Step II Step 2 CS...

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je355804

Mew Nember
15+ Year Member
I took CS a week ago... and it went... disastrously to say the least.

It all started at the beginning of the day. I practiced typing patient notes for about 2 weeks to prepare for this test, using a bullet format given on their Interactive Patient Note. Well it turns out this is a sham... on the real test, if you use bullets the remainder of the line is counted as a character for each remaining character on that line. While having to type in prose isn't the biggest issue in the world, when you've been practicing a certain way for a few weeks and have to entirely change your strategy on test day... needless to say, it's an issue that can definitely hurt you.

After that it's all downhill:

1. I ran our of time while telling the patient their diagnosis on 2 cases. I ran out of time while trying to tell the patient some closing remarks on another 3-4. Luckily for the most part I counseled during the HPI, so I was running out of time while trying to say some lame statement like "yall come back now ya heard?" Not literally, but if you've taken the test you know what I mean.

2. I was not able to complete very good physical exams on nearly anyone. Pain case, got ROM and gait, but was unable to get straight leg, or motor strength... heart case and I forgot to take femoral pulses, no JVD (getting the patient to lay back with "5 MINUTES HURRY THE HELL UP" sound of doom playing in the back ground is a daunting task.) And a myriad of other tests which I forgot to/ didn't have time to perform.

3. Documentation, documentation, documentation. I performed SOOOOOO many tests that I didn't document in my note either due to fear, pressure, stress, anxiety or whatever adjective for pissing my pants exists. This is where I am deriving my most fear. On a case where it was absolutely critical, I did not document heart of lung tests that I performed because I was sooooo proud of myself that I remembered to perform a fundoscopic exam👎... major major error. I think there were several other instances where I didn't document the critical test related to the exam.

4. A guy smoked 1PPD x 40 years... did I think this was important enough to document? Well yes, but guess what... I ran out of space because I couldn't write in bullet form and time ran out so I couldn't go back and figure out what to delete quickly enough to fit it in.

5. Pertinent negatives? Who needs 'em? Apparently not me, because I didn't list any in the DDx portion.

Well that pretty much sums up what I can remember. I have lost a lot of sanity over these idiotic mistakes I made. It's saddens me to think my career which I've dedicated hundreds of thousands of dollars and countless thousands of hours of hard work, may now be over... 🙁
 
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I think you'll be ok, most people only remember the stuff they messed up on after the exam...

Just had a q tho why did u think u ran out of time on so many cases? Long history? The physical exam?

Have my exam in a few days and just wanted some tips, thanks

And I know you can't divulge into what cases u exactly got but were most of them from fa or did u have some **** outta left field? Thanks again and good luck on your result.
 
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EaglesAllDay said:
I think you'll be ok, most people only remember the stuff they messed up on after the exam...

Just had a q tho why did u think u ran out of time on so many cases? Long history? The physical exam?

Have my exam in a few days and just wanted some tips, thanks

And I know you can't divulge into what cases u exactly got but were most of them from fa or did u have some **** outta left field? Thanks again and good luck on your result.
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Without disclosing anything I will say every case I had was fair, you don't need to be Gregory House to know whats going on. The actors were nice and good at making you believe they were real, albeit I felt like a few of them were unnecessarily taking up a lot of my time by having casual conversation, not in a crazy person sense, just in a normal human being chit chat kind-of-way... also not to the point where it would have been appropriate for me to interrupt them. Often they would carry on about some minor detail which was indeed related to the case, however they would give long winded expansions on something we had pretty much already discussed.

The reason I personally ran out of time was because on the first 5 cases, I spent WAYYY too much time saying things like "Ohh my I'm so sorry to hear that... that must be so difficult for you to deal with." etc etc.

I was also trying to do as much as I could on the physical exam, which in retrospect I should have cut short (considering I forgot to document it most of the time :scared:)

When they say try to be halfway through your physical exam by 5 minutes, listen to that advice. I think that is a golden rule. I did it for my last 7 cases and still ran out of time once....

Also a warning to those with size Large hands.

Major issue - 3 of my rooms only had medium gloves in the room. These are the non powdered, non silicone gloves. Good luck trying to fit large hands into those... I stupidly wasted about 45+ seconds in every room trying to fit those damn gloves onto my hand.

If this is the case for you, then you need to just wash your hands. Don't make the same mistakes I did.
 
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Thanks for the advice, appreciate it

And don't worry I'm sure you'll be alright, many people have had same experience as u and end up passing, not many people have posted their experiences on this forum but other forums (img) have a lot of them
 
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If you run out of time on a case are you supposed to act like you just got paged or something?

I keep hearing people say they said "I'm sorry Mr. X but I have an emergency page."

This sounds ridiculous to me... I just said thank you, shook their hand, smiled and walked out of the room.
 
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je355804 said:
If you run out of time on a case are you supposed to act like you just got paged or something?

I keep hearing people say they said "I'm sorry Mr. X but I have an emergency page."

This sounds ridiculous to me... I just said thank you, shook their hand, smiled and walked out of the room.
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LOL...no.

What you did is completely fine...there is no need to lie.
 
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Ronin786 said:
That sounds unbelievably ridiculous. If I was the SP I'd fail you for doing that.
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Once the encounter is over an SP is not supposed to assess you.

Although it makes sense to do certain things:

1. If you are doing PE tie the gown back before leaving the room.
2. Make some excuse to leave or just say-I have to leave now. Thank you for your cooperation. Goodbye.
OR you can say-I have to leave now but we will meet again to discuss the results of the tests ( as previously discussed)
OR I have to leave now but I'll be back with the results.

Must do it quickly since you are losing time for the Patient Notes.

Making excuse does not hurt in any way since they know the whole test is "acting" out what you would do in a real scenario.
 
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Transposony said:
Once the encounter is over an SP is not supposed to assess you.

Although it makes sense to do certain things:

1. If you are doing PE tie the gown back before leaving the room.
2. Make some excuse to leave or just say-I have to leave now. Thank you for your cooperation. Goodbye.
OR you can say-I have to leave now but we will meet again to discuss the results of the tests ( as previously discussed)
OR I have to leave now but I'll be back with the results.

Must do it quickly since you are losing time for the Patient Notes.

Making excuse does not hurt in any way since they know the whole test is "acting" out what you would do in a real scenario.
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I just kind of assumed when the bell for our 15 minutes went off the individual who met me for approximately 13.5 minutes was done deciding the fate of my $300,000, thousands upon thousands of hours of time, and all of my 20s investment.
 
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je355804 said:
I just kind of assumed when the bell for our 15 minutes went off the individual who met me for approximately 13.5 minutes was done deciding the fate of my $300,000, thousands upon thousands of hours of time, and all of my 20s investment.
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And that children is what Kubler-Ross was talking about when she outlined the 5 stages of grief. Lol.

With at least a minimum amount of introspection in mind, it's probably time to stop lamenting CS on forums 👍
 
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je355804 said:
I just kind of assumed when the bell for our 15 minutes went off the individual who met me for approximately 13.5 minutes was done deciding the fate of my $300,000, thousands upon thousands of hours of time, and all of my 20s investment.
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That's assuming that the SPs are doing exactly what they are supposed to do and NOT have any hidden agenda ( personal vendetta) of their own.
 
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Ughhh so true. I know personally it can be difficult to not judge someone right away... I'm sure SPs are no different.

Also I just thought of two things which I've been wondering about.

1. On my 3rd case my mouth was so dry I felt like I was in the desert. I asked the proctor for water, but naturally they told me I could get it in the room... So I did my greeting and kindly asked the pt. if she minded if I had a drink of water... I filled up the tiny cup and had a drink just so I could talk, my mouth was that dry. I wonder if that is going to cost me?

2. While I maintained perfect eye contact, I looked in the patients eyes while I wrote my notes - I noticed the second I started taking notes, the pt. would look down at my notes, almost as if to see what I was writing... as if they haven't done 10 other cases that day, and it surprised them I was taking notes. Did anyone else notice this?

The notes were on my leg, so they were able to see the paper... are we supposed to hold the clip board away from their vision?
 
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B52 said:
any updates on if je355804 ended up passing CS?? i could really use some good news right about now
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Sorry for not updating, I hate when people do that... (I think it's safe to say if people don't update they passed.)

I'm 3 weeks out from CK so I'm going to keep this short...

Let me throw some rumors that are so rampant in these parts into the shredder for you guys...

CLOSURE is not so important like everyone makes it out to be. I didn't finish closure in approximately 8 cases and I scored with a star on CIS.

What I did however do was go through the CS Handbook that is on the NBME website and I did EXACTLY what they said you are being scored on there. I comforted the pt., asked for their concerns, put things in easily understandable terms, asked if they had any questions.... etc etc.

Because I spent so much time kissing the pts. ass, my physical exam was crap, and my data collection was just ok.

I had a horrible time with the typing. I am not an amazing typer as it is, and the keyboards there were like those from the early 90s. You know, the massive elevated clunky letters... I was running out of time on almost every note... (not to mention I was literally the last one out of the room on every single case.)

Bottom line, I passed CIS/SEP will stars to the right (even though I didn't do nearly any closure on 8 pts.... what a load of crap that rumor is, it had me in a state of terror for 6 weeks.) On ICE I was borderline, but still in the borderline/pass range.

Edit: I should also say, my step 1 was 230 so it's not like I'm a brilliant genius but I'm certainly not an idiot.... so I don't think ICE is in anyway correlated to your intelligence. You have to pick if you want to secure ICE points or secure CIS points... People on the forums had me more concerned about CIS. Which I'll probably attribute to the fact that most people failing on forums are foreign students who aren't entirely familiar with american culture, which for obvious reasons would be detrimental to the CIS score.
 
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je355804 said:
Sorry for not updating, I hate when people do that... (I think it's safe to say if people don't update they passed.)

I'm 3 weeks out from CK so I'm going to keep this short...

Let me throw some rumors that are so rampant in these parts into the shredder for you guys...

CLOSURE is not so important like everyone makes it out to be. I didn't finish closure in approximately 8 cases and I scored with a star on CIS.

What I did however do was go through the CS Handbook that is on the NBME website and I did EXACTLY what they said you are being scored on there. I comforted the pt., asked for their concerns, put things in easily understandable terms, asked if they had any questions.... etc etc.

Because I spent so much time kissing the pts. ass, my physical exam was crap, and my data collection was just ok.

I had a horrible time with the typing. I am not an amazing typer as it is, and the keyboards there were like those from the early 90s. You know, the massive elevated clunky letters... I was running out of time on almost every note... (not to mention I was literally the last one out of the room on every single case.)

Bottom line, I passed CIS/SEP will stars to the right (even though I didn't do nearly any closure on 8 pts.... what a load of crap that rumor is, it had me in a state of terror for 6 weeks.) On ICE I was borderline, but still in the borderline/pass range.

Edit: I should also say, my step 1 was 230 so it's not like I'm a brilliant genius but I'm certainly not an idiot.... so I don't think ICE is in anyway correlated to your intelligence. You have to pick if you want to secure ICE points or secure CIS points... People on the forums had me more concerned about CIS. Which I'll probably attribute to the fact that most people failing on forums are foreign students who aren't entirely familiar with american culture, which for obvious reasons would be detrimental to the CIS score.
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I don't post much, but honestly thank you for updating! I have been freaking out about my step 2 cs and hearing your encouraging story helped ease the anxiety! 🙂
 
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Yup, I'd like to know if you were able to dx all 12 cases accurately as well. I felt like a few of my cases were way too hard to dx one probably dx. I would say that's true for about 3 of my cases.
 
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I dont think anyone has to worry about being able to dx every case 100% right. Theres no physician that can dx every case without the use of labs or imaging. There have been so many times that an attending thinks of a dx and then finds out its wrong after labs or imaging gets back. I dont think we as students will be held to a higher standard than actual attending doctors. I think we need to make sure we make reasonable ddx and support them with labs/ imaging
 
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I don't believe thats true Bagheera. I believe the vast majority of students get 12/12 diagnoses correct. If a case seems vague, that is either because the student did not ask specific questions on history, or because the student did not know of some disorders.

I for instance, misdiagnosed two patients. I hadn't studied for Step 2 CK yet. My differential was correct (anyone of them could technically cause those symptoms), but the obviously correct diagnosis was absent.

Also I ran out of time and didn't do a Neuro exam on two lightheaded patients..... so that's not helping me either.

So, if you are still around je355804, please let us know. Thank you.



Bagheera said:
I dont think anyone has to worry about being able to dx every case 100% right. Theres no physician that can dx every case without the use of labs or imaging. There have been so many times that an attending thinks of a dx and then finds out its wrong after labs or imaging gets back. I dont think we as students will be held to a higher standard than actual attending doctors. I think we need to make sure we make reasonable ddx and support them with labs/ imaging
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Bagheera said:
I dont think anyone has to worry about being able to dx every case 100% right. Theres no physician that can dx every case without the use of labs or imaging. There have been so many times that an attending thinks of a dx and then finds out its wrong after labs or imaging gets back. I dont think we as students will be held to a higher standard than actual attending doctors. I think we need to make sure we make reasonable ddx and support them with labs/ imaging
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I def agree with you on this. I do know of many people that come out of the exam and say- i def didn't get a lot of those dx right. Unfortunately, only that person and that person alone can say how they truly did on their exam. I don't know of anyone that gets 12/12 of the dx correct though. What i want to know from ppl who passed are how may dx did you think you were notable to reach.
 
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Coxsackie,

I haven't gotten my results yet, but my friends who have gotten results all say they were confident they got 12/12. Now that obviously doesn't mean you must do this to pass, as I have heard of students passing with 10.

Missed info from history (-1) ---> Missed positive finding (-1 again) -----> Incorrect diagnosis (-1 again).

That chain leads to minus 3 points. The diagnosis itself is not a do or die scenario, rather why a student missed the diagnosis becomes a failed score.
 
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To answer your question, was I able to DX all 12 correctly, who knows? I would assume so, almost all the cases are very simple and straightforward.

From reading everyone's responses I now understand why people struggle with this test... The same reason I was scared going into it.

Everyone is so worried about the minutia, such as, did I make all 12 DXs correctly? Guess what, this doesn't matter.

The test is LITERALLY attempting to determine, A. can you interact with a patient in an intelligent, empathetic, understanding manner... where you can relate to the patients wishes/fears and help to alleviate their concerns while at the same time remaining planted in reality, and giving the patient information about what may be going on with them, and what you are going to do to alleviate the issue, if possible. B. Is your clinical reasoning sound. They literally want to know if you can make reasonable clinically based differentials... for instance if a guy has blood in his urine... well, what can cause blood in the urine? Cancers, stones, etc etc. They literally want you to just demonstrate that you can identify the most basic clinical presentations, and a few reasonable methods for diagnosing them... i.e. a urinalysis, KUB, maybe get all crazy and do a CT scan, etc etc...

This test is really about the basics...

I hope some people who are future takers will read this and take it to heart. I know this test gave me an absolute unnecessary amount of stress because of all the BS I was reading on forums.
 
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Will you get marked down if you only have one dx in the differentials? For ex, if a sp presented with something so obvious like appendicitis, so that's the only thing you wrote down. I'm not saying I had that, but it's an ex. Nothing else they said could make it so you would have a 2nd differential.
 
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Just to add...don't get me wrong, i def asked tons of questions for each chief complaint eventhough it seemed like it could be the dx that I had in mind. But when it came time to document, it didn't make sense to write down any other differentials except for the one that seemed obvious.
 
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So just to make sure everyone is on the same page, when asked if a passer thought she got all of the diagnoses:

"I would assume so, almost all the cases are very simple and straightforward"
 
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coxsackie said:
Will you get marked down if you only have one dx in the differentials? For ex, if a sp presented with something so obvious like appendicitis, so that's the only thing you wrote down. I'm not saying I had that, but it's an ex. Nothing else they said could make it so you would have a 2nd differential.
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Probably. Even a classic appendicitis can actually be something else... An ectopic pregnancy in a young woman, diverticulitis in an older male, etc. After one of my friends took the exam, he noted that the histories that the patients gave weren't always consistent with one diagnosis... They may have symptoms of, say, GERD and diverticulosis at the same time (which is possible, but doesn't lend itself to a single diagnosis).
 
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Exactly, it's not possible right? Well, that's exactly what i'm saying. I asked every question that could possible relate to some other dx...and the sp said no to everything. no other pain anywhere else. absolutely nothing else was wrong. no pertinent family hx. I mean i could have written down random differentials. I had so many differentials written down before i went into the room. I made sure to ask copdcsfliqraaa, ros questions, questions based on all my differentials, pamhugsfoss, nothing else made sense to write down. the main reason i didn't want to write down more than one is because i didn't want to throw in a bunch of random things and get marked down for that.

what i did do was in the ROS part, i made sure to say denies so and so symptoms pertaining to my differentials in mind. Basically my way of documenting...heyy i explored all the other avenues..what else do you want me to do...and i made sure my w/u was obviously loaded with different things to try and rule out other options.

I did u world, so i was def trained to make sure to explore other options like you said. A history presentation with more than one possible thing like GERD and diverticulosis.
 
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yes, i did. I found the cases to be a bit harder than first aid, which really helped with my prep. I just liked that it catered to the exam changes. Other than that, first aid is good too. I did all the mini cases from first aid.
 
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Did anyone do crappy/bare bones physical exams for pretty much all patients and still pass? I only auscultated 4 places on back for lung exams, auscultate/JVP for cardiac, and auscultate/percuss/palpate for abdomen. Never did a CN exam (didn't really ever think it was appropriate) and missed a bunch of physical exam maneuvers (forgot to check for rebound on a patient with abdominal pain, didn't do an abdominal exam on a patient with hepatitis B, etc). I think my HPI's were excellent, but my physical exams were definitely lacking.

Thanks, thoughts are appreciated.
 
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guyutewas said:
Did anyone do crappy/bare bones physical exams for pretty much all patients and still pass? I only auscultated 4 places on back for lung exams, auscultate/JVP for cardiac, and auscultate/percuss/palpate for abdomen. Never did a CN exam (didn't really ever think it was appropriate) and missed a bunch of physical exam maneuvers (forgot to check for rebound on a patient with abdominal pain, didn't do an abdominal exam on a patient with hepatitis B, etc). I think my HPI's were excellent, but my physical exams were definitely lacking.

Thanks, thoughts are appreciated.
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I'll let you know on Wednesday once I get my result. I made far worse errors than you though on PE, so I am not the best indicator for you.
 
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Monkey Jones said:
I'll let you know on Wednesday once I get my result. I made far worse errors than you though on PE, so I am not the best indicator for you.
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Best of luck Monkey Jones, I'm sure that you (like many of us) are focused on your mistakes and forgetting all of the stuff you did correctly. The wait is almost over!
 
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Make some excuse to leave or just say-I have to leave now,If you are doing PE tie the gown back before leaving the room.😍
9cfbY
 
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Monkey Jones said:
I'll let you know on Wednesday once I get my result. I made far worse errors than you though on PE, so I am not the best indicator for you.
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I'm concerned about my physical exam thoroughness too, so I would love to hear how you did Monkey Jones. I did a bear bones physical exam as well, but what do they expect when they say do a focus physical based on the chief complaint. Was I supposed to listen to heart and lungs for a completely unrelated gyn case?

The real reason I am worried is that I had trouble with my school's clinical skills exam and wound up in one category being in the "at risk for problems on Step 2 CS" group. That really shook my confidence. We get more feedback than what CS provides, so I know that on my OSCE I got reamed for not doing physical exam the way they wanted it (i.e. a baseline history and physical including heart and lungs for everyone). The feedback from the "vaginal bleeding" SP at my school wrote "he never took his stethescope out"...my thought was, "was I supposed to listen to her vagina?" I'm pretty sure you can't hear vaginal bleeding through the lungs. When I evaluate someone for carpal tunnel in orthopaedic hand clinic I don't listen to their heart and lungs, so I don't know why I would do that when instructed to do a brief physical based on the chief complaint.

Sorry for going off on a tangent...just stressed because I cannot imagine getting many orthopaedic residency interviews if I failed CS (it would just be an easy "red flag" to get my application filed away in the trash can).

Anyways, I hope you did well Monkey Jones.
 
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You are supposed to auscultate heart and lungs on every single patient!!!!

lrkoehle said:
I'm concerned about my physical exam thoroughness too, so I would love to hear how you did Monkey Jones. I did a bear bones physical exam as well, but what do they expect when they say do a focus physical based on the chief complaint. Was I supposed to listen to heart and lungs for a completely unrelated gyn case?

The real reason I am worried is that I had trouble with my school's clinical skills exam and wound up in one category being in the "at risk for problems on Step 2 CS" group. That really shook my confidence. We get more feedback than what CS provides, so I know that on my OSCE I got reamed for not doing physical exam the way they wanted it (i.e. a baseline history and physical including heart and lungs for everyone). The feedback from the "vaginal bleeding" SP at my school wrote "he never took his stethescope out"...my thought was, "was I supposed to listen to her vagina?" I'm pretty sure you can't hear vaginal bleeding through the lungs. When I evaluate someone for carpal tunnel in orthopaedic hand clinic I don't listen to their heart and lungs, so I don't know why I would do that when instructed to do a brief physical based on the chief complaint.

Sorry for going off on a tangent...just stressed because I cannot imagine getting many orthopaedic residency interviews if I failed CS (it would just be an easy "red flag" to get my application filed away in the trash can).

Anyways, I hope you did well Monkey Jones.
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dendrites said:
You are supposed to auscultate heart and lungs on every single patient!!!!
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According to whom?

I highly doubt you get any points for listening to the heart on someone who presents for a mental health problem or something like arthritis.

It is suppose to be a focused history and focused physical.


If you forgot to auscultate a COPD or CHF patient that is a different story and you probably did lose several points.
 
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je355804 said:
Comments like these are seriously cutting into my study time.

I did not auscultate heart and lungs on every pt. I only did it when it was necessary. And again, I did just fine.
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This is BS. If there is a purely psych patient you do not do a physical exam. Imagine going to your shrink and telling him you have obsessive compulsive disorder and he wants to palpate your abdomen.
 
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je355804 said:
Comments like these are seriously cutting into my study time.

I did not auscultate heart and lungs on every pt. I only did it when it was necessary. And again, I did just fine.
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That's good to know you passed without doing heart and lungs on patients where it was not relevant. Everything I have read indicated you only get points for physical exam maneuvers pertinent to the chief complaint; any unrelated maneuvers gets you nothing.
 
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Well I am now on board the "Panicking about Step 2 CS" train. Took it recently and am freaking about everything I did wrong.
I am going to be panicking over the next couple of months that I have never failed anything medical school related yet I'm going to fail this test. I'm really concerned about the ICE component of scoring.
 
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