USMLE CS Guide
I will post my thoughts here. as well as attached it as PDF file below. May my effort help you in ur USMLE CS Journey.
USMLE Step 2 CS Guides
*** Word of caution: this is a long story. So get comfortable before U start reading. A cup of tea or hot chocolate may be & a good sitting.
1. The exam day Orientation Tutorial:
In orientation tutorial try all the tools that are there from bed to tongue depressor. If talks come up socialize with other examinées don't be a brick also don't be talkative. Ask questions to proctors if U have any don't shy away.
2. Time management:
It is very important. Build a timeline & practice with it all ur cases before the exam.
Ex: 1 min: doorway. 6 - 7 min: introduction & Hx. 4 - 5 min: PE. 2 - 3 min: Summary & Closure. 10 min: write patient note.
What to do in the doorway? Two things are important here: The Bluesheet & The entrance.
a. Bluesheet (the paper that will be given to U by the exam proctors): on top write put name, age, gender, VS. Divide the rest of the sheet into 4 parts & write ur Hx Mnemonic. & in one quarter write ur DDx from the CC to prime ur thinking.
b. Entrance: double knock at door; take a deep breath in & out (it will relax U as well as enough time to get a response from the SP inside the room - so yep BREATHE); smile then open the door. Walk towards the Patient, when U r close then start talking.
Know how to introduce urself. Know different ways. Yet Memorize one & stick with it throughout ur practicing time to the exam date. So even when U r nervous during the exam. Ur brain is wired well to do its routine. After you introduced urself always drape the patient.
a. Introduce urself: ex: Good Morning. I am Dr. .... & I will be ur physician today.
b. Drape the patient: here is a cover for U. Let me cover U with it. Make sure ur patient is comfortably draped & now move on to ur history.
a. Develop a History Mnemonic in ur first few days of studying for the exam & memorize it gold. One for adults, one for adolescents & one for Children. This is what u will write it in the Blue sheet before U enter the room to guide ur Hx Taking (see 3 above). Ex: Adults: SIQORAAA PAM HITS FOSS ROS or LIQOPRAAA.
b. Know how to start the Hx & conduct it "Patient centered". Ex. Doc: What brought U to the hospital today? Patient: I have a very bad abdominal pain Doc. Doc: Oh I am so sorry to hear about that ... come before tell me more about that. Empathy dear colleagues Empathy (= Patient centered).
c. Keep eye contact with the patient at all time. Write ur findings quickly (scratch them if must). Don't loose eye contact with the patient. Have I stressed this enough.
d. Don't forget transitional statements. Ex: I now want to ask U about ur health in the past for PMH
f. Do a focused Hx. Ex: Cough = cough Hx even in ur ROS it is all questions about associated cough symptoms Dont go on to ask how is ur vision? Perfection is good but this exam is about efficiency under time frame not perfection. Are you listening perfectionist?!
6. Physical Exam:
a. Starting the PE with permission & announcement. Ex: Doc: I would like to examine U now if it is ok. Patient: ok Doc. Doc. Well, thank U. Let me first "wash my hands" or state whatever that U r going to do (i.e. Say this phrase if U r going to wash ur hands in another words don't memorize this biblically to say it & then move on to wear gloves in the exam day - I can only imagine how the SP would feel towards such incompatibility of words & action. & don't tell me it won't happen - it is exam day where anything that is not suppose to happen is happening. LOL).
b. As U r washing ur hands or wearing ur gloves to do the PE. Don't leave the room in some awkward silence. Talk to the patient. Ex: Do U have any other concerns or questions before I start examine U? Or U can ask about the super ball if it is the season for it? This is called communication skills every good Doc must have one.
c. Also, in ur first few days of studying for the exam develop a PE methodology for each body system & memorize it gold. That is where to start, where to finish & how to pass through the parts in between while making the patient alternate b/w positions as less as possible. Ex: CVS: Start Examination of which by the hands then head, neck, heart, (chest, abdomen, not a must) then lastly toe. This is called a hand to toe approach.
d. In PE, talk to patient about what U r going to do & always take permission. Don't hijacked someone body just because U r a Doc & one is ur patient. Yep again Empathy if it hurts. Ex: I would like to examine ur chest/lungs now. May I untie & lower down the gown for U please.
e. No writing during or after ur PE. Train urself to memorize the PE & go write it directly in ur patient note.
f. Be Gentle. Try not to harm the patient with ur PE tools or methods. Ex: poke some ear with otoscope. Hammering a nail instead of using a hammer to get a reflex. & etc.
g. Again focused PE. Ex: cough = full chest examination with little heart if time allowed & that is it. Don't even think about doing planter reflex now. Thus, U will find many PE under FA cases don't attempt to do all of them in the exam day. Time won't allow U my friend so be efficient.
h. Do the PE moves as accurate as ur ability don't repeat those moves. Ex: 2 hit on one knee is more than enough to get ur patellar reflex which is most of the time normal unless ur case is a NS case. Don't repeat the moves till U get z perfect knee jerk of ur life. This is not the time for ur medicine "aha" movements, neither for assurance. OCD traits (which most Doc are) are you getting this?!
7. Closure & Summary:
a. Conclusion of the Encounter is very important. Don't miss it at all. It encompasses summary of Hx & PE, some DDX, some work up, counseling if U didn't do it as part of Hx, & the magic phrase do U have any questions for me?(always every encounter in real life or the exam end with this phrase. This is what one can call 101 medical interview art. Great, now U know why U get marks for asking this in CS), then finally, goodbye (patient name), I hope U get better (or any other appropriate phrase).
8. Exit the room:
a. U r not allowed to enter after U exit the room. & those left minutes from the patient encounter will be added to ur patient note. Again time management. & don't be afraid to leave the room before the time is over if U finish ur encounter well.
b. Exit gracefully even if time is up & U didn't finish ur encounter as U wish. Ex: U r there nervously innocent minding ur own PE & then U hear the terrifying call of doom: Time is up, Examinées please leave the room now. Don't look up to ur patient with dum look & some little tears in ur eyes for the case U mess up in ur exam, remove ur hands from off him/her & walk out of the room. Instead say: I am really sorry. I have to answer this emergency page. Let me adjust ur drape & cover U up (now do it). & add I will be back as soon as I can. Goodbye (patient name). Give ur patient a reassurance look & smile & walk out gracefully. U can do this quick & don't be late till the proctors come to expel U out of the room. No no Doctor U r far better than this I am sure.
9. Patient Note:
a. Again, in ur first few days of studying for the exam choose ur patient note style either: bullet points or story telling & develop that well.
b. Typing, Typing, Typing. How fast do U type? U need to type > 35 words per minute to get a decent PN in the allotted exam time of 10 minutes.
c. How to write the PN? (1) Start by writing the 3 DDX with the most likely Dx on the top, then 2 or 3 Work Up, then write the PE, then go write the Hx fast. (2) After that copy-paste from ur Hx & PE to fill in the support for ur DDX. (3) now add more Work up if there is any to be 5. (4) Now add more information to ur PE & Hx if U miss some & try to perfect ur patient note. Why this way so that if U run out of time, ur patient note is not skewed to the left or to right but rather it is somehow normally distributed (Wink. Wink. U think ooh thanks God this exam has no biostatistics in it but nope I have to bring it up & sabotage ur relief mood).
d. Don't be afraid to use common medically approved abbreviations. Yet don't overuse those abbreviation in ur patient note. Remember, U need ur PN to be readable & understandable to the common health professional population, it is not by any means ur personal notes.
e. For God sake. Fair grammar. Well written sentences. Right spelling & minimize typos.
f. When time is up, it is up. Stop writing & press submit. The last thing U want is to be reported for misconduct by the exam proctors. Yep they can do that, report U. It is part of their job remember.
10. General Rules:
a. Good Manners & Compassion go a long way. Have a good manner & be compassionate with people around U in day to day live encounters all the time & U will easily have it with all ur patients & in ur CS exam day as well.
b. Communication skills is important. Know how to communicate with another human being. Ex: ur voice tone, a relax smiley face, a confident not arrogant posture & look, ur body language, keeping the personal space, etc.
c. The exam is not about being perfect but about doing all the procedures for all ur cases even if moderately. So make sure that all ur cases got: Patient encounter of Hx, PE & Closure. Patient note of Hx, PE, DDx & work up. Don't leave any allocated section totally blank.
d. One bad encounter isn't the end of the world. Brush it off & get a new mindset when entering the next one. Thus, every new case = new positive mindset & best performance U can deliver let the past be the past wether it was good or bad.
e. Step 2 CS is a role play exam. U must know ur role. The best way to think about it is: (1) There r no SP. U can scan the above 9 points & U will get I didn't even once said the word SP because there is no SP those are ur patients so treat them like one please. (2) There is no exam. The exam day is another normal day in the ED in the hospital where U r working. This ur environment so U r in control, U r confident & quite familiar with it. The SP is the concerned vulnerable patient who is new to all this. So be a Doctor, it will be easy for the SP to be a patient. Now go look at points (8.b) & it will make perfect sense. Isn't it?
f. What to do if U got the case that ur mind decide to hide the right DDX from U. Such that as U ask the patient more & more questions in Hx, ur mind is screaming I don't know. Very simple follow the procedures, U might loose the mark of the right DDX but U still get the case. This is how doctors operate on the day to day bases isn't it? Ex: abdominal pain patient that U don't know a heck of his/her Dx or even DDx. Do a full history around his main symptoms. Perform a full Abdominal PE. Do a decent closure which include I suspect (this Dx) but am not sure we will do (these work ups) & will be with you till we figure out what is going on (assurance & Empathy). & go on write a decent patient note from the information U have collected. This is one point that I wished someone told me before I did the exam & I wished someone told me in my early years of medicine. However, thanks God I came across Dr. Steven P. Shelov and Dr. Daniel Bernstein writings after my CS exam & now my mistakes are your correctness. Dr. Steven P. Shelov and Dr. Daniel Bernstein said "To be successful in medicine, you are repeatedly told that certainty is always the achievable goalIndeed, you soon learn that clinical medicine is far from certain and that any attempt to make it certain quickly leads to a sense of frustration, disappointment, and confusion. Some of this confusion and frustration is avoidable if you recognize that medicine is often uncertain and that in spite of this fact we can still do much for our patients and derive much satisfaction from the careful application of what we have learned." These words change my life. & I bet they will change ur life too. Thank you so so so much Dr. Steven P. Shelov and Dr. Daniel Bernstein.
g. Even if it is role playing. Don't lie to the patient. If it is I don't know then it is I don't know. Trust is a very important element of any Patient-Doctor relationship & liars are not trustable. Don't lie to any patient, Don't lie to any patient even if ur life depends on it. Yep, Medical Ethics goes a long way outside of USMLE MCQs.
11. Useful Resources:
*** "suggestions not inclusive materials & What I used & I found useful". So, yes it is my biased humble opinion. & yes U can decide for more of those or less of those materials or even none at all. It is ur choice.
a. For mannerism & what is the exam is & isnt: "esp for IMGs"
(1) Kaplan USMLE Step 2 CS Core Cases: Section 1 The Basics: Pg 1 - 78. U may or may not practice the 43 core cases in this book. Depends on ur choice & the time U have till the test.
(2) Kaplan Medical USMLE Step 2 CS: General outline of course (U can purchase online). It goes well with the above book.
b. For History:
(1) Kaplan USMLE Step 2 CS Core Cases: Section 1 The Basics: Pg 1 - 78.
(2) CS Blue-Sheet Mnemonic - USMLE Step 2 CS - www.medical-institution.com. See: http://www.medical-institution.com/b...-cs-mnemonics/
(3) How to do the Blue-Sheet: Laura on youtube: title "blue sheet". See: https://youtu.be/AE0Xu6OF6ss
c. For Physical exam:
(1) Kaplan USMLE Step 2 CS Core Cases: Section 1 The Basics: Pg 1 - 78.
(2) Website of OSCE Skills. See: http://www.osceskills.com/
(3) YouTube is full with many videos of PE. Don't watch them all. Just pick the ones U want to check well. Ex: I watched videos on Fundoscope exam & Otoscope exam because I didn't come across those Examination technique & equipment recently.
d. For an example of a Whole encounter:
(1) step 2 CS YouTube Channel. See: https://youtu.be/AZbPmkICD7I. I found this video in particular useful, U don't need to watch every video in this channel neither in other medical channels of YouTube.
e. For Patient Note:
(1) Typing speed. Just google, typing speed & U will have many websites. Pick one & start practice ur typing speed.
(2) Medical Abbreviations. Just google, abbreviation approved for medical records & U will see for urself wealth of information to pick from.
(3) Some useful YouTube Videos. See: https://youtu.be/duL_BpwAgh4
f. For everything about this Exam & ur no. 1 Helper to success:
(1) First Aid for USMLE Step 2 CS the latest edition. Read it from cover to cover. & practice all the cases that are in this book. Once or twice according to ur decision & ur time. It is a must.
(2) The Latest USMLE Step 2 CS Content Description & General Information. Read it well & read it several times through the course of ur preparation for the exam.
g. A Reference to consult (Remember not to read from cover to cover). Consult only when U need more depth or understanding or clarification of some point.
(1) Bates Pocket Guide to Physical Examination & History Taking.
I have the book, I like it so well I used it. U may use for consultation any Physical Examination & History Taking book U have. There is nothing special about Bates except that I have it & I like it. Or U may not consult at all. I consult because (1) I studied alone no study partner, (2) I did self study no live course.
12. Main points in the CS exam preparation:
a. No USMLE need U to take notes as the CS needs. So, while U r moving through ur different preparation resources (whatever U choose) take notes to: (1) Develop ur Hx Mnemonics as I mentioned in (point 5.a) above. (2) Develop ur PE methodology checklist for each system as I mentioned in (point 6.c) above.
b. Practice FA CS practice cases as closely to the exam situation as possible. Preferably with a study partner (or in my case a study room as my encounter room & pillows to examine). Those cases will highlight ur weaknesses & will help U improve. So evaluate urself fairly & Improve ur techniques as U move through the cases.
c. Don't brush over the FA CS minicases. Use them to improve ur skills in performing a focused Hx & PE ,as well as, good DDX & work ups. I pimp myself through them several times.
** I can't write every nitty gritty details of my USMLE CS preparation experience or that will be a novel book. So I just gave U what I thought were the pearls of wisdom. Excuse me & my judgements if my knowledge felt short on some aspects. Thank you.
** If I didn't mention it then (1) I don't know about it. I am only human I cant know everything. Or (2) I didn't use it. Example: UW CS, I knew it exist but I didn't use it. I choose not to use it.
** From where I got the knowledge before the exam. My Friends helped me, in particular two. One told me to use FA CS only. He said it is enough unless I have time & money then I can move to do UW CS if I want. Another friend give me general tips & point me to some materials. So ask ur friends who pass the exam before U. Bulk of knowledge I learn it myself trial & error & my right wing partner Google. So don't hesitate to branch from the normal road of FA CS only if U think ur shortcomings need more honing. Remember it is ur exam (about U) not the common norm.
** Why did I decide to write this Tips. I was so fearful when I was studying for the USMLE CS because I did it alone without study partner & I didn't find any comprehensive well rounded guide to preparation for USMLE CS anywhere. So I pray to God a day before my exam when I felt the weakest of all. I said God if U help me to pass USMLE CS, I will write a comprehensive guide of USMLE CS based on my experience to benefit all those who are going to attempt this exam in the future. Specially, those who are preparing for the exam alone & isolated from their peers.
** If U like this guide or it helps U. May U please pray for me that God grant me my lifelong dream. Amen.
** Lastly, Good Luck to U & rest assure that U can do it. Give it ur 100% & all will be well. if I did it & I pass CS first attempt with good performance profile so can U.
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