoking is bad for you? If you need help quitting there are options -- patches and gum -- you might be interested in. Ever tried those?"

6. They only expect 5 tests. Try to pick the 5 that you deem most useful in the scenario.

7. Break it up into categories. Look at the sample notes on the USMLE website and use that format.

8. They give you a list of common abbreviations and say that the graders are familiar with most of the other common ones. So use ones you are sure are common abbreviations, and write out ones you don't know if are common. WNL is probably fine.

9. Always say what you are doing. The SPs are the ones who grade you and they are actors told to give you points for doing X,Y and Z parts of the physical exam. It helps them give you points if you tell them you are examining for eg hepatosplenomegaly or CVA tenderness rather than have them wonder if that's what you were doing.

10. I'd say you always try to find out if the diabetes is under good control because out of control diabetes can result in a lot of symptoms/presentations. Again, it's just like real life.

11. You can touch the patient in a non-sexual way on an arm/shoulder if that's the way you normally are -- if you are a touchy feely person, that's fine. Do not try to force this or it comes off weird. If your normal inclination would be to say -- sorry to hear that -- do you need a tissue, then just do that.

12. SIG-E-CAPS is to rule in depression, not out. If patients have multiple factors then MDD is going to be high on your ddx. So if depression is likely, ask them all. If you don't really suspect depression, you can ask about eg sleep, interests, appetite, and if the answers are no, then move on.

13. The history should be targeted toward the chief complaint. I wouldn't bother asking a 70 year old woman complaining of headaches about her miscarriage history. But a 25 year old woman complaining of amenorhea is a different story.

14. Do whatever works for you. If you tend to forget things while in the room, then by all means make notes of things to explore. But bear in mind that you have to be flexible enough to go where the history takes you. TREAT THIS AS YOU WOULD A REAL PATIENT. If their sheet suggests they are here for hypertension, but they clearly want to talk about something else, then let them talk. If they seem to have a constellation of symptoms, explore them all. Don't handcuff yourself by your pre-interview notes. Treat it like a pleasant conversation with a patient you know nothing about. Ask lots of broad questions. Be inquisitive.

I think you are focusing a bit much on details, trying to "game" the encounter. Seriously you just need to treat it like you would in real life. Did you ever have a family medicine, community medicine or ED rotation where you went in and tried to get a quick history from a patient to present to an attending? This is exactly the same kind of encounter. Most med students will have done dozens of these. If you treat it the same as real life, you will be fine.

 

[superoxide]

Thanks Law2doc!

Anyone else, feel free to chime in!

 

[moosepatrol77]

Please help if you can. Thanks

1) Can we shake the patient's hand without washing them? I mean when you enter the room and introduce yourself, do you shake their hands and say "Hello, I am Dr. Superoxide. Nice to meet you". Do you lose a check mark if you don't shake hands? Can I just introduce myself without touching the patient and wash my hands before I start the physical? That's what I did both times.

Yes, I would shake hands without washing first to establish a rapport. Wash before you go to the physical or go with gloves.

2) When you wash your hands, do you have to use soap? For both my previous attempts I just washed hands with water.

I would go with just a light drop of soap. Make it look good, they're watching you the whole time.

3) When asked about sexual activity, if the SP replies "with husband/wife only" do you ask about Hx of STDs, HIV test, contraception etc. If the case is something related to STDs (lets say woman comes in with vaginal discharge, then I know I would ask those deeper questions), but what about a case which has nothing to do with STDs? I also noticed in FA that when the SP is not married (has a girlfriend/boyfriend) they almost always ask about hx of STDs, protection etc etc.

In a monogamous relationship, I wouldnt bother unless the history indicates abuse or female/pelvic issues.

4) While going through the different cases, I really couldn't see a pattern as far as CAGE questioning is indicated. There were some cases where the reply was "just a few beers a week" and CAGE was asked, but in other cases the SP probably had the same amount, but CAGE was not asked.

I never really had an etoh case to speak of, but I asked CAGE on people that had more than the standard drink/day. 1 beer or 1 glass wine

5) Do you counsel as you go, or you counsel right at the very end. What I mean is while I am getting the Hx and if I ask about smoking, and the SP is a heavy smoker, do I counsel to stop smoking right then, or do I make a note to remind myself to counsel her about quitting smoking at the end of the encounter. I always counseled along the way, because I was afraid I'd forget to do it at the end.

Up to you how you do it, as long as you do it. I usually liked to counsel as I did it so I would not forget it.

6) Lab testing - Do you get points taken off if you list more tests than are necessary? I always put "CBC/electrolytes" or "CT/MRI", even if I wasn't sure electrolytes or MRI were indicated. My theory was that it is better to be safe and put more. Do you lose points for unnecessary tests? I'm not going to order totally unnecessary tests like ordering an head CT for someone with abd pain, but what about always putting "CT/MRI" or "CBC/electrolytes"?

Just make sure it makes sense within the case vignette. Have a reason for ordering an MRI, etc from your differential dx. Dx's and tests should match up. An attending is grading this portion.

7) Patient note - I always typed my notes, because my writing is terrible. Is it OK to put everything in one line, or separate lines for each catergory. For example:

Allergies: NKDA, Meds: Aspirin, PMH: Hypertension, PSH: none

OR

Allergies: NKDA
Meds: Aspirin
PMH: Hypertension
PSH: none


I always wrote my patient notes all in one line. According to the score report, my patient notes was "borderline". Do you think it makes a difference?


I would make it look neat and organized. I'd vote for the 2nd style.

8) In case # 4 in First Aid, the Patient Note example has "WNL" written in the PE section. I was always told never to write WNL and instead write the whole think out. I always wrote it all out (example: "no exudates, no erythema or discharge etc etc")

Yes, I would write it all out, that would be a pertinent negative.

9) While doing the physical, do I have to explain what I am doing? While I am listening to the heart, do I have to say out loud "OK, Mr. D. I am going to listen to your heart for any irregular heart beats or murmurs"? or "I am now inspecting your joints for ROM, any redness, swelling or pain" etc etc? I didn't do that previously. Do you think that hurt me? For both my attempts my data gathering section (which includes the physical was weak) I think not explaining what I was doing hurt my score.

Yes, I explained as I went. Otherwise I have noted the tendancy for fake patients at my school to 'accidentally' forget these manuevers if you don't say them out loud. You have to treat the patients like they're going to forget everything you do. If they can't remember you did it, then you didn't do it....

10) If the SP mentions a disease/condition when I ask her about PMH which is unrelated to the CC, do I have to dig deeper? Lets say someone comes in with joint pain, but when I ask about the PMH, the SP says she has diabetes, do I ask about blood sugar readings, last HbA1c, diet?

Yes, always dig.

11) Is it OK to touch the patient to show empathy or is that getting "too close"? Is it OK to touch the patient on the shoulder when saying "I'm really sorry about your condition, but I am here to help you etc etc"? I showed empathy and support, but never touched the patient. Does it matter?

Touching is fine. The elbow is the most non-sexual portion of the body to touch. Top of the knee is a decent place for showing empathy as well.

12) To rule out depression, do you have to go through the whole SIG EM CAPS? What if after two or three questions (lets say I ask the SP the SIG questions) and they are all negative, should I skip the EM CAPS? or do I have to ask every single one? Same thing if the SP answers positive to the SIG questions, do i continue to ask the rest, or can I say that the SP has depression because he answered positively to the SIG questions?

My depression patients were either all or none pretty much.

13) Do I have to ask *all* women about OB/Gyn hx? Age of menarche, LMP, Last pap smear, Hx of abnormal pap smear, pregnancy hx etc etc. If the CC is something related to OB/Gyn, then yes, but what about some woman who comes in with ,lets say, chest pain? I asked Ob/Gyn hx for *all* women SPs. Is that a waste of time?

Yes.

14) Finally, is it OK to stand outside the room for 30-45 seconds once the encounter starts so that I can come up with a differential before I enter the room? I never did that before and I think that hurt my history, because I didn't have a strong differential. Is the SP/staff going to think something is wrong??

Yes, this helped me alot to have something to ask questions off. You can stand out there as much as you like.

Once again, I know some of these questions are fairly trivial, but I want to make sure that I am not doing anything wrong this time.

You can either reply here or PM me.

Thanks.[/quote]