My USMLE Step 2 CS Tips-n-Tricks

A Simple Protocol(SP) for your SP(Standardized Patient) Encounter

2007-09-11T16:34:00.000-07:00

Did you know that, on the USMLE Step 2 CS exam (formed called Clinical Skills Assessment), having a standard protocol saves times and prevents memory lapses ? Read on...

This simple pattern can be used for almost all cases - except of course for telephone encounters and patients for lab results counselling...I used the following protocol myself!

First Sight...

Knock 3 times with confidence , a smile , walk in and say, "Good morning Mr. Smith, I am Dr. Digitaldoc and am here to see you today as your physician." Shake hands with the patient, look around the room and say "Is everything in the room alright for you ?" - SP says yes - Then you say "Let me make you a little more comfortable".....and while saying so, drape the patients legs up to his belly (applies to a sitting or a reclining SP) . Then, "So Mr. Smith, how may I help you today?"

Warning: A friend of mine who took his exam before me, told me about an incidence where a student asked the SP - "What brings you here today ?" and the SP replied "A bus !!" - to avoid such nasty mishaps, ask "How may I help you ?" or use a new style being discussed these days - "Mr. Smith, it seems you have come in today for a racing heart - could you tell me more about it?" ( Chief complain is already stated on the door before you enter !

After the patient tells you the chief complaints and stops, first express sympathy - say, "Oh I am sorry to hear that, I shall try my best to help you. Hope you dont mind if I make a few notes as you speak" This makes you free to write or pretend to write as you try to recall what to ask without showing ur nervousness - actually a good time to write ur mnemonics !! If the setting is appropriate - you may sit on a stool and bend forwards as if listening - I did so because it created a feeling of showing humility and friendliness.

After finishing off with data collection, i.e. "PAM HUGS", before you move on to "FOSS", it is good to say, "Mr. Smith, the way clinical medicine works, there could be some clues hidden in a few personal questions I need to ask you - is that OK with you ? " and then move on to FOSS.
If you think you have finished or can't recollect what else needs to be asked, do give the patient a final chance by saying " Is there anything else you want to tell me ?" then move on to washing hands and examination. Warning : Dont ever express explicitly that you have concluded your questioning, because you might remember something during physical examination and it is ok to ask then !

Transitioning to a hand wash:

There have been quite a few concerns about how to handle a change from history mode to a hand wash mode ...A sample transcript :

You = "I shall now need to perform a quick general examination and then look at your heart - is that fine ?" (No need to say Head, Neck, Eyes, Feet, etc and waste seconds ! - you're gonna be graded for doing it , not for u saying it in detail !)

SP = "Sure, doctor"

You = "Arrite ! Before we begin Mr. Smith , excuse me for a moment here to wash my hands" (smile)

I had reserved the time to wash my hands to enquire about occupation and say "thats interesting, my uncle used to do something similar" or something like that.

Transitioning to a Physical exam:

Before you begin physical examination say "I will now need to perform a quick general examination and then we shall have a look at your chest [or abdomen - wutever the chief complaint is]" and do keep talking during each thing your examine - like "lets start with your eyes, could you look up for me" while examining pallor. By the way , a good mnemonic of quickly completing general examination is "PICKLE" - Pallor, icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy and Edema Feet" along with Jugular veins, carotid bruit if a CVS case.

At the end of the entire general + systemic examination, summarise : "Based on what you told me and your physical exam, there are certain diagnostic possibilities like 1._____, 2. ________ or 3. _______ and others. But to be more certain, let us order a few tests - like blood tests, chest x-ray , an EKG , and then discuss further management. "

The last minutes...

While concluding, keep this 4-stage pattern in mind to cover everything and to be courteous:

a. First, Counsel !!! For example - for a case of diabetes, it is good to say a few words on foot care ! if the patient smokes or drinks alcohol - say "are you aware of the harmful effects of smoking / alcohol ? Have you ever considered quitting - if you wish to , we have a good support team that is willing to help you quit the habit" thats it - dont get personal about it .

b. Then say " Have you understood everything we have discussed today ?"

c. Then "Are there any special concerns you have ?"

d. Finally " Thankyou very much Mr. Smith . I shall leave my contact information with my nurse - feel free to contact me anytime if you have any questions"

A Trick, in case Time falls short...

If you have to leave, dont make it abrupt and embarrasing. Rather it is good to pretend looking at your beeper and say "Oh ! Mr. Smith, We have an emergency and I have to leave - I will see you as soon as I get free" and leave with a smile. ( ...Speaking of showing those SPs that you are no less when it comes to some fine acting ;-)... )

Hope this helps guys....

Q. What if I miss out on some clinical test due to lack of time ?

A. Mention that as an investigation on your Patient Note ! (Some may argue that since the PN is graded by physicians separately later, while the actual encounter by the SPs on the spot, it may be ok to bluff on the PN ... I am not sure if that's how grading is done but nevertheless mentioning missed physical exams on the PN should be safe too)

Q. Should we auscultate in ALL cases ?

A. Yeah - make it a part of the routine ! Except, of course, for Lab result explanation cases.

Q. Carotid Bruit auscultation : Bell or Diaphragm ?

A. Use the Bell !

Joke: Heard this one ? : Doctor to patient: "Well, Mrs. Cole, I'm afraid you're not quite as sick as we'd hoped." :-) :-) :-)

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The art of Medical - Clinical History Taking

2007-09-11T16:30:00.000-07:00

...or is it a science ? They say medicine is both an art and a science. Hell forget it - I like to keep it logical and simple so that it works for me when I need it. We can't really have mnemonics for everything on the USMLE clinical skills assessment, but we sure can have protocols...

Step 1: SP tells you his/her chief complaints,

Step 2 : O.D.P + Details ..yeah that's right ! Ask about the Onset, Duration and Progress for each of the above complaints, followed by complete details about the complaint - for example, LIQOR AAA for pain; severity, pattern, chills/rigors for fever, quality, sputum, hemoptysis for cough etc.

Step 3 : Spefic Data-Collection for the case - If you have a specific Data-Collection mnemonic for the case - NOW IS THE TIME - for e.g. FACE SLIPS for Depression / Fatigue case.

Step 4 : History of all other symptoms that are possible for the system that is involved, which were not covered in Step 3 . Keep this handy - like cough, dyspnea, chest pain, wheezing, etc. are all symptoms possible in a respiratory case.

Step 5 : History of possible complications - if any

Now move on to 'PAMHUGS FOSS SODA'

Again this is guideline for those who are not confident about their history taking styles. But I do stress the importance of memorizing D/Ds and Data-Collection for each symptom complex - that makes asking the right questions during history taking get easy.

This approach rocks especially for those times when we suffer an idiopathic mental black out in front of the SP !! ;-)

To see the above approach in action - Look up the explanation for Heel Pain case on this blog: Click here

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Standard Clinical History Taking Mnemonics

2007-09-11T16:29:00.000-07:00

"PAMHUGS FOSS"

This standard mnemonic helps us in completing a clinical history after the chief complaint and related relevant history-taking steps have been taken care off.

P-ast medical history
A-llergy hx
M-edication hx
H-ospitalization hx
U-rinary problems
G-I problems
S-leep probs
F-amily hx
O-b/gyn hx
S-exual hx
S-ocial hx - use 'SODA'

"SODA"

'SODA' is a mnemonic to enquire about a detailed social history :

S-moking
O-ccupation
D-rugs (Illicit)
A-lcohol + CAGE questionnaire

"LIQORAAA"

This is a standard mnemonic for eliciting a complete history for any kind of pain chief complaint:

L-ocation (of pain)
I-ntensity
Q-uality
O-nset + Progression
R-adiation
A-ssociated Symptoms
A-ggravating Factors
A-lleviating Factors

None of the mnemonics themselves make any sense, I mean does the word SODA, in anyway remind you of 'social history', unless you can devise a way such as we guys drink sodas in groups with friends - a kind of social drinking - reminds one of social history. This is contrary to what I believe a mnemonic should be - a great mnemonic itself indicates what it's for - like my mnemonic CAPTOPRIL. But then these mnemonics above are standard history taking mnemonics and not too tough to remember and they serve our purpose on the USMLE Step 2 CS and perhaps will help us through all our clinical lifespans !

Also Check Out:

- Exciting Books On Medical Mnemonics

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Step 2 CS Patient Encounter : Should you Sit or Stand ?

2007-09-11T16:27:00.000-07:00

To Sit or to Stand during the encounter is the question...

During a SP encounter, use your own judgement to decide this. This is simple - just think of the clinical setting before deciding on sitting - (wow, did that just rhyme) - would that patient be seen in an emergency setting ? (acute abdomen, chest pain) or in an outpatient clinic setting? (Pre-employement checks, chronic knee pain).

You would not be sitting in an emergency setting , would you ? Likewise, you are free to sit or stand in other settings !

Q. Which side of the patient to stand on the exam ? (Forum question to me)

A: Really speaking does not matter - but most of us, I guess, are used to standing on the right side of the patient..in fact on my exam - the beds were positioned such that I always naturally ended up standing on the SP's right.

To give you guys an idea of the setup - when you enter the door of the SP's room, it will be a square room with the wash sink diagonally opposite your door. The SP's bed will be aligned on the other diagonal of this square with the SP usually sitting/lying facing the same side of the wall that you will see when you open the door. Hope this gives you a picture !

How much does the USMLE Step 2 CS Cost ?

2007-09-11T16:26:00.001-07:00

How Much would the USMLE Step2CS Cost you ?

Exam Fees = $1,200.00
Hotel Stay = $80.00(approx.)
Flight to Exam-Center = $250.00 (approx.) [Depending on how early u book]
Food/Drinks = $20.00 (appox.)

For International Medical Graduates, the following Currency Converter provides the current value of the costs in your local currency.

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'Lost' Your Step 2 CS Permit ?

2007-09-11T16:21:00.000-07:00

Damn ! Where did my Orange Permit go ?

Ha ha - That reminds of how stressed I was - all with with sweaty palms & forehead, when I thought I had "Lost" my "Orange Permit" - just 2 days before my exam - and my jaw dropped like Ashton Kutcher's after the party in his classic comedy "Dude Where's My Car" !

Though I mentioned this elsewhere, lets go over this again - you DO NOT GET an Orange Permit for the Step 2 CS - all you get is an email confirmation ! so go back to your email and search for the confirmation and make sure it exists. If not, you can always ask ECFMG to email you again.

You need to take a print-out of that email for the exam.

Hmmm...Can anyone tell me Why ECFMG would do such a thing in the first place! Why not keep procedures standard for all exams and have either an Orange permit for all steps or have email confirmations for all steps ?

Beats me... :-)

Tips for the USMLE Step 2 CS Exam Day

2007-09-11T16:18:00.000-07:00

So your Step 2 CS Exam Day has arrived !!!

Yeah ... after all your preparation, tips from various sources and other 'secrets' you gathered, finally the real truth is out there somewhere - - - In your exam center - - - somewhere between what you think you should know and what USMLE Step 2 CS exam really has in store for you...

...Not freaking you out , just helping myself dramatize this blog !!!

Mom's advice, "Have cold yogurt with sugar before doomsday to soothe your nerves and improve memory" - deep inside I always smiled at it as a no-science , but I had it anyways !! No that's not my advice - that was supposed to be a funny deviation from a serious topic. Well, on your Step 2 CS exam day be chilled out but kindly arrive on time :-)

Get these things with you for the exam :

1. 2 Photo IDs - atleast one for sure
2. Print out of the Email confirmation about your Step 2 CS exam
3. Doctor's coat + Stethoscope
4. Dial-watch(no digital please) that are strictly without calculators, alarms & hourly beeps

Everything else including ophthalmoscope, BP instrument, Gloves, Food and water is provided at the Center guys ! Hurray !!

And please don't Freak out if ...

a. You think you "lost" our orange permit: Remember we never get one for CSA - all you get is an email confirmation. Print that out and get it for the Step 2 CS test

b. You forgot your doctor's coat : No Probs - Exam center will have some spare ones.

c. You forgot your stethoscope : Again, they have some spare ones will ask if anyone needs it. (try not to forget all of this though)

Some Important Don't Do's:

1. In the lunch break, though there is lot of food - eat in limited amounts so that you dont feel sleepy.

2. Avoid too much liquid intake, you dont have permission to go Pee-Pee during the exam !

3. Don't Don't DON'T discuss cases or any clinical information with other students at the center at any time - Got that ???

4. Don't write anything on your paper until the announcement to proceed with the Step 2 CS exam is made. You may take some time to write your mnemonics, patients name before you enter the SP room - But rules for this may change - it is best to inquire with your proctor before the session begins.

[Watch out this section for updates...and good luck on your test !]

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Step 2 CS Exam Timings and Schedule of Breaks

2007-09-11T16:15:00.000-07:00

As most of you may already be aware - the Step 2 CS [Clinical skills] exam is conducted in two sessions : the Morning session that begins at 8:30 am and the Afternoon session that begins are 3:30 pm

The Morning session ends at about 3:30 to 3:45 pm , while the evening session will be done at around 10:30 pm - it's important to know that so that you can schedule your return flights accordingly, in case you are flying.

This is how the schedule will look !

- Attendance, Orientation and Light Breakfast

- 5 Cases (each has 15 Minutes SP Encounter and 10 Minutes Patient Note)

- Long Break = 30 Minutes

- 4 Cases

- Short Break = 15 Minutes

- 3 Cases

- Run Home as Fast as you can ! !

There are two batches of 12 cases each that go on simultaneously for each session :-)

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WHEN SHOULD YOU TAKE THE USMLE STEP 2 CS ?

2007-09-11T16:14:00.000-07:00

As some jokingly say - Yesterday ! Thats because our ECFMG guys are sooo slow about giving out the results that sometimes they may not even come out on time for the Residency Match you are planning to participate in ...and then - you lose a year :-(

So ..beat the system - get going fast and finish up your Step 2 CS fast

1. Yes you can give Step 2 CS even before Step 1 !
2. Yes studying for the exam is not tough - 2 to 3 weeks of right study with the right practice partner is good enough !

STEP 2 CS Experience at ATLANTA: By Waqas Tariq, MD

2007-09-11T16:11:00.000-07:00

This one deserves a separate post of it's own to credit the extremely detailed experience and tips that this dude has provided us with !

Thanks Waqas ! - you cannot miss him on Orkut ;-)

"
I dunno where to start my experience but I read for step 2 CS for almost 2 months. Wasnt regular at all as I was also having my regular classes in my medical school....
Read UW first and then I read somewhere that digidoc studied FA so I started FA as well and found that FA is sufficient enough to go with the exam.
also went through www.csprotocol.blogspot.com website. A very useful link indeed.
FA is DEFINITELY BETTER than UW but as my friends told me that UW is the best I did 6 to 7 readings of UW and 2 readings of FA.
Screwed a lot of cases in the end just because I knew too much. This test is not a TEST of your proficiency in MEDICINE...thats for sure...
15 days are MORE than enough for study and yes ...
water in the CS center is too much SOFT so try using very less amount of soap to wash hands. I took 2 minutes to wash my hands that just made me go helpless in the end and I wasnt able to complete 7/12 patients. Tragic isnt it? :P
anyway...
started with UW and read the basic protocol...I made my basic protocol first that starts like:
examinees.. you may begin...this is the first command...look at the door information...write down the LAST NAME ON THE SHEET provided to you in big letters...with age
then write the abnormal vitals and then write the D/D or the specific mnemonic for the case...I also wrote RECTAL EXAM and COUNSELLING in the end along with JCO CVA(jvp, carotid bruit, ophthalmic exam, CVA = costovertebral angle tendernes) because I tend to forget them .... rectal exam/pelvic exam counselling I used to do along with examining the patient...
Knock on the door...dont forget to smile and then open the door...
Good morning Mr. LAST NAME. I am Dr. FIRST NAME LAST NAME and am here to see you as your physician today. Nice to meet you. (shake hands) dont shake hands with SPs in severe pain. Then ask ...
Is everything in the room allright for you?
and after that ... say... LET ME MAKE YOU A BIT MORE COMFORTABLE...saying this open up the drape ...OPEN IT COMPLETELY...a friend of mine told me to open it half and I messed it up just because half sheet doesnt cover the legs of the patient.....cover the legs in the beginning as it seems more corteous...
afterwards...if its an office case...sit down on the chair and if its an emergency case...keep standing...
start with ... THE NURSE TOLD ME THAT YOU ARE HAVING ________ (THE CC). CAN YOU PLEASE TELL ME MORE ABOUT IT? and the patient will start telling you ...it will be only a single sentence... :P
after that ....you say...OH I AM SO SORRY TO HEAR THAT. I SHALL TRY MY BEST TO HELP YOU (SMILE). HOPE YOU DONT MIND IF I TAKE SOME NOTES WHILE YOU SPEAK.
and then write quickly the mnemonics ...NOW ASK THE PATIENT ...ODPFAAA (onset,duration, progression, frequency, aggravating, alleviating, precipitating,associated) factors...read bout ART OF HISTORY TAKING from the blogspot website of digital doc...
I had basic mnemonics for every symptom...
when you finish with them...then start with

questions specific for D/D...5 or 6 in number...

after that... ask

F fever
F fatigue
A apetite
W weight changes

you dont have to ask these questions in every patient but its better to ask them..

then say..
OKAY MR. XYZ NOW I WOULD LIKE TO ASK YOU SOMETHING ABOUT YOUR HEALTH IN GENERAL. IS THAT OKAY WITH YOU?

start with

P past medical history past surgical history
A allergies
M medications
H hospitalizations
U urinary problems
G GIT problems
S sleep problems

again ask a transition question:
NOW I WOULD LIKE TO ASK YOU ABOUT YOUR FAMILY HEALTH. OKAY?
F family health

again another transition:
NOW I WOULD LIKE TO ASK YOU ABOUT YOUR GYNECOLOGICAL AND SEXUAL HEALTH. WHATEVER YOU WILL TELL ME WILL BE KEPT CONFIDENTIAL. IS THAT OKAY?
O obs/gyn
S sexual history

another transition:
NOW I WOULD LIKE TO ASK YOU ABOUT YOUR LIFESTYLE.OKAY?
S do you smoke?
O what do you do? Is your work stressful? (I used to ask this during handwashing)
D do you take any recreational drugs?
A do you drink alcohol?
T have you travelled recently/trauma?
A do you have ANY other thing to tell me before I start your physical?

OKAY MR. XYZ. NOW I NEED TO DO A QUICK PHYSICAL EXAM AND LOOK AT YOUR HEART. IS THAT OKAY WITH YOU?

he will say okay

say ARRITE THEN. EXCUSE ME FOR A MOMENT HERE SO THAT I CAN WASH MY HANDS. OKAY?
go for hand washing ceremony. and wash them for REAL because they are watching you.

come back and start. OKAY NOW I NEED TO SEE YOUR EYES FIRST. CAN YOU PLEASE LOOK UP FOR ME. and now keep on doing the running commenty while you keep on doing the physical exam. what I did was that
I thought to auscultate lungs and heart with general physical exam. STARTED with eyes, then oral cavity, then neck glands + thyroid, then chest, then feet (edema) and in case if calf tenderness has to be seen, I check it as well...

NOW UNCOVER BACK AND auscultate plus CVA and spine tenderness checked...

after that...

COVERING THE PATIENT BACK... I said... THANKS FOR YOUR COOPERATION MR. XYZ. NOW I WOULD SIT AND TALK OVER WHAT I AM CONSIDERING SO FAR. YOU TOLD ME THAT YOU HAVE HAD THIS PROBLEM SINCE _ DAYS AND IT IS PROGRESSIVELY GETTING WORSE AND ON PHYSICAL EXAM I WAS NOT ABLE TO FIND ANYTHING SIGNIFICANT/I WAS ABLE TO FIND THAT YOU HAVE DECREASED BREATH SOUNDS ON LEFT SIDE etc. BASED ON THIS THERE ARE A FEW DIAGNOSTIC POSSIBILITIES LIKE TB AND PNEUMONIA BUT THERE ARE OTHER POSSIBILITIES AS WELL AND WHAT I AM GOIN TO DO NOW IS TO RUN A FEW TESTS LIKE BLOOD TESTS AND CHEST X RAY ON YOU AND ONCE THE RESULTS OF THESE INVESTIGATIONS COME OUT WE WILL SIT TOGETHER AGAIN AND DISCUSS YOUR PROBLEM IN MORE DETAIL.

I did counselling during the encounter but most of the peopel do counselling at this place. What I did was that. e.g. if they smoked, drink alcohol and take drugs. I said after aksing all the questions about them. THE REASON WHY I AM ASKING YOU THIS IS BECAUSE SMOKING, DRINKING EXCESS ALCOHOL AND TAKING DRUGS PUTS YOU AT HIGHER RISK OF GETTING MANY DISEASES. SO AS YOUR CONCERNED PHYSICIAN I MUST ADVISE YOU THAT YOU SHOULD EITHER CUT IT OR IDEALLY QUIT IT. ARE YOU WILLING TO DO THAT? if they say YES. say EXCELLENT MR. XYZ. THERE ARE ALSO A FEW PROFESSIONAL SUPPORT GROUPS AVAILABLE THAT WOULD BE HAPPY TO HELP YOU. IF YOU ARE WILLING I CAN CONTACT THEM ON YOUR BEHALF OR YOU CAN CONTACT THEM ON YOUR OWN. PLEASE LET ME KNOW IF I CAN BE OF SOME HELP TO YOU. if they say NO then say I UNDERSTAND THAT IT IS VERY DIFFICULT TO QUIT AN OLD HABIT BUT SMOKING DAMAGES YOUR BODY A LOT AND IT MIGHT BE ONE OF THE CAUSE OF THIS CONDITION OF YOURS. THERE ARE A FEW PROFESSIONAL SUPPORT GROUPS ALSO AVAILABLE THAT WOULD BE HAPPY TO HELP YOU. PLEASE LET ME KNOW IF I CAN BE OF SOME HELP TO YOU. thats it!!!!! dont push them to quit smoking or do what you want ... :)
as some patients might say that they arent here for smoking or alcohol counselling but YOU HAVE TO COUNSEL..

for DIABETES just use the same way:
ask for diabetic control, diet, exercise, foot care n then say
THE REASON WHY I AM ASKING YOU THIS IS BECAUSE NOT CONTROLLING DIABETES, TAKING FATTY FOODS, NOT DOING REGULAR EXERCISE AND NOT WATCHING YOUR FOOT REGULARLY PUTS YOU AT HIGHER RISK OF GETTING COMPLICATIONS OF DIABETES. AS YOUR CONCERNED PHYSICIAN I MUST ADVISE YOU TO OBSERVE STRICT DIABETIC CONTROL, TAKE LESS FAT, DO REGULAR EXERCISE AND WEEKLY OBSERVE YOUR FOOT.
same goes for Hypertension except that there is BP control and NO FOOT CARE :P in the counselling...
for SEX COUNSELLING after sexual history you can say:
THE REASON WHY I ASKED YOU THIS IS BECAUSE NOT PRACTISING SAFE SEX METHODS THAT INCLUDE USING CONDOMS AND LIMITING YOURSELF TO ONLY SINGLE PARTENER WHO DOES SEX WITH YOU PUTS YOU AT HIGHER RISK OF GETTING STDs, HIV AND CANCER OF THE NECK OF YOUR WOMB. AS YOUR CONCERNED PHYSICIAN I MUST ADVISE YOU TO OBSERVE SAFE SEX METHODS....bla bla OKAY ?

for difficult and challenging questions:
make your own protocol for answering them:
always say first...

I UNDERSTAND YOUR PROBLEM/CONCERNS/ that you want to go for hiking/you are in pain etc etc..

then in the next sentence GIVE YOUR HONEST OPINION BUT IT SHOULD BE PEP TALK. you can say. BUT RIGHT NOW IT IS DIFFICULT FOR ME TO SAY FOR SURE AS I NEED TO RUN SOME TESTS/INVESTIGATIONS AND ONCE THE RESULTS COME OUT I WILL BE IN A BETTER POSITION TO TELL YOU WHAT WE ARE DEALING WITH. etc etc...

in the third sentence
use:
I WILL KEEP YOU INFORMED
IS THERE ANYTHING I CAN DO TO MAKE YOU FEEL MORE COMFORTABLE
PLEASE BEAR WITH ME I WILL VERY MUCH APPRECIATE YOUR PATIENCE....
believe me all of your challenging questions will be answered if you use this protocol :D

anyway after counselling that you can do during the history or in the end but its always to do that during the history because most of the people forget the counselling part...

after that ask

"ARE THERE ANY SPECIAL CONCERNS YOU HAVE?"

"HAVE YOU UNDERSTOOD EVERYTHING THAT I HAVE TOLD YOU TODAY?"

"OKAY THEN MR. XYZ. I AM GLAD THAT I WAS ABLE TO WORK WITH YOU AND I ASSURE YOU THAT I AM ALWAYS HERE TO HELP YOU. THANKS FOR YOUR COOPERATION AND IT WAS REALLY NICE MEETING YOU. (SHAKE HANDS) BYE FOR NOW AND TAKE CARE".

that's it...

always remember time is VERY SHORT during the exam...so try to practice practice and practise plus shorten your questions...
dont WORK TOO MUCH ON QUESTIONS.....

for timing they dont allow you to use digital watches so what I did was that I used to bring the hands of my clock to 12:01 o clock before the encounter and that wud make my clock a stop watch :D
it really helped me but I did it in the end :(

I had a few mnemonics that I want to share:
A (Amount and frequency)
B (Blood)
C (Content, Consistency, color)
O (Odour)

can be used for
vaginal discharge: with additional questions of Itching and sores
vomiting: with additional questions of nausea
sputum: preceded by a question like is cough productive or dry?
diarrhea: with additional questions of tenesmus and fecal incontinence
constipation: with additional questions of tenesmus and fecal incontinence and pain on defecation

FOR CONCISE EXAMS. USE KAPLAN BOOK FOR STEP 2 CS. EXAMS ARE BEST WRITTEN IN KAPLAN.

for general exam..i follwed the PICKLE and added O of opthalmoscope to it...check pedal edema now...and ask fr it also...check pulses...take BP

now this is what i did personally for,, systemic exam...

--i started with sp sitting untie the gown with back chest insep/percussion/tactile fremituis/ascultation....check for spinous tenderness and CVA tenderness at the same time..

---SP still sitting..come front take the gown down ..sternal tenderness/ supraclavicular nodes axillary nodes...PMI...all 4 heart sounds and ascultate the lungs..

--tell the SP to lie down....look for JVP..carotid pulse...go for abdomen...IAPP..

here is what you should do a night before step 2 CS

iron ur clothes in the evening and practice ur cases with tie on( u may laugh on this but it might be a bit diffcult with trousers and tie)

sleep as ealy as u can...get up around 6...practice

1) general case

2) pedis case

3) pyshicatry case

4) absue case

5) telephone case..

6) enuresis case

OASIS trick :
Step 1: Go to this website: http://oasis.ecfmg.org/
Step 2: Click on the OASIS button at the right
Step 3: Fill out your USMLE ID and password
Step 4: Click on USMLE/CSA Score Reporting Information at the left
Step 5: Check if your score has been reported. ( both of your exam date and score report date must be appeared )
If your score has been reported, go back to h ttp://oasis.ecfmg.org/
Step 6: Click on the ECFMG Home button on the left
Step 7: Click on Interactive Web Application (IWA)
Step 8: Scroll down
Step 9: At the bottom left you will see "Begin new application"
Step 10: Click on "Step 1,2, or CSA"
Step 11: Scroll down and click on "Proceed with IWA application"
Step 12: You will see this:
ECFMG Examination History
Have you ever submitted an application to ECFMG for any examination, even if you did not take the examination?
Yes, and I know my USMLE/ECFMG Identification Number. Yes, but I do not know my USMLE/ECFMG Identification Number.
No, I have never submitted an application to ECFMG.
Step 13: Choose the first option and click next
Step 14: You may have to log in again on the next page with your USMLE ID and password
Step 15: The screen will ask which exam you are interested in. Select the exam you took and click next
DRUM ROLL
The next screen will be in red print saying that you have successfully taken this step and can't re-apply for it if you passed. If you failed, it will let you go on.

Note:
1. OASIS is usually updated on Wednesday at midnight (East Coast time)
2. Mine got updated 1 day late...
3. Once your score is updated on the OASIS website, it means that they have mailed out your score.
4. You will get your score in the mail in a weeks time usually."

Excellent advice and tips Waqas !

Travel Resources for the "New-to-USA" IMG

2007-09-11T16:08:00.000-07:00

I suppose a lot of IMGs who come to the USA to take the Step 2 CS are newcomers to the United States. This information might be useful for such IMGs

Air Travel within the USA :

The General rules are:

a. The earlier you book (i.e. in advance), the better the deals you get
b. The wierder the time you choose to fly (the non-rush hours), the better the deals you get.

If you did not already know, the "ticket" is not mailed to you - its a virtual e-Ticket. When you go to the airport on the day of your flight, at the airline kiosk, you will need to swipe the same credit card that you use to buy the ticket online.

Here are some reliable sites that one must check out to see which offers the best deal and allow you to buy tickets online. It's best to compare fares over all the sites to get the best deal.

1. South West Airlines (SouthWest.com) : These guys don't connect ALL cities, but they are known to offer the cheapest airfare. That's the first site I lookup for air-tickets :-) Southwest Airlines is the current darling of the United States - not just the customers, but most new management books use the firm to give examples of superior management. I love them ,especially the fact that the pilots crack jokes on the speaker system to make us all laugh - now I would have loved that when I flew for my Step 2 CS ;-)
2. Cheaptickets.com
3. Orbitz.com
4. Hotwire.com
5. Expedia.com
6. Priceline.com: Here you can name your own price and Bid - at times you may get lucky !
7. CheapAir.com

And recently, a new site that aggregates results from all these sites to show the best fares - SideStep.com is not bad either ...

Apparently, the best time to buy an air-ticket in US is on a Wednesday , at least 21 days before your flight ! There is something about Wednesdays ! I mean, OASIS updates on Wednesdays, USMLE exams get mailed out on Wednesdays from exam centers ..hmm. So why Wednesdays for an Air Ticket ? I picked this up from smartmoney.com :

"Airlines make major pricing changes (and run fare sales) every week, typically on Tuesday evenings and Wednesday mornings. About 21 days out from your flight, you'll see plenty of deals out there as airlines scramble to fill seats, says Anne Banas, executive editor of SmarterTravel.com, a consumer travel advice Web site. Don't wait much longer, she cautions; prices jump significantly from 14 to seven days ahead of departure."

Suffer from Flight Anxiety ? Then you gotta read this article from New York Times - "You are cleared for Takeoff"

[More coming soon]

Search keywords to this blog post:

- "Traveling advice for IMGs Step 2 CS"
- "affordable travel tips step 2 cs"

Liked This ? Wont you tell your Friends ?

2007-09-11T16:05:00.000-07:00

Well...it is a competitive world ! But if you are feeling extraordinarily kind and would like to share this information with your buddies - would appreciate if you spread the word about USMLEtoMD.com :-)

Secondly, if you use Google's Orkut.com, you are welcome to join my Step 2 CS community by clicking Here .

For those inclined towards the popular MySpace Network - join my USMLE group HERE
My best wishes for your exam !

Search keywords to this blog article:

- "good usmle videos"

USMLE Step 2 CS Experiences

2007-09-11T16:02:00.000-07:00

If you find CSprotocol useful for your CS prep - its a personal request to all of you to come back after your exam and share your CS experience and tips at the CS-experience database at USMLEtoMD.com :-)

1. Sukanya, MD: Center = Houston

This is what she had to say immediately after she took her CS :

"Did my CS in Houston a few days ago & although I didn't do so hot coz's I was so nervous I wanted to give everyone a few tips so here goes. First of all RELAX!! It is not as terrifying as you think its going to be! If your fluent in english cool, if not as soon as you get to your exam centre start talking to people to get you flowing - its all about chatting up the SP, showing friendliness and compassion. Here's something I thought was sooo important - when the announcer says "OK you can look at the doorway info now, take a moment to take it all, stand in front of the door, write down the SP's name! coz' when you are inside its sooo easy to forget! Then look at the chief complaint and immediately jot down a few D/D's, this gives you a point of refernce when ur stuck abt what questions to ask - and that can definitely happens when ur all stressed out. Then write down ur Mnemonics like PAMHUGSFOSS or anything else that might be relevant to the case - Then, once you've done that knock and enter. It is really worth the time to stand outside the door for 45 seconds to a minute and sort your game plan out. Although despite me having said this - if its a case of confusion/ tremor/ any psych case i'd advise you to go in as quick as possible coz the questions take long and so does the examination. For the telephone case and also the other type of peds case where the parent comes but no child, take as much time as you want formulating what ur going to ask and how you will counsel cos no examination so you really don't need the full 15 minutes for discussion.
Be friendly, smile alot (of course not so much at the depressed SP!) and try to stay calm!
good luck guys! you can all do it, it really is nothing like as hard as you might imagine. if you got thru final year exams at whatever college you graduated from this will be a piece of cake!"

And lets see what she had to say after she got her results :-)

"
Houston, November : walked out of the exam and though "farewell america"!
Houston, January : rebirth of hope!
Guys YOU CAN DO THIS! Have confidence! Be friendly and courteous and when you need to be, be firm but not rude. I really think alot depends on how you treat the SP cos I felt like my cases were going so badly but I was always very friendly and cheerful with the SP's (except the lady in acute pain!) I honestly walked out and felt like I'd failed, but I just told myself there's nothing you can do now so just prayed really hard! If you've taken it already, and are waiting for results just do things to occupy your mind. If you're still waiting to take it, remember this - 80% pass rate! practice your english (by talking to anybody and everybody!) and SMILE!
"

Way to go Sukanya !

2. Janna Swe, MD: Center = Philadelphia

About the Center:

Philadelphia Center: Friendly SR, proctors, good atmosphere. on my day was about 7 AMG and 4IMG.

My CS Experience:

Guys, like everyone says FA+UW is enough. If you have gone thru 50+ cases you will be fine. Do timed cases, not less than 20-30 I would say, it helps a lot to have an intuitive timer set for 15 min (do not check your watch, it looks bad). I was finishing most of cases at the same moment I asked my final question : do you have any other questions or concerns? the same moment the final announcement sounded. And I believe this time-feeling was v helpful and reduced the stress quite a bit. I did CS before CK, so that proved possible.

English: not a problem I would say, SP are very easy to understand and friendly (unless they have ugly role of course-).

Length of preparation: my suggestion not listen what other ppl say in this respect. each one in a unique situation with regard to fluency in English, clinical experience, exposure to US office practice, etc. so make you own estimate of time needed (can be 4 days or 4 months, just make it realistic).
The most difficult by far was waiting for the results. Thanks God its over! After you exit the center all you remember- mistakes, mistakes and more mistakes. I was sure I would not make it. But now I think if you master very key things – you are thru. Like: knocking, greeting with identifying uself, transitional qns, washing hands, letting know SP what you are about to do and verbalizing physical. I always wrote DD before entering the room so that I remembered to ask ruling out qns (I was last one in a corridor to enter, but worked for me). One more tip: if you reached PE and not sure what to do , start with lung, heart,,abd. Hopefully you will come down and get idea as u move, if not you still have fair chance for scoring some points. In one case I was totally clueless, so did quick standard exam. In some cases I could only list 3 DD. Sooo, no matter how bad you think u have done, wait. It might be over. Exam is about basic skills level.

Notes - practice and more practice again! V. easy to run out of time.
"

Many Thanks Janna Swe, for this sharing your experience and advise ! and hope you are enjoying your Europe Vacation :-)

Google Keywords to this blog:

- "step 2 cs things to do"

HOW MUCH MEDICINE DO THE STANDARDIZED PATIENTS (SPs) KNOW ?

2007-09-11T15:58:00.000-07:00

This is rather something for my own curiosity than readers asking about it - but think it might
interesting to know anyways. What more better source of evidence to answer this question can there be than to look up the SP employment requirements put up by the ECFMG for the SPs - found it an amusing read. You can read it here.

I was of the opinion that maybe they did need to have some medical background if they were to grade medical students, but was surprised to read this on the their job requirement for medical knowledge:

"No. We would teach you what you do need to know. We actually prefer people who have not had medical training, and we do not normally hire medical professionals, nor do we hire medical students or graduates who may be required to take Step 2 CS. The patients you would portray are not medical professionals. Most SPs find that they learn quite a lot from the work and enjoy this. However, we remind them to act like they know less than they really do, in order to keep the simulations realistic."

That brought me thinking of a second question : So what role are they really expected to play in the grading of Step 2 CS Examinees. The document says:

"SPs record the events of the encounters on a checklist and evaluate the examinees on their interpersonal skills and their proficiency in spoken English. These marks are used, along with other indicators of the examinee's performance, in determining the examinee's final score."

So, in effect, while the medical world generally discourages the use of "cook-book" medicine, on the Step 2 CS, students are graded by non-medicos with a cook-book style checklist of questions to tick-off. I totally understand empowering SPs with grading us on interpersonal skills and spoken English, but a little less comfortable about the medical questions / examination checklist - after all, there are a hundred ways to ask the same thing ....

But then again, I don't figure anyone with a medical background would work those monotonous hours for 18 $ an hour either..

Dark Urine / Blood in Urine Case : A Mnemonic

2007-09-11T15:55:00.000-07:00

Don't Let your Mind go Dark in a case of Dark Urine

Again ...a Mnemonic to help you memorize the Differential Diagnosis :

"Fellow Has DARK Pee"

F-Foods like Beet, Blackberry

H- Hematuria

D - Dehydration + Drugs like Rifampin, Vit-B
A - Alkaptonuria
R - Rhabdomyolysis
K - Kernicterus ( well not really - but let the word remind u of Hyerbilirubinuria)

P - Paroxysmal Noct. Hemoglobinuria

Search Keywords to this blog:

- "dark urine errors"

Depression Case on Step 2 CS: A Mnemonic

2007-09-11T15:50:00.000-07:00

Is the depressed SP depressing you ?

Don't be - coz you got help :-)

First things first - get your data collection sorted out (Step 3 of History Taking) - and we a have a mnemonic for doing just that...

This pic should help you remember this mnemonic :

"FACE SLIPS"

Yeah...when depressed and sad , did your face not slip into your hands ? Arrite..here we go :

F - Feelings of : Guilt, anger and worthlessness ?
A - Appetite (include diet , weight history) ?
C - Concentration levels ?
E - Energy levels in daily activities ?

S - Sleep disturbances ?
L - Libido Levels ? + Loneliness ?
I - Interests , hobbies ?
P - Psychomotor symptoms ? Pleasure Levels ?
S - Suicidal Ideation , any plans for suicide...?

So here we are armed with specific data-collection points for history.

But what if ...your SP seems bugged and does not seem to come out with why on earth he/she is sad in the first place...so get smarter and try this :

" I know this is a very tough time in your life, but I assure you that we can deal with this much better together. I really want to understand your problems and help you as a friend and a physician. You said you were perfectly happy and healthy 3 months ago - could you try and tell me what exactly happened 3 months ago that started this ?"

This should hit the nail right on the head ! coz, basically the SPs are trying to assess whether you can connect with them at a emotional level or not ....logical, since they are testing your psychiatry skills...

Sticky Situation: What if SP goes "I want to Die Doctor!"

Hmmm...Again lets modify our formula a bit - "I know this is a very tough time in your life, but I also know that running away from problems is not the answer. I really want to understand your problems and help you get your strength back, because I know it is possible. We can deal with this together."

Some pep-talk like that and gently divert the SP back to your questioning :-)

In a way, if the patient puts on the "I wanna die" comment, it saves you the trouble of ascertaining whether the patient has any suicide ideation ;-) - LOL - Am I mean or funny ? Anyways, here's a way to ask the patient about suicide ideation, as I answered to a reader on the comments to this post.

I prefer the Two Question Series -

Question 1:

"Have you ever felt like you don't want to ever get up from sleep"

OR

"Have you ever had thoughts about ending your life"

Question 2:

"In the recent weeks, did you make any plans or attempts on hurting yourself or killing yourself"

Why two questions ? - coz' asking only the first question can mean nothing - "wanna kill myself" is something I feel & say too when really frustrated with myself, but dont mean it, while asking only the second question could take them off-guard and put the patient on the defensive.

Click here for an article from the American Psychosomatic Society that deals with how to ask about suicide ideation

Search keywords to this blog article:

- "How to tackle depression case on the Step 2 CS"
- "psychiatry cases USMLE step 2 CS"
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Menstrual / Vaginal Bleeding Case : A Mnemonic

2007-09-11T15:36:00.000-07:00

On the first day of my Gyn-Obs clerkship rotations during the second year med-school days, as I stood behind a resident observing, she told me that the first patient was a follow-up case of a PV Bleed. I felt dumb then when I asked - "What's PV?" - he he, but yeah, I was only in my second year ...so maybe we can discount that a bit ! (PV = Per Vaginal)

But now the phrase "A PV BLEED" helps us remember the possible reasons for a PV Bleed...

As always, on the Step 2 CS, let the D/Ds drive hisory taking and your list of Investigations :-) The same mnemonic should also be useful later on your USMLE Step 3 CCS cases!

"A PV BLEED"

A - Abortion + Adenomyosis

P - PID + PCOD
V - Vaginal Injuries

B - Bleeding Diathesis
L - Leiomyomas (fibroids)
E - Ectopic Pregnancy
E - Endometriosis + Endocrine causes (Thyroid, Prolactin)
D - DUB ! (e.g. Anovulatory Cycle)

And another reader, Lisbeysi Calo, MD, was generous enough to share another great mnemonic, which, I admit, is far better than my own ..

"VAGINAL BLEEDS"

V - Vaginal injuries
A - Adenomyosis + Abortion
G - Genital cancer
I - Infections: PID
N - Neoplasms [Maligant(endometrial CA) + benign ( fibromas)
A - Abruptio placentae

B - Beeding disorders
L - Leiomyomas
E - Ectopic pregnancy
E - Endocrinopathies, Endometriosis
D - DUB
S - Sores, Condylomas ( after trauma)

Search keywords to this blog article:

- "what is the reason for a PV bleed"
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Chest Pain Case: A Mnemonic

2007-09-11T15:31:00.000-07:00

A Mnemonic to remember what else you need to ask the SP besides specifics of the pain itself i.e. LIQOR AAA.

This one is of good help for data-collection in a case of chest pain ...

"CHEST P"

C - Cough
H - Hemoptysis
E - Emesis (Vomitting) & Diarrhea
S - Shortness of Breath (SOB), Sweating, Syncope
T - Temperature (Fever), Tenderness on the chest ( chondritis) + Tenderness of Legs (suggestive of DVT that can predispose to Pulm. Embolism)

P - Palpitations - "Did you feel your heart pounding or racing ?"

Now don't tell me u need a mnemonic to remember this mnemonic ;-) . An interesting trivia : The word "mnemonics" is derived from Mnemosyne who, in Greek mythology, was the goddess of memory! That's why it humors me tons when someone spells it as "pneumonic" ..he he

'CHEST P' Mnemonic by Digitaldoc

Knee Pain Case: A Mnemonic

2007-09-11T15:08:00.000-07:00

The Knee is a pretty common injury in Sports....So lets use the word 'SPORT' to our advantage on the Step2CS - a pretty good mnemonic for D/Ds for Knee Pain !!!!

S - Septic arthritis
P - Pseudo-gout + Patello-femoral pain syndrome + Psoriatic arthritis
O - Osteoarthritis
R - Rheumatoid arthritis, Reactive arthritis (Rieters syndrome)
T - Tophi (Gout), Trauma (Fall, Elderly Abuse and SPORTs!)
S - Sac Inflammation (Bursitis)

Again, as I mentioned before, each of these D/Ds should help you ask specific data-collection questions:

For e.g. :
Septic Arthritis : - Ask about fever, and a warm joint feeling
Rheumatoid Arthritis - Ask about morning stiffness and other small joints...and so on.

Shoulder Case on Step 2 CS

2007-09-11T14:56:00.000-07:00

Shoulder examination ?

Let us look at examination for a case of Shoulder Pain (People you gotta supplement this with your standard notes). Assuming that you have already washed, wiped and warmed your hands...

1. Expose both the shoulders - and examine as if you are comparing both shoulders for swelling, deformity. Especially look out for painted bruises - cause those suggest elderly abuse (besides a fall) and implies you got to address that part while counseling.

2. Next, say this to ur SP = "Let us examine your shoulder gently to locate the origin of pain - is that ok ? Let me know immediately if it hurts anytime"

3. Palpate affected shoulder for tenderness and look out for any sign of wincing on the SP's face. Should there be any wincing/moaning, say "sorry that hurt" and never repeat at that site.

4. Ask the patient to perform shoulder motions to check for his/her range of motion - A more effective way to do it is ask the SP to mimic your actions-then you move your shoulder the way you want him to move - simpler than explaining each action and wasting time eh ?

5. The above can aslo be combined with you resisting his motion and checking out strength of motion in addition!

6. And dont forget to feel for his pulses in the affected hand and verify they are felt normally.

A Quick Mnemonic for Shoulder pain D/Ds : (Think of a deformed shoulder)

'DEFORMS'

D - Dislocation
E - Elderly Abuse
F - Fracture
O - Osteoporosis / Osteomyelitis
R - Rotator Cuff Injury
M - Myositis
S - Sac Inflammation (Bursitis) + Sprain (as suggested by a reader in the comments below)

Q. Does the Patient / SP Understand 'abduction', 'flexion' etc. of the shoulder - do we have to spend time explaining all that to him/her ?

A. While asking the patient to perform ANY maneuver, remember that actions speak louder than words - "Could you move your shoulder out like this " for abduction and then doing it yourself to indicate how is better and faster. OR, while checking active Range of Motion (ROM) you could simply say at the start, "Mr. Allen, I will now make various arm movements at my shoulder joint and I want you to copy my actions, to help me understand how severe your problem is - Is that fine ? shall we begin ? "

Search keywords to this blog article:
- "Shoulder case Step 2 cs"
- "examination of shoulder"

Sore Throat Case ? No Probs !!!

2007-09-11T14:53:00.000-07:00

Here's an excellent mnenomic submitted and published with permission from Dr. Birju D. Shah, M.B.B.S, Medical College, Baroda

It is a complete study in itself ! giving all pointers to data-collection and investigations too :-) Applause ...

SORE THROAT WAS BAD !

S- wallowing food is painful ?
O- rigin, Duration, Progress
R- unny Nose
E - ar Problems ?

T- emp ? / Chills ?
H- eadache
R- espi. Sympt - Cough, SOB, Chest pain
O- ccupation ?
A- spiration + Abdominal Symp.- Nausea, Vommiting, Pain (esp in LUQ)
T- iredness(Fatigue), Touch with ill people (ill contacts - boyfriend, girl friend)

W- t. loss ?
A- ppetite Change / Alcohol ?
S- moking Sleep changes ? Sexual History

B - owel Habbit
A - nything else do you wanna tell me ???
D - rugs ( illegal IV drugs ?)

As if this weren't not good enough, we have a another cool one for investigations ! :-)

THROAT

T - hroat Culture
H - IV antibody and viral titer
R - apid streptococcal antigen
O - mOnospot test
A - nit EBV Antibody
T - routine Tests - CBC, Pripheral smear

Handling a Lab-Result Explanation Case ?

2007-09-11T14:45:00.000-07:00

This presents an amusing paradox - on most cases on the CS, we are worried about finishing on time, whereas the main concern on this one is how to expand all you can talk to fit those 15 minutes ! This somehow reminds me of my daytime sleep ;-) it seems to effortless expand and fill-up all the space it gets ;-)

But tell you what, lets have a protocol to tackle any kind of Lab-Result Explanation cases. Here's one for, say, a Trichomonas lab result:

1. Reveal the lab findings to the SP and explain the diagnosis in layman terms
2. Tell the SP it's nothing too serious and explain how Trichomonas is contracted
3. Get History about Vaginal Discharge, then Sexual + Menstrual history
4. History pertaining to other STDs (rash, genital lesions, lymph-nodes, etc.)
4. Ask her if she has any new complaints and tell her you would like to repeat a general physical exam
5. Ask her if she has any specific questions and if she knows how to avoid Trichomonas in future

6. Counseling should cover the following :

a. Explain that both the SP and her partner would treatment.
b. Tell her that if she will put on Metronidazole therapy - alcohol is to be avoided, since that will cause nausea and vomitting (Disulfiram like reaction)
c. Abstinence from sexual intercourse until therapy is complete
d. Counsel on protection, risk of other STDs like HIV & risk of cervical cancer (need for PAP smears) .
e. Ask her if she has had a pregnancy test recently and when - if not done, ask her to consider having that done. (and mention that on your PN as an Investigation)
f. If not pregnant, advise about birth-control methods.

I guess this particular case is more about SEP and CIS component !

On the PN - merely include general exam in the Physical Exam section - the rest of the PN will be like any other case.

Search Keywords that led to this article:

- 'good mnemonic for differential diagnosis'
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THE "GET UP AND GO" TEST

2007-09-11T14:43:00.000-07:00

This test is to used as a measure of balance in elderly patients. I would rather that this test were called "Get up, go and Get back" Test ..you will see why.

How is the Test Done ?

Have the patient sit in a straight-backed chair and ask him/her to:

1. Get up from a chair to standing position
2. Walk forward feet in a straight line
3. Turn back around & walk back to the chair
4. Sit down again

Interpreting the test:

You can either score it by the timing (Less than 20 seconds for the whole procedure is normal , More than 30 seconds indicates gait/balance problems) Or you can score it on a grading system like:

0 - patient does not use arm-rests to get up
1 - uses arm-rest in one attempt
3 - needs multiple attempts
4 - cant get up without assistance

all this Besides noting gait stability while walking

On the USMLE Step 2 CS, I would rather recommend either doing the easy timed method OR simply noting what you observed during the test - like difficutly in getting up , unsteady gait and needed assistance to sit back down..etc.

Now...if only there were a similar test to measure how worthy our politicians really are for their chairs ;-)

Google Keywords to this blog article:

- "standing balance gait"
- "scoring for get up and go tests"

ASKING ABOUT SEXUAL HISTORY

2007-09-11T14:41:00.000-07:00

Check out this logical pattern that I learned during a lecture I attended during my observership sessions - which means this should not only help you for the CS , but also when you get into a residency :-)

Q 1. "Mr. John, Are you Sexually Active ?"

Q 2. "How Many Partners are you active with ?"

Q 3. "Are your partners male or female or both ?" [Unless the SP says wife or husband in question 2]

Q 4. "Do you use protection during intercourse ?"

Q 5. If yes in Q. 4 "What kind of protection do you use?"

Q 6. Ask about anal intercourse in male homosexuals

This should be good enough :-)

Search keywords to this blog article:

- "asking about sexual history"
- "history taking sexual"
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THE "DIX-HALLPIKE" MANUEVER / TEST ?

2007-09-11T14:38:00.000-07:00

Every now and then, on various USMLE forums you come across a message asking about the Dix-Hallpike Test or maneuver ! Since the blog is dedicated to be a beacon of light for everyone thinking of , planning to or taking the CS, here goes ;-) :

This funny-sounding Test is a confirmatory diagnostic test for "Benign Paroxysmal Positional Vertigo", which accounts for probably about 1/5th cases of dizziness in the USA. So, this means, if you get a case of vertigo on the CS, or complaints like "Doctor I get dizzy", "The world goes round and round around me", etc. etc. .you should do this clinical test as a part of Physical Exam.

Beep : Dix-Hallpike test is also called the "Tilt Test" - you will soon see why ...

Yo Digitaldoc ! How do you do this test ?

Get the Standardized Patient (SP) to sit erect on his/her bed. Then, have the SP lie supine on the bed quickly , with the head turned (tilted) 45 degrees to one side and extended about 20 degrees backward. Once supine, the eyes are typically observed for about 30 seconds. If no nystagmus occurs, the person is brought back to sitting stance, only to test again with the head now turned to the opposite side.

On the exam , I don't expect anyone to get a positive test, simply because I don't imagine anyone with the condition actually volunteering to get Nystagmus 12 times a day ! But lets note that this test is considered "Positive" if the patient exhibits a burst of nystagmus when lying supine :-)

Dr. Timothy Cain does a much better job at explaining the test along with cool diagrams ! Click here.

Search keywords to this blog article:

- "dix hall pike"
- "what is tilt test"
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A MNEMONIC FOR HEADACHE CASE

2007-09-11T14:35:00.000-07:00

The girl in this picture is Jennifer and she's got a headache [ she most probably is a medical student ;-)]

Mom: "Jennifer - u holding your head..wuts wrong ? "
Jennifer: Mm...It aches mom

"MM...IT ACHES" - that phrase gives us our mnemonic for the differential diagnoses for a headache..

M - Migraine
M - Meningitis

I - Increased Intracranial Pressure
T - Tension Headache + Temporal Arteritis

A - AV Malformations
C - Cluster Headache
H - Hypertension
E - Eye Disorders (Refractory Errors + Glaucoma)
S - Sinusitis + Sub-Arachnoid Hemorrhage + most Systemic illnesses

[Mnemonic generated by Digitaldoc, MD]

Thus, this mnemonic helps you in the "Step 3" of history taking technique...each D/D suggests a data-collection question. For Example : Photophobia for Meningitis, attack pattern for Cluster headaches along with Eye pain / watering, Auras / Nausea for Migraine, "worst headache of my life" history for Sub-arachnoid hemorrhage / meningitis and so on....

I agree that I am not feeling particularly bright about this mnemonic - but if it does serve your purpose and eases your headache about a Step 2 CS case of headache, I shall give myself a pat my back ;-)

Again, if anyone has clever modifications or additions to this mnemonic, you are welcome to drop a comment below this post and leave us your good name for credits...

Search Keywords to this post:

- "medical differential mnemonic"
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COMMON BRAND NAMES OF DRUGS FOR STEP 2 CS

2007-09-11T14:29:00.000-07:00

What's in a name ? When it comes to drug industry a Brand name synonymous with a drug = Billions of Dollars ! Thanks to the strict patent laws in America, a single drug is associated with a single brand name - unlike some other countries where it isn't unusual to find 20-30 brands of acetaminophen as against the single "Tylenol" in the US. It's good to know that a patent protects the drug brand name for 20 years, wherein the company is expected to recover its costs and make a decent profit. AFTER that period, other companies can produce the same drug as a 'Generic' Drug - which won't be an issue on the Step 2 CS anyways. A Generic drug is usually the chemical name of the main ingredient, not always.

What's more relevant to us is that as a result of the patents business, the layman remembers a drug by the name of the single Brand name ! So if the patient tells you he took a Tylenol when he felt feverish - you don't wanna make a fool of yourself and say "Oh ! does that mean Acetaminophen ?" ('Paracetamol' is not a well-known name in American medico circles) . Forget Step 2 CS, even when you practice real-time, such a question may invoke a blank expression from your patient !

Hence, for the benefit for the IMGs / FMGs, it's a good idea for us to compile some commonly used drugs and their Brand Names in the US.

Tylenol = Acetaminophen / Paracetamol
Advil = Ibuprofen
Allegra = Fenoxifenadine (allergy relief)
Maalox = Antacid (Aluminum Hydroxide and Magnesium Hydroxide)
Mylanta = Antacid (Mg. OH and Ca. Carbonate)
Nexium = Esmoprazole
Prilosec = Omeprazole
Zantac = Ranitidine
Lopressor = Metaprolol
Augmentin = Amoxcillin + Clavulanic Acid
Zyban = Bupripion (Antidepressant + smoking de-addiction )

For that matter, if you are already in the US and watch T.V. , you are bound to see some pharma-commercial daily. Indeed, the pharma biggies spend millions on marketing to earn their billions !

[Shall keep posting more relevant drugs]

Search keywords to this blog article:

- "paracetamol and advil"

Patient Note Tips for Step 2 CS

2007-09-11T14:26:00.000-07:00

Be patient about the 'Patient Note' (PN)

Whew!! You are done with what you dreaded the most - the SP (Standardized Patient) encounter ! You come out of the room relaxed and ready to write the PN - but lets bear in mind that quiet a few people have been failing on the patient note. We need to get professional and have a protocol for that one too !

First things first: To write or type the PN is the question - Personally, I handwrote the PN.

Two reasons for this :

a. Though I type really fast - I tend to type using the Instant Messenger lingo like "ur" instead of "Your", "2" instead of "to" and so on ...and with the tense atmosphere I was sure I will make those errors subconsciously
b. What if the computer shut down or something ? .Aaaaaaarrrrggggh !!! I know a few unfortunate guys whose scores were not reported due to technical errors on the USMLE Step1 and Step2 exams. Not heard that on the CS yet...but...what if...

General Rules for PN :

a. Practice , practice , practice writin' patiently within 9 minutes
b. Broken English is fine , like Google keywords ! Grammar can take a back seat
c. Have a protocol like the one mentioned below to manage time well !
d. Use only standard abbreviations permissible on the PN - Read more about this below
e. D/Ds don't have to be 5 in number ! You could write even 2 or 3 but its EXTREMELY IMPORTANT that you arrange them in the order of relevance / possibility to the SP that you saw !
f. Some people tend to mention therapy in the Management - NEVER do that , you are only supposed to write Investigations on the USMLE Step 2 CS Exam.

My Protocol for completing a PN on time :

1. D/D and Management first
2. Then Chief Complaints and their description
3. Significant Negative History
4. Systemic Examination

This ensures that the Higher grade-earning points are done within time.

5. In the time left, finish off PAM HUGS FOSS and General Examination (Always copy vitals from the door please - even if you got different readings !)

Sample Patient Note: If you would like to see two examples of handwritten Patient Notes - follow the PN sample link on the Left side-bar. The pages have been extracted from the old ECFMG CSA manual and gives two excellent samples - one using complete sentences and one using short broken english. Both are acceptable, though I recommend practing the short way to save time :-)

By the way, for your D/D needs - I highly recommend wrongdiagnosis.com ! - an excellent resource...

Q. My Handwriting Sucks and looks pathetic - will I lose Points ?
A. Well, as long as it is UNDERSTANDABLE - you are fine. If it is totally illegible and cannot be understood - either due to miserably bad handwriting or appalling spelling errors, you lose points. And this is what USMLE.org has to say:

"The patient note is considered a communication tool; poor legibility or spelling errors that interfere with the patient note reader's ability to comprehend the note may have a negative impact on your score. If your handwriting is difficult to read, you should probably type your patient note."

Basically practice writing some timed PNs and ask someone to read it - if his/her tempers shoot up due to irritation caused by inability to understand what you wrote, you need to either practice more or seriously reconsider typing ;-)

Q. Are we allowed to use Abbreviations on the PN ? Do you have a List of acceptable abbreviations for USMLE Step 2 CS?
A. OYOCYC ! Did you get that ? It was MY abbreviation for "Oh Yeah Of course You Can" - note how it puzzled you a bit. Now imagine trying to decipher thousands of wierd abbreviations ! The point is that you don't wanna bug the examiners with abbreviations that seem very commonplace to YOU. Let's either not use them at ALL, or keep them at minimum with Standard Abbreviations. Click Here to look at the list of Standard Abbreviations for the Patient Note as published by the 2007 USMLE Step 2 CS Manual.I hardly used any myself though !

Q. Do we mention about counseling on the PN - like DM , HT, etc. ?
A. No ! Counseling only inside the room with the SP :-) The Patient Note is only for D/Ds, Findings, History and Investigations - No Interventions !

Q. I wanna practice typing the Patient Note - is there a sample Patient Note Simulation online?
A. Sure ! Usmle.org site has exactly that - Click here

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Sticky SP Encounter Situation B

2007-09-11T14:24:00.000-07:00

Patient moving with extreme pain on the bed the moment you enter the room !

1. Introduce Yourself with appropriate soberness
2. Say "I am sorry that you are in so much pain - I shall go through some quick questions and physical examination - as soon as I am done, I shall promptly have my nurse give you something for your pain. I only ask you to bear with me for a few minutes - Is that ok Mr. Clinton?"
3. Drape the SP
4. Start

Search Keywords to this blog article:

- "usmle CSA note form"
- "Do we examine a patient on an area of extreme tenderness on abdomen?"

Sticky SP Encounter Situation A

2007-09-11T14:22:00.000-07:00

Patient refuses to answer questions about his/her sexual history?

"Dear Mrs. Bush, I understand the sensitive nature of this question, but be assured that this will not go out of this room. The way clinical medicine works, there may be important clues hidden in this kind of information and I want to do my best to help you. So shall we try answering these questions again ?"

LIST OF ACCEPTABLE ABBREVIATIONS / SHORT-FORMS FOR THE PATIENT NOTE:

2007-09-11T14:18:00.000-07:00

Short, they say, is good at times. In fact, I was amazed to find a amazing support organization for short people explaining the various physical and biological advantages of being short. I do recommend giving that a read Here.

Well, on the Step 2 CS, if it saves time , short-hand or Abbreviations are cool for the Patient Note :-)

I have borrowed these Standard Clinical History Abbreviations from the USMLE.org site, since many readers have complained that it was not easy searching for these there. Please do not labor to memorize these, have a general idea and only use the ones that you are comfortable with or get used to while you practice. Coz, on the exam, in your effort to save time using abbreviations, you may actually waste more time trying hard recalling them and then not even being sure of it..he he. And secondly , remember that every writing station at the Step 2 CS Exam center (i.e. the cubicle immediately outside the SP's room where you are supposed to write the Patient Note) , will have this list of abbreviations.

So Read on:


yo    year-old
m     male
f     female
b     black
w     white
L     left
R     right
hx    history
h/o   history of
c/o   complaining of
NL    normal limits
WNL   within normal limits
Ø     without or no
+     positive
-     negative


Abd    abdomen
AIDS   acquired immune deficiency syndrome
AP     anteroposterior
BUN    blood urea nitrogen
CABG   coronary artery bypass grafting
CBC    complete blood count
CCU    cardiac care unit
cig    cigarettes
CHF    congestive heart failure
COPD   chronic obstructive pulmonary disease
CPR    cardiopulmonary resuscitation
CT     computed tomography
CVA    cerebrovascular accident
CVP    central venous pressure
CXR    chest x-ray
DM     diabetes mellitus
DTR    deep tendon reflexes
ECG    electrocardiogram
ED     emergency department
EMT    emergency medical technician
ENT    ears, nose, and throat
EOM    extraocular muscles
ETOH   alcohol
Ext    extremities
FH     family history
GI     gastrointestinal
GU     genitourinary
HEENT  head, eyes, ears, nose, and throat
HIV    human immunodeficiency virus
HTN    hypertension
IM     intramuscularly
IV     intravenously
JVD    jugular venous distention
KUB    kidney, ureter, and bladder
LMP    last menstrual period
LP     lumbar puncture
MI     myocardial infarction
MRI    magnetic resonance imaging
MVA    motor vehicle accident
Neuro  neurologic
NIDDM  non-insulin-dependent diabetes mellitus
NKA    no known allergies
NKDA   no known drug allergy
NSR    normal sinus rhythm
PA     posteroanterior
PERLA  pupils equal, react to light and accommodation
po     orally
PT     prothrombin time
PTT    partial prothrombin time
RBC    red blood cells
SH     social history
TIA    transient ischemic attack
U/A    urinalysis
URI    upper respiratory tract infection
WBC    white blood cells

Wut ? Did I hear you say "I like it" ? ...Well, Thank you, thank you, thank you ..

Note: (As per USMLE site) : This is not intended to be a complete list of acceptable abbreviations, but rather represents the types of common abbreviations that may be used on the patient note. There is no need to use abbreviations on the patient note; if you are in doubt about the correct abbreviation, write it out.

Google Keywords to this blog article:

- "aCCEPTABLE ABBREVIATIONS Step 2 CS"

Most Common Errors on the USMLE Step2CS

2007-09-11T14:16:00.000-07:00

All IMGs - do take note of these and avoid them :-)

Not washing hands before phy. exam

Not calling SP by name

Not looking for Carotid Bruit and JVP (cardiac SP)

Not mentioning D/Ds in the descending order of probablity on PN

Not using ophthalmoscope in HT, DM or visual complaints

Not asking about Hematuria in a case of Hemoptysis (& vice-versa)

Not asking SP for permission to examine

Not asking menstrual history in a female SP

Not counselling about smoking and alcoholism

Not using Layman language & wasting time explaining medical terms

Not inquiring about Illicit Drug Use

Not displaying sympathy to the patient

Not warming up the Stethoscope bell before auscultating

And can you guess the most deadly error after the exam is done ? Giving out the cases on Forums and Chats !! That's not me saying people - Read this message from ECFMG - Copy-paste this link "http://ecfmg.org/announce.htm#irreg"

g/l

Phone Encounter Case ! : A Mnemonic

2007-09-11T14:09:00.000-07:00

Inside the Telephone Room: Wouldn't it be hilarious if someone actually knocks on the door for a phone case ? Ha ha..hmmm...Jokes apart - after you enter, wait till you are ready, then pick up the handset and press the Red Button/Yellow Button on the phone when you are ready ! However, please follow the instructions given to you before the test - they may change. One useful hint - Smile while you pick up - will show in your speech and also give you more confidence. And don't forget to write your mnemonics on your paper before you start !

Personally, I feel a Telephone case is simpler as there is no clinical physical examination which gives you a comfortable time to finish the case well within 15 minutes (I was done in 10 !)

Instructions for using the Telephone:

These instructions come from USMLE.org :

When you enter the room, sit at the desk in front of the telephone.

* Do not dial any numbers.
* Push the speaker button by the yellow dot on the phone to be connected to the patient
caregiver or patient.
* You will be permitted to make only one phone call.
* Do not touch any buttons on the phone until you are ready to end the call – touching any buttons may disconnect you.
* You will not be allowed to call back after the call is disconnected.

Handling a Telephone Case:

Handle it like any other case, don't forget to ask the kid's name and refer to him/her by name.
At the end of your questions, explain possible diagnoses and mention that you need to examine the kid and do some investigations. If the mom has no time / no car / no one else to get the kid - ask her to call 911 !! And don't forget to keep the kid sipping on a rehydrating solution like Pedilyte or home-made ORS (See Below)

Most people seem to be failing on the CS due to inadequate data collection. If this is of any help, I would like to share a mnemonic I formulated to ensure u ask everything during a phone encounter for a case of diarrhea in an infant ( The person on the other end would typically be the kid's mom )

"ON CALL IDIOT"
['On Call'since this is a phone encounter] - please dont think about "idiot" being offnesive - it is just a mnemonic people !

O - Onset ?
N - Number of Times a Day?

C - Consistency ? / Color? / Content ? [Blood, Fat, Mucous ?] + Crying ? Cramps Suggestive ?
A - Associated Symptoms [Fever, Runny Nose, Rash, Cough, Ear Discharge, Vomitting, Rash ?]
L - Listless baby ? Lethargic, not Sleeping ?
L - Liquids not passing ? [i.e. not urinating ?]

I - Immunization up to date ?
D - Diet Change ? Dehydration signs ? Day Care Center ? Developmental Milestones
I - Infections in family ? Immunicompromised mom ? [HIV ?]
O - ORS counseling (Oral Rehydration Solution - see below)
T - Travel history recently ?

Write this mnemonic down on ur sheet while you sit front of the telephone, before u pick it up...and u are ready to rock and roll !! practice the order of questioning at home on a phone while u practice with ur study partner!

For a case of vomitting, I guess you can tweak the mnemonic a bit !

Practice this with a phone partner and encourage the person at the other end to ask you challenge questions..

ORS Counseling : Enquire if the woman knows about Oral Rehydration Solution and whether she has Pedialyte at home - if Yes, she can start having her baby sip on it. If she does not, you can suggest a quick home-made solution like this:

1. Water - 4 Cups
2. Salt - 1 TeaSpoon
3. Sugar - 8 TeaSpoons

And yes ....you do have to write a PN even for a Phone Case - but leave the physical examination section blank ...or perhaps a better idea would be to write "Will be performed when Damian arrives at the hospital"

Rock-N-Roll

Q. Does everyone always get a Phone Case / Telephone Encounter ?
A. Not Always ! On the other hand, some may even get two phone cases...

-------
On these lines, did you heard of the man who called and spoke frantically into the phone, "My wife is pregnant, and her contractions are only two minutes apart!"
Resident : "Is this her first child?"
Man: "No, you idiot!" the man shouts. "This is her husband!"

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A Potent Mnemonic for Impotence Case

2007-09-11T14:06:00.000-07:00

LIMP P³ENIS

When things don't stand ... it's time to use this outstanding mnemonic for data-collection in a case of Erectile Dysfunction on the Step 2 CS ;-)

L-ibido changes
I-njury
M-edications (B-blockers)
P-ast medical history (HTN, DM, Vascular= e.g.: Leriche Syndrome)

P-revious prostate Sx
P-erformance Anxiety
P-eyronie's Disease
E-rection at all? (Are you able to have an erection at all?)
N-octurnal erection ?
I-ncontinence
S-tress/Depression

Published with persmission from:
Lea Ramos-Famularcano, MD (Thanks !)

Note : If you have an excellent Mnemonic that you are willing to share - your mnemonic will be featured on this site with your name [why not have a little fame ;-)]. The only requirement is that the mnemonic must be highly suggestive of what it represents !

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Blood in Stools Case (Hematochezia): Mnemonic

2007-09-11T14:03:00.000-07:00

Not to confuse this with Melena, which implies black tarry stools (most commonly due to a bleed within the upper Gastrointestinal track making the blood turn black due to it's digestion to hematin).

Hematochezia is frank blood that goes down the drain - i mean the Pot :-) I used the word Drain here for a reason : A Mnemonic !!

DRAIN gives us the D/Ds for Hematochezia :

D - Diverticulosis (Most Common Reason)
R - Rectal Bleed [Piles, Fissures]
A - Angiodysplasis + Anal Sex
I - Inflammatory Bowel Disease [UC + Crohn's], Infectious Diarrhea, Ischemic Colitis + Injury (as suggested by a cool reader)
N - Neoplasms

Not bad huh !

Speaking of toilets, my dad once sent me a forward about some restaurant that was themed on restrooms (American for toilet) ...Check out this picture ...Jeeeezz !

Does anyone know what place is this ? leave us a comment :-)

Google Keywords to this blog article:

- "usmleworld free download"
- "How to copy from USMLE WORLD" (Huh ! Someone's trying to be illegal here ;-))

How to make a Mnemonic Online !

2007-09-11T14:01:00.000-07:00

The nerdy looking alien you see in this pic makes them for me..he he

But yeah, seriously, do you really want to spend your vital time trying combinations & permutations of letters to make a sensible word ? How about a computer to do the same for you ?

So click that mouse HERE to take you a fast site that does just that. Merely supply the alphabet letters in the box and throw in 1 or 2 vowels additionally , if there are none to begin with and Presto ! Of all the possible results you get - try to choose a word that you can associate the most with what you are trying to remember :-)

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Doctor's / White Coats & Step 2 CS ...

2007-09-11T10:51:00.001-07:00

There was some Hollywood Movie, I don't recollect which, which had this funny miserly guy all dressed up in Suit and formals and all, arrives home daily and removes his suit - and what do you see ! Within that suit , the only components he actually wears is what was visible from outside ;-) The Collars and the upper half of the shirt, A Half Tie and Formal Sleeves - Thats it ... And when he opens his closet , he has a nice collection of these half components. I think that was genius at work - afterall , who's gonna know whether you are actually wearing a complete shirt or a complete tie within that suit ? He He

No , I am not suggesting you do the same with the Step 2 CS and your Doctors Coats ;-) But, on those lines, I really don't see a strict need for wearing a complete Suit and stuff - a formal comfortable shirt with a tie , good trousers with a formal belt works just fine - most of it is gonna be hidden inside your coat ;-)

Oh Well..this post is about Doctor's coats - so lets get back on track.

1. Yes, You need to have a doctor's coat for the exam

2. Yes, Exam centers do provide you with a Doctor's Coat and they will ask you if you need a coat and a sthethoscope before the exam begins - but I still suggest you arrange for you own - coz I am not sure if those coats are washed very often and how many people wore it before.

3. Which Type of Coat to get ? There are two kinds of coats : A Knee-Length coat that goes all the way to your knees and the other one is a Medical Student Coat (Also called a Lab Coat) that travels upto the middle of your thighs. I recommend using this second category of coats for the exam - since the first is used when we become full-fledged residents / physicians :-).

Ofcourse make sure the one you eventually get is Full-Sleeved , neat and not torn

4. Where can you get them ? : Besides Borrowing and Stealing - You can get good deals for Coats Here! If you get one less than 25-30$ - Its a fair deal.

5. What !! Your coat has your name tag and your Med-school tag too ? You are screwed man ! - He He Kiddin' ! Don't worry about that - the proctor will provide you with a sticky tape large enough to cover all that up :-)

This Last Picture demonstrates How NOT TO GO for the Step 2 CS ;-)

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STEP 2 CS Attire / Dress Code / Clothes for the Males / Guys

2007-09-11T10:48:00.001-07:00

Royal Blue, Sky Blue, White or a Grey shirt with an appropriate sober tie and formal pants are good. Though some people wear suits, I preferred not going ballistic over dressing and I kept mine simple, comfortable yet professional. After all, your dressing is only going to matter inside the SP's room, where you have a doctor's coat almost completely covering your shirt :-) and additionally I did not have to stress over carrying an extra suit-luggage item with me. So lets keep the suits for those Residency Interviews Later! ( I don't mean suits are wrong - I merely expressed my opinion !)
Also, lets keep nails and hair trimmed and our shoes be a formal black or brown...( Well if you are stickler for attire - I guess you would wanna match your shoes color to the color of your belt !)

Lastly, Americans hate body odor - deodarants /Perfumes recommended ! Don't make them too strong though - I used light sprayings of Polo Blue By Ralph Lauren perfume on a Tag Deodarant base. [always get me compliments now and then ;-)]

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Did You Fail on the USMLE Step 2 CS ?

2007-09-11T10:43:00.000-07:00

Failed & feeling blue ?

No - I wouldn't say "It is OK, next time" and I wouldn't say "Don't worry" .

Take the defeat to your stride, keep aside all wrong emotions that pin you down, think not of the world pointing fingers and do not drown yourself in self-pity.

In the last 25 to 35 years of your life, we all have seen so many defeats and we were dejected each time...but life never stopped, did it ? Instead, we moved on with more successes and surprises.

Some very big things are waiting to happen - it's upto us to keep moving, to reach out to them, to try again to get on the other side of each hurdle. Since you now know how the exam is conducted and what is graded, the ball is your court this time. So dear pal, reboot yourself - it's time to spend some time with yourself, to reflect and to contemplate - not on your defeat but on your strengths. Strategize by listing down the errors you think you made and get ready for another attempt.

Use the score-report to your advantage to focus on what you are lacking. If you did not have a practice partner the first time, find one now.

"Throw your guilt into the fire,
Let success be a constant desire...
coz' if you do it right the next,
A 1000 others...you will Inspire..."

A Smile....Makes you beautiful and strong!

Speaking of smiles, On the lighter side - did you hear about these lady robbers who smiled and laughed even as they robbed a bank ?

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Case of Amenorrhea

2007-09-11T10:40:00.000-07:00

A Stupid Mnemonic for Amenorrhea !!!

Well..calling it stupid coz the word really means nothing and it against my principles of having a mnemonic that is self-suggestive. This one really means nothing - Do you even wanna know what it is ? ..well..if you think it will help you on the CS -( coz it did help me ) so why not !!!!!

P⁶ A⁵

i.e. PPPPP AAAAA

P- regnancy
P - rolactinemia (Prolactinoma / Hypothyroidism)
P - COD
P - ills
P - erimenopausal woman (ask for Hot flashes / Dry Vagina)
P - Post-Partum Hemorrhage (As suggested by a kind reader)

A - Anorexia Nervosa
A - novulatory cycles
A - nxiety
A - sherman's syndome
A - Adrenal Hyperfunction !

This includes the common causes - others to keep in mind would be those loads of genetic abnormalities .

And please please oh please... do not forget to ask about menarche :-)

Heel Pain Case : Mnemonic

2007-09-11T10:39:00.000-07:00

Heel Pains ? Foot Pains ? Same thing ? Well almost - atleast for the sake of our Mnemonic for Heel Pain ;-)

This mnemonic was generously contributed by Dr. Nikhil Gohokar, MD [ GMC - Nagpur, India]

"FOOT PAINS"

F - Fat Atrophy of the heel (age related)
O - Osteomyelitis (not common)
O - Osteoporosis (not common)
T - Tarsal Tunnel Syndrome, Tendonitis (Achilles) + Tumor

P - Plantar fascitis (Most Common Cause), Periostitis(Calcaneum)
A - Apophysitis (Calcaneal), Arthitis (Reiters, Rheumatoid, Reactive)
I - Ischemia (Peripheral Vacular Disease)
N - Nerve Entrapment (Jogger's Foot)
S - Stress Fractures in Athletes and Spurs in Bone (Calcaneum)

Thus, the above mnemonic also tells us what questions to ask in the history taking, as per the Steps I mentioned in the Art of History Taking. Applying the steps to this case ...

Step 1 - Patient tells you that his heel pains

Step 2 - you gotta drill him about the pain (LIQOR AAA)

Step 3 - Data-Collection for this case ( Ask about leg swelling, redness, fever, trauma history, footwear preference, walking habits, long standing hours, morning stiffness, rashes, etc.)

Step 4 - Other Leg symptoms you can think of - like Numbness [Can u feel the heel ;-)], tingling, weakness, et. )

Step 5 - Complications like associated Knee Pain due to change in gait - and then move on to PAM HUGS FOSS..

Hope this is a good indicator of how to go about a case using the history-taking steps...

g/l

To read more about Heel Pain - Check this out !

A few pointer to Clinical Exam in Heel Pain :

As in Shoulder pain, expose Both Feet ! Then check out for swelling, redness, foreign body and trauma signs in Inspection along with range of active movements. Next palpation: first check for warmth (active inflammation) , superficial and deep palpation to pinpoint location. Then go ahead and check peripheral pulses, sensations over both feet, passive joint movements , power, etc...

At each stage, dont forget to compare with the normal leg..

Finally ask the Pt. to walk to futher qualify the pain

Counseling for heel pain ?
1. Use soft-heeled or soft-padded footware
2. Refrain from long standing or long walking
3. See us again if presribed pain medications do not work

Using Gloves on the USMLE Step 2 CS Exam

2007-09-11T10:36:00.000-07:00

I have been avoiding writing anything about gloves for a while - coz the topic always seems to be debatable - at the same time I don't wanna risk sounding diplomatic. So let me just tell u how I handled it and suggest a few more points.

1. I did not use Gloves at all. The pro-gloves student society might say a big "U Nuts ? How about Oral exam". Well, I simply asked the patient to open up his mouth , while I shined in a torch and said "Aaaaah" - that was good enough an oral exam for me (for this exam at least, that is) .

2. On the other hand, there have been some people who have used gloves for the whole physical examination and avoided the hand-washing 'ceremony' ;-) - But I did not and I would not do it even with real patients. Unless, of course, I had to examine a possibly infectious rash or other infective skin lesions or actively bleeding wounds - I would have worn gloves but I did not have such cases warranting use of gloves.

(Light Bruises and other non-bleeding wounds - no need for gloves, u can feel around them for tenderness which automatically means the main wound is tender too ..right ?)

If I come across any other concerned issues, or if you can point them out to me, shall put them up !

Q. My Hands get abnormally sweaty (Hyperhidrosis) - Should I use gloves ?
A. Analyze how serious is the problem with your practice partner - I mean, do your hands really cause embarassment and discomfort during physical examination ? Your practice partner should be able to tell. If yes, gloves should be fine. About specific treatments, I happened to read this article on Sweaty Hands and Feet on the website of Americal Academy of Family Physicians

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Auscultating Patients (SPs) on the Step 2 CS

2007-09-11T10:34:00.000-07:00

Yo Listen up yall ! This is 'bout Auscultation...

Many of us always have doubts about how far should we go about auscultation on the Step 2 CS - especially if the case is not about Cardiac conditions or Respiratory condition. Do we auscultate in other cases at all ?

Let's keep a simple rule:

Ausculate the usual complete details in a CVS and RS case - in ALL OTHER cases, with the SP in a sitting position , quickly listen to the four heart valve areas and then listen to the breath sounds at the lung bases on the front of the chest in a sitting position (should cost you about 30-45 seconds). So with the SP sitting we go, "Lets quickly listen to your heart - would you mind holding your breath for 5 seconds". And then "That was great, lets listen to what your lungs have to say - could you take in a deep breath Mr. Knoxville" ........... and you are done :-)

Notable Reminders:

1. Ofcourse for a GI case - you will be auscultating for bowel sounds

2. In a CVS and stroke case - in addition you need to auscultate for Carotid Bruit !
3. And between all the smiles and dialogues and acting ...remember to warm up the diaphragm before use !

4. Do not auscultate over the gown - go under the gown if you have not exposed the area already

5. One excellent and valuable tip from Jay Raj, MD, which he employed to good effect on the Step 2 CS! These are his words :

"I did do one thing which I have not seen any one telling on all these USMLE forums or USMLE books and that was cleaning the stethoscope with an Etoh swab (Alcohol / Spirit Swab), each time I started a physical. I always asked the SPs if they were allergic to Etoh, before using the swab to clean. Each time I did this, I noticed an instant pleasant response on all SP faces. It was obvious that no one was using this hygiene technique on the exam. I strongly recommend it! Honestly all these patients in exam are being seen by all those examinees with one stethoscope touching all 12 patients. You can try imagining if you would like if it yourself if it is cleand infront of you before put on to your skin ! I believe it helped me big time in passing the Step 2 CS Exam - Since it is heavily dependent on how you perform with SP's"

Well done Jay and Thanks for generously contributing this tip !

Q. Do we need to use only Littmann stethoscope or will any steth do ?

A. Any brand of stethoscope will do as long as it appears in a good, working condition - there will hardly be any positive findings anyways (but I don't mean to say that you should not listen carefully for murmurs, rales and ronchi, bowel sounds and bruit )

Useful Links:

- Buy Littman or other stethoscopes for Less: Click Here for yours!

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- "littmann stethoscopes usmle"
- "carotid bruit step 2 cs"
- "heart sounds step 2 cs"
- "where to put stethoscope to listen to lung sounds"
- "clinical skills auscultate over gown"
_ "auscultation videos"

Measuring JVP (Jugular Venous Pressure)

2007-09-11T10:31:00.001-07:00

After ur general examination...i.e. 'PICKLE'

1. Recline the patient at 45 degress..
2. "Before we look at the heart, I need to see if I can see any
pulsations on your neck - could you please look to your left Mr. Smith ...Thank you"
3. Shine a light on the neck so that light falls almost at 180 degrees on the surface - Of course u woudn't see any pulsations on the Step 2 CS test (No need to get your own pen-light to the exam, use the light from the Otoscope hung on wall of the SP room !)
4. After u are done , then proceed to auscultate for carotid bruit..

U dont need to 'measure' with rulers and all since you will not see a raised JVP in a normal SP....fine tuning our acting skills aren't we ?

*****

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Measuring Blood Pressure on Step 2 CS

2007-09-11T10:28:00.000-07:00

Were you planning to measure BP?

Don't need to - Yeah ! you heard me - you don't need to measure it on the Step 2 CS - All measurements provided on the door are to be assumed to be officially recent and accurate.

This is what the instructions on the ECFMG site manual for Step 2 CS says:

"The examinee instruction sheet gives you specific instructions and indicates the patient's name, age, gender, and reason for visiting the doctor. It also indicates his or her vital signs, including heart rate, blood pressure, temperature (centigrade and Fahrenheit), and respiratory rate, unless instructions indicate otherwise. You can accept the vital signs on the examinee instruction sheet as accurate, and do not necessarily need to repeat them unless you believe the case specifically requires it. For instance, you may encounter patient problems or conditions that suggest the need to confirm or re-check the recorded vital signs and/or perform specific maneuvers in measuring the vital signs. However, if you do repeat the vital signs, with or without additional maneuvers, you should consider the vital signs that were originally listed as accurate when developing your differential diagnosis and work-up plan"

Secondly, when you land up on the test center for the pre-test orientation, a video will tell you the same thing !

However, you need to tackle it on your Patient Note :

1. Do mention the exact Blood Pressure measurements provided to you on the door

2. If the case warrants checking Orthostatic Blood Pressures and other pressure measurement tests - definitely mention that as a diagnostic workup on the Patient Note, don't have to do it inside the room

3. Even in a suspected case of Aortic Dissection, mention BP measurement in both arms as an Investigation on ur PN ...

Hmmmm...having said this - I might consider actually measuring the SP's B.P. in these cases - if time permits ...

a. Pre-Employment check-up
b. Hypertension Follow-up

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- "Should we measure BP on the Step 2 CS?"
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Using the Opthalmoscope on the Step 2 CS

2007-09-11T10:25:00.000-07:00

Darn ! Are you forgetting that Ophthalmoscope...

Well bad news and good news ...

Bad News - Yes you do need to use the Ophthalmoscope....

Good News - Only required if the patient gives a history of Hypertension, Diabetes and Visual Complaints ..

Very Good News - You only need to 'pretend' that you are using it , but you got to pretend in a technically correct fashion. Look at the dude using one in this picture...

Switch it on ..ask the patient to gaze across the room and inform her/him that you will shining a small light into her/his eye to have a closer look. Then holding the instrument in front of, say, your right eye, shine the light on the patients right eye....

What I am trying to stress here is that if it is your left eye, then shine on the patient's left eye - basically the eye diagonally opposite to yours. When you right the Patient Note outside the room, just make a mention that u did it !

One more thing to soothe your nervous neurons - you have enough time before the exam to handle the instruments , switch on he light, etc. - cooooooooool !

Q. Do you need to get your own Ophthalmoscope ?

A. No !

Q. How do you write Opthalmoscopy findings on the Patient Note ?

A. 'No Abnormalities Detected on Ophthalmoscopy' - or you could be more explicit like the reader mentioned in the comments below : "ophthalmoscopic examination : No retinal exudates , A-V malformations, or hemorrhage."

*****

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Female Chest Examination

2007-09-11T10:21:00.000-07:00

Many exam takers have questions about modesty concerns while examining the chest of a female patient. Here are the facts you should know so that you don't get your SP angry and embarass yourself !

1. It is perfectly OK to expose the Bra in a female SP - - BUT politely inform the patient before proceeding to untie the gown knot present behind her neck. So, you go : "I will need to untie your gown & expose your chest to listen to your heart / lungs properly- hope it is fine with you".

2. Never Never NEVER remove or even attempt to remove or even go underneath the Bra - it is enough to auscultate around it or maybe a little area over it at the borders.

3. After you are done with examination, you inform the SP and say "You can now tie it back - thankyou"

They told us this before the exam started - so it is not something I made up - this is standard people :-) So just follow this , feel comfortable and both you and the SP will be all smiles !

****

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Draping Patients on the Step 2 CS

2007-09-11T10:14:00.000-07:00

Drape them right dude !

The pic shows how to 'Drape' the patient in a case of Abdominal Examination. Notice that the 'gown' (SP's Shirt) is pulled up to expose just the abdoment. For the rest of the cases, the SP will be sitting and we only have to take the drape and cover the legs while the SP is sitting...

Under no circumstances will we ever need to expose the area below the waist - remember that !

Q. Where's the Drape placed in the exam room ?

A. Neatly folded on a stool right next to the SP !

Q. Do I need to fold the drape back before I leave ?

A. No - just leave it as it is on the SP - they fold it back for the next student ...

Q. What about the SP's gown ?

A. The SP will be wearing in his gown

Q. So are the SPs completely naked under the gown !

A. No. They do have their underclothing on. This is what the ECFMG Manual for the SPs says:

"SPs wear hospital gowns so that the examinees can perform physical examinations. You would keep your underwear on underneath the gown. In some cases, the examinee may check certain pulses underneath the patient's underwear, but the underwear does not need to be removed."

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The Dreaded MMSE (Mini-Mental Status Exam)

2007-09-11T10:11:00.000-07:00

Breath in - Breath out - Breath in - Breath out and relax.......feeling the tension ease away ? :-) The MMSE is really not such a big deal as your mind and peers would make it sound like - provided you are prepared for it. Here's what you need:

First things first- When to do an MMSE ? In cases of non-focal-deficit CNS Cases like memory Loss / dementia, Delirium / Confusion, Delusions / Schizophrenia.

Would you do it for every CNS Case?Not really - use priority + time judgement. If patient has a symptoms suggestive of Focal Neurological Lesion/s - Its more important to do a complete CNS exam + gait and then think about MMSE.

Note: Sometimes the Case Description on the door may mentioned that the MMSE has already been performed and may indicate the score or say it was normal - in such cases, DO NOT DO THE MMSE and waste time ( All data provided by the test center is to be assumed to be correct)

So, how do we do a MMSE ? Its basically a series of questions to ask the SP to test various basic brain functions to assess the degree of its dysfunction. If you practice talking this with your practice buddy or even with yourself while having that great warm water bath, after a while - trust me on this - it becomes very easy to rattle it out! The titles in blue tell you which quality is being tested.

Before you begin the MMSE, use a statement like this,

"Mr. Watson, I will now ask you simple questions to test your memory and thinking, shall we begin ?"

ORIENTATION

1. Which state or city are u in ?
2. What's your name OR Do you know who I am ?
3. Can you guess what time it is now ?

REGISTRATION

Mention three objects slowly and clearly - ask the patient to repeat once u are done. (e.g. Pen, Watch, Ball)

ATTENTION AND CALCULATION

1. Ask patient to say "WORLD" backwords
2. Ask patient to count back from 7

RECALL

Ask the patient to repeat again those 3 words u told him before (To not forget these yourself in the heat of the exam, practice with three standard words ready)

LANGUAGE

Show him ur pen - ask him wut color is it

COMMAND FOLLOWING

On a piece of paper, draw intersecting pentagons, each side about one inch and ask him to copy it exactly as it is. To score correctly, all ten angles must be present AND two must intersect. Tremor and rotation are ignored.

No - I don't want you to only memorize this and think you are done - the importance of actually practicing it is having standard dialogues ready to perform the MMSE - so practice talking...then practice again ...do the MMSE questions flow out of your mouth as easily as that crappy hit song that you have been humming ? lol...

Here's a another useful link explaining how to go about performing and scoring the MMSE (Thanks to the kind reader who left the link for us as a comment)

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Miss or Mrs. ?

2007-09-11T10:08:00.000-07:00

Another concern that has been doing the rounds on many IMG USMLE forums now and then is the issue of addressing a female SP! And brings us to an interesting light discussion here. It is amusing how a 'Miss' is hurt by calling her a 'Mrs.' while a 'Mrs.' is bugged when you push her to her teens by calling her a 'Miss' - Remember Freaky Friday ? ;-)
- which although is not universal , coz some 'Mrs.' do feel complimented by a 'Miss'.

Back to our topic - A good way out is to use the Marriage-Neutral "Ms." ! Pronounced as "Mizz"
Another good alternative is simply asking the lady how she would like to be addressed - once you have introduced yourself - am sure that question will also make you sound more courteous...

Feel the need to read more ? Check out this Wikipedia Entry on Ms.

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Snellen's Chart, Visual Acuity and Step 2 CS ?

2007-09-11T10:03:00.000-07:00

So should you perform the Snellen's chart reading on the CS ? Don't bother about it on the CS ... merely mention that as an Investigation on the Patient Note (PN). But yeah guys - do the Finger counting test instead.

This is how : Ask the SP to look striaght ahead and then hold your fingers in front of the SP at approximately 3 feet from his/her eyes. Request the SP to count them for you. Now, in real life situations, if the patient cannot count them - it means you gotta perform the next level of testing - that is moving finger test for motion detection. But on the Step 2 CS , since the SPs have normal vision, you wouldn't need to go that far.

On the patient note, mention "visual acuity done by Finger Counting at 3 Feet". And of course mention Snellen's chart testing for visual acuity on the Patient Note, [ repeating that in case your eyes missed that on the first line ;-) ]

Q. On what cases would you bother testing visual Acuity ?

A. Cases with Visual Problems, cases where visual complications can occur, like DM, HT AND in cases where you will be checking out Cranial nerves !

Be Ready for "Challenge Questions" on Step 2 CS

2007-09-11T09:57:00.001-07:00

Will I die ?

SPs are amazing actors - and they are trained to asked amazing questions ! Their idea is to stump you - but your goal is to stump them and leave them without any more questions ! The idea is 'never to commit anything' - and why is that skill important ? So that you don't give any false hopes to your patients in real life and get sued and screwed !

Here are some common SP 'difficult questions' with a possible reply you can use ...

Question: Doctor will I die ?
Possible Answer: Mrs. Ray, it must be very tough for you, but we must wait for all the investigation results to comment on that. Lets hope for the best (Smile), I will keep you informed.

Question: I am in pain ! Please give me a pain killer !
Possible Answer: I know it is not easy to bear the pain, but without unless we know what we are dealing with, it will be tough to decide the right pain-killer. As soon as we are done with a quick examination, I will have my nurse treat your pain. Is that fine Mr. Harrison?

Question: Doctor, do you think I have a fracture ??
Possible Answer: It is a possibility, but we must wait for your X-ray to arrive.

Question: Is this cancer !!!!!!!!
Possible Answer: Mrs. Hicks, I understand your apprehension, but we need to wait for investigations. I will keep you informed.

Beware !! There is another kind of questions they would love to ask you and eat your time - medical term clarifications questions, like "Did you say arrythmia ? Is that a new drug ?".
Sure - it sounds ultra-cool to use those sophisticated medical terms, but these SPs are testing your communications skills towards a layman - so let us stick to layman terms and not give them a chance to ask for clarifications ! Use (and contribute) to the Layman Terms Database enlisted under 'Hot Hot' on the left side-bar.

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Look for these 'Acting' Hints and Tips from the SPs

2007-09-11T09:55:00.000-07:00

These are soft signs that SPs might display. Showing that that u noticed it says oceans about your observation powers ! and courteous behaviour ! I looked for these the moment I entered the room and introduced myself.

1. Yawning SP : Ask - "You look tired Mr. Smith, did you sleep well ?" This could unearth a duodenal ulcer that kept the patient awake at night ! Ofcourse other possibilities exist.

2. Shivering SP: Could mean fever or also could mean the room is too cold .right ? so first do ask the SP if the room temperature too cold for him/her. Surely shows u as very courteous and sensitive to the patient - if he / she says yes, say " Ok, I will have the nurse fix the temperature very soon". Or could it mean hypothyroidism :-)

3. Sweating SP : It is important is to remind yourself that this case could be a case of bleeding with hypotension like Bleeding varices , hematemesis, etc.

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About washing Hands !!!!! he he

2007-09-11T09:51:00.000-07:00

Man!!! Haven't we all been washing hands all our life ? ...and suddenly for this one exam we get freaked out about washin' them right ;-)

Follow this :

1. For the SP to grade you on washin', you need to show the SP how you washing them, right ? ..which logically means you should not face your back to the patient while washing. The sink (or wash-basin as some might call it) is located such that washing hands and talking to the patients is very much possible.

2. Wash them with soap and water - and do it for real please !

3. After you wash - wipe them dry with the paper towel hanging right near the sink. And guys - I hope you won't be rubbing them against your coat or pants to dry them - a deadly mistake. A friend of mine did that and the SP said "Doctor don't touch me with those hands"

4. Before you touch the patient - rub your hands against each other to make them warm . The SP should feel as if he was touched by a humane, compassionate doctor and not by a snowman !

Hand washing takes about 30 seconds and you can use the time to ask about your patients occupation - that way your time ain't wasted ..and asking occupation is not forgotten either !

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Fun Stuff on the Internet

2007-09-11T09:50:00.000-07:00

Don't even ask me why I am writing this post - these are just random links and things that could perhaps serve as a temporary amusement detour while taking breaks from your monotonous studies....

- Cannot access or download your favourite chat messenger program at a public computer lab or a library ? Then Meebo.com is just for you.

- For those of you addicted to laptops and hi-speed wireless Internet like me, how 'bout a free software that plays Live TV channels on your computer like HBO, ESPN ? No Kiddin! Check out this Free TVU Player !

- Based on Fuzzy Logic, check out this Interactive Darth Vader that guesses what object you were thinking by asking a few intelligent questions. I think it's real cool !

- Like a scary game ? Click Here (Disclaimer : Digitaldoc ain't responsible for mental stress, heart attacks, sleepless nights or any other effect directly attributable to this link) ;-)

- Lot of us would like to try out various hair-styles without having to actually wear wigs or have them cut empirically. If you are one of those, Check out this virtual hairstylist !

- Wanna Poke Some fun at President George W. Bush ? Can get no better than this ;-)

- Most of us heard about the Y2K problem, which passed by without causing so much as a dent - Heard about the Year 2038 Problem ?

- We believe it was Osama who did the 9/11 catastrophe , but an increasing group of Americans believe lotsa evidence apparently points to a theory that it was US govt itself who staged the whole thing to buy an excuse for war. Jim Walter's www.Reopen911.org is trying hard to gather momentum to publicize those theories...

- For the Indian and Pakistani IMGs who happen to read this blog, www.VideoDuniya.com has Bollywood Hindi Movie Downloads and other movie downloads for Free ( I still can't figure out how this stuff is legal !!). Other sites for hindi downloads : Stage6-Divx, Bollymovie.com, Hindijoy.com and Desitorrents.com :-) [Forgive me for the Hindi Bias - I happen to be Indian] www.Loosu.com was a good one once, but is now busted.

- Dancing and Singing babies were a blast of the past - but this Singing Baby Mabelline was too cute to be labeled a Cliche...

- Ever tried adding 'Mama_pendse' to your list of friends on Yahoo Messenger ;-) Try it...It's amusing

Keep coming back for more Cool links !

Step 2 CS RUMOR MILL: We churn out rumors here !

2007-09-11T09:48:00.000-07:00

In this post, I shall be including floating rumors about Step 2 CS we tend to believe in and don't seem to find a way to confirm it...unless one of you has a definite answer and would be kind enough to leave a comment on this post at the bottom !

1. Step 2 CS will be scrapped for AMGs from the next year, while IMGs will continue to face SPs (whatever the facts, be I think it is inconsequential to IMGs, except perhaps availability of more dates !)

2. Some Centers are more IMG-friendly than the others ... Houston , chicago and atlanta are rumored to be more IMG friendly. Hmmmmm - I hate to believe this one.

3. CS Results are "Recalibrated" towards the end of the year to maintain a certain failure rate - which means if too many guys passed amongst the IMGs, the people who took their exams at the end of the year will be subject to more stringent grading to bring up the failure rates. If true, thats another reason to take your CS as early as possible ;-) - wow , almost sounds plausible !

4. Physicians who grade the patient Notes have no idea about how and what you actually did in the clinical encounter . If that were really the case, anyone who forgot to do a clinical testcould easlity get away by merely mentioning the "findings" on the patient note !!! He he...take no chances people !

[more coming up as I come across more...]

Search Keywords to this blog article

- "anyone have the USMLE cs results"

SHOULD YOU JOIN LIVE CS-PREP COURSES ?

2007-09-11T09:46:00.000-07:00

There are many of them around - like C3Ny, PassCSA, Kaplan CS Prep , etc. For those who are not aware, these are short courses that simulate the exam with their own people and coach you for a fee.

Well, I did not take any because I did not believe I needed them and yeah - as if the Step 2 CS was not expensive enough !!

But all the same, these course could have definite value for some cohorts of candidates - some of these would be :

1. Candidates who have been away from clinical practice for tooooooo long and really need a solid boost to kick you back into the clinical lingo

2. Those are who are extremely low on confidence and believe formal training will improve confidence

3. Those who who get nervous about speaking english ..and that too with american people

4. And ofcourse, those with the financial capability to make 1200$ look like their regular shopping bill - meaning very rich ;-)

All in all, this is a matter of personal choice to take up these courses. I always believed reading the right material and practicing lotsa times with the standard clinical encounter protocol I have put up on this blog - should be enough for most of us :-) So give it a thought and then give your best at whatever approach you take !

Q. Which of these courses are known as good ?

A. Have heard good things about C3NY. Kaplan is mostly said to be too expensive for what they offer - but not bad.

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- "kaplan cs courses"
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Which Exam Center to choose for CS?

2007-09-11T09:44:00.000-07:00

This is another common doubt that crops up amongst most IMGs. Questions like "Do some centers have better passing rates for IMGs than others ?" " Will LA guys hate my accent ?" "I Have heard center 1 is more IMG-friendly than Center 2" .....

Lets solve this now and for all ! - Any center is fine and equally IMG-Friendly ! No Bias there.

The Human Mind gets biased easily - so if John flunked his CS in Chicago, Jessica will avoid it like plague and choose Los Angeles - because she did not meet Girish, who had easily passed at Chicago ! and also did not meet Farah, who had flunked her CS in Los Angeles ...see how the bias works ? Lets try something more - I took my exam at Houston and so did my friend - and both loved it there and passed - notice how u feel more comfortable about Houston now ? He he he he.

The next natural question is - how do you explain the huge preponderance of CS takers at Philadelphia and why are dates not available there for a long long time...

Hmmm...let's go back to a little bit of history: A few years back, Philadelphia was the only center available for CS (Then called CSA). When more centers were introduced, CS was also made compulsory for the American Medical Graduates (AMGs). Naturally, USMLE board had to give the AMGs preferential booking to accomodate the sudden increase in exam candidates. ECFMG had blocked out IMG test bookings at Philadelphia for that year (I think 2004) and only allowed the AMGs to take the Philly center. Even today there are some people who are not aware of other centers for CS besides Philadelphia. So bias, history and trends come together to make Philly center the apparent hotspot.

So back to our Question "Which center to choose for the USMLE Step 2 CS ?" I say:

1. Take the center that gives you the earliest date ! Coz' you need to more concerned about getting your results back on time ... unless you are one of those lucky brats who are staying in any of those cities which have the centers. But again, you dont want a date too late.
2. Houston and Atlanta are relatively cheaper to stay ! Houston can be about 50$ a night while LA can be 100 $ a night :-)

*****

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TEST / EXAM CENTERS FOR STEP 2 CS

2007-09-11T09:41:00.000-07:00

Including this info since quite a few visitors land up on this site searching for test center information !

Currently, Step 2 Clinical Skills Exam can be taken ONLY in the United States and ONLY at 5 City Test Centers as Follows :

City: Atlanta
State: Georgia
Address:
Clinical Skills Evaluation Center -
Two Crown Center
1745 Phoenix Boulevard, Suite 500 (5th Floor)
Atlanta, GA 30349

City: Chicago
State: Illinois
Address:
Clinical Skills Evaluation Center - Chicago
8501 West Higgins Road, 6th Floor
Chicago, IL 60631

City: Houston
State: Texas
Address:
Clinical Skills Evaluation Center - Houston
400 North Sam Houston Parkway, Suite 700
Houston, TX 77060

City: Los Angeles
State: California
Address:
Clinical Skills Evaluation Center -
100 North Sepulveda Boulevard, 13th Floor
El Segundo, CA 90245

City: Philadelphia
State: Pennsylvania
Address:
Clinical Skills Evaluation Center -
3624 Market Street, 3rd Floor
Philadelphia, PA 19104

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Get Step 2 CS Practice Partners/Buddies here...

2007-09-11T09:40:00.000-07:00

Why is a Practice Partner Important for CS ?

Recently I watched an executive briefing video of a Professor lady presenting a talk at Stanford University on how an Organization Culture is important for the performance of a Company. She cited an interesting study done on how people's behaviors are affected by the presence of another individual: 90% people were found to wash their hands in public rest-rooms at an airport when in presence of another individual, while only 10% washed their hands when they thought they were alone ( video surveillance of the wash sinks showed this). I was like - Ewwwwwww ! I am never gonna shake hands on airports with anyone anymore ! Lol...that was not my point..the point as she put it was : "We are phenomenally governed by the expectation of others"

Very true for CS study ! Study for the patient encounters alone and you may give yourself a lot of discounts with thoughts like "Yeah - I can do it, no need to practice this simple stuff" - but in the presence of a driving practice buddy, you feel the need to do better and drive yourself more. It's natural to imagine yourself talking to the patients when you read those dialogues in First Aid or USMLEworld - but, just try getting out of your room closing the door behind you at this moment, knock and come in and say, "Good Morning Mr. Simmonds - I am Dr. .........." - You will sense the immediate awkwardness :-) It's better to feel the awkwardness at home and get over it via practice ..rather than feeling that first on the exam day and letting nervousness cloud your thinking.

So - Are practice partners useful ? Big time !! How else would you discover ways to squeeze everything in 15 minutes..and develop your own SP encounter protocol ? While you can practice a physical on any person you know, it is better to practice history taking with someone who has finished or is preparing for the exam.

Launched www.USMLEBUDDIES.com to look up a live list of USMLE Step2CS examinees scheduled to take the exam with you. The site also includes people who have enlisted themselves to search partners for Step1, 2 and 3 too! Recently a Residency Interviews Database has been introduced on the site for voluntary expereince submissions by interviewees.

Other ways to use this list :-)

1. Share accomodation on exam day - or maybe share-a-ride too !
2. Exchange Step 2 CS dates
3. Borrow steths / notes from recent exam takers
4. Contact recent exam takers for doubts and center-experiences...