Yasmin Gabr- HOUSTON

HOUSTON - Dawatkum Please
By Yassmine Gabr in CS for Egyptians (USMLE) (Files) · Edit Doc
this is the experience of a very decent group member who was keen to share his advice about preparing for the CS & the logistics involved for Houston test center. please join me in praying for him & wishing him all the best isA. :-)

can't believe the amazing spirit of our members in helping each other & sincerely hope Allah swt rewards each & every one of you with health, happiness & success always. :-)

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Booking the Test
Through www.ecfmg.org , as early as possible . usually it takes 2-3 weeks to get sceduling permit . I was told that the easiest test centers to have ur CS exam are Houston , philli and chicago .

Resources I used :
- First aid book for cs " try to get the latest edition " sometimes they add new cases .
USMLE world videos
CSE videos
My own scheme to remember questions I have to ask
USB keyboard .
www.usmle.org/practice-materials/step-2-cs/patient-note.html for practicing typing exactly like the program used for typing in the exam

Studying plan :
- CS studying time plan usually takes 1-2 months
- The keyword of this exam is PRACTICE , PRACTICE ,PRACTICE …….
- Try to find study partners and its better if both of u will have the same flight from the start .
- Start with 1st Aid for CS , practise 3-5 cases every day then u will study all cases within 10 days
- Try to make regular scheme fits all cases like the one at NEERAJE notes or whatever any other source . With every case in 1st Aid try to mark the FIXED questions which r specific to the case . So , every case u have fixed questions and changeable ones . This way will be easy to remember questions to ask .
- The best study partner is " life one " , better than skype study partners as u can notice facial expression , eye contact , smiling and emotions ……
- 2 persons practicing together are better than 3 or more , the maximum benefit and saving ur time . Although , 3rd partner is good to catch mistakes for the one who plays the Dr part . from time to time try to practice with strangers to put ur self under some stress J)
- After finishing the 1st study of 1st Aid cases , try to increase the no. of daily practice cases to be 6 cases a day for each of u " incase of 2 persons " … then make it 8 cases ….. then 10 … and 12 cases a day 1 week b4 the exam is okay.
- Timing is very important , at the beginning " the first 2 weeks " u have to practice with 15 minutes for history and physical exam . 10 minutes for patient notes . 2 weeks before the exam , u have to practice with 13 minutes for history taking and physical exam . 8-9 minutes for typing patient notes
- My advice for slow typers : try to stick to 1st Aid abbrreviations at the end of the book . try to type too much before the exam . some friends used to type all letters capitals and others all letters are small , both of them passed the exam . I didn’t do like them .



Scheme I used :

L location
I intensity
Q quality
O onset
R radiation
A aggrevation
A alliviation
A association " these are the changebale questions accord to each case , u have to make ur own questions from 1st Aid "
P past medical history
M medications
A allergy
H hospitalization history " surgery , trauma , hospitalization "
U urinary symptoms
G GIT symptoms
S sleep symptoms
F family health
O OBS/GYN
S sexual history
S smoking history
A Alcohol
D recreational drugs
W,S work and stress

I followed this scheme in all cases and I realized that it fits all pain cases but I have to pick certain items only from ( LIQORAAA) through rest of cases . In other words , any case except pain I picked what fits it from ( LIQORAA) + ask the associated questions that changed with each case +
( PMAHUGSFOSSADWS )

Precious advices :

- NEVER NEVER NEVER to forget to do these in ur exam :
1- Knock the door
2- Drap the pt
3- Introduce ur self
4- Wash ur hands
5- Miss closures , summarization
6- Counceling
- At any time u hear the 5 minutes announcement u have 2 choices :
1) Incase u r washing ur hands or already starts physical examinations , u r in the safe side to continue general and specific exam . do closure
2) Incase u r taking history , its over my friend and u have to wash ur hand …. Do SPECIFIC physical exam according to the complaint …. Do closure .

Booking flights :
-Try to be in USA 7-10 days before ur exam to avoid jet lag " I had 1 week of it J " I was like a drunk 24 hours .
- Book your airline ticket from Orbitz.com , Expidea.com or vayama.com . take care while filling in , ur 1st name and last name are important to be correct . the rest of name is not a big deal to be written . " I had some troubles with vayama regarding my name " .
- In case of connection flights , make sure that u have enough time to catch ur next flight " at least 1 hour " between flights is okay .
- The best hotel is Baymnot inn and Suites, 502N. Sam Houston Pkwy E. Houston, TX 77060. Tel: (281) 820-2101 Fax: (832) 554-0884 . The hotel is, clean and 3-5 minutes walking to test centre. There is a shuttle could pick u up in the airport. Reservation could be online through their website but u will pay by credit card or in cash .debit card or internet card are not accepted " I had a problem with that the 1st night I was there J .

Food :
- Breakfast : provided by the hotel .
- Lunch and dinner : r not provided by the hotel . so u have to eat on ur treat . best and so close restaurants r " MAC , ARBYS , PIZZA " . ask for 1 $ sandwich menu " khaleek nase7 J "
- Walmart market : u can go by shuttle .

Transportation :
I don’t have much infos regarding that but I think the best way is to check google then take the bus to ur destination .

Medications :
Antibiotics , analgesics , antipyeritics , antinal and streptokine " incase u r planning to eat in MAC " J .

Day before the exam and exam day :
- Revise YOUR scheme and specific changeable question for each case .
- Practice 1-2 cases " history , physical exam and typing " to warm up J
- Believe in God for the best .
- Believe in ur self that u can do it coz thousands did it too .
- Watch orientation vedio on www.ecfmg.org , CS materials .
- Iron ur clothes and white coat " 2-3 days before the exam is better coz life happens , one of my friends burnt his trouser J "
- Go for the exam with white coat , stethscope , ur scheduling permit , confirmation letter and ID " passport " .
- Try to be there at 7:50 a.m .
- The exam day will go with this sequale ….. 8 a.m registeration ….. taking blue or red cards ….. check ur stethoscopes ….. clipboards room ….. waiting hall for orientation vedio …. Few minutes for any one who want to drink or go to restrooms …. Then making 2 lines " red and blue " …. Then the marathon will start …. 5 cases first … 30 minutes break …. 4 cases …. 15 minutes break … 3 cases … then u r set free , u can go home J .
- The more u practice the less u will be nervous at the exam .


Yassmine Gabr


In the name of God*, the most Gracious, the most Merciful


Greetings of peace to all readers,

First, great news; you will PASS the CS -God willing! If I did it, so can you… all you have to do is read this till the end & carefully check off all the items as you finish them.

Second, due acknowldgements; my deepest gratitude to our Creator*, Who answers all prayers- directly or indirectly- in its proper time... & special thanks to my family & friends for their valuable guidance & ongoing support, I couldn’t have done it without them!

Third, a disclaimer; this is written permission that you can share/print my note to spread the benefit , as long as you don’t intend to make money out of it or wrongly attribute it to yourself.

Fourth, the lay out;


A-Useful Links …………….......… (official links, USMLE forums)

B-Resources Used ……………….. (books, websites)

C-Things to Memorize ………… (Diff. Diagnosis, History Qs, Physical Exams, Investigations)

D-Scoring System ……………..... (3 major categories)

E-Communication Skills……..….. (check list, scoring points)

F-Important Advice………..…... (draft sheet, practicing)

G-Learn to Write……………….…. (Draft Sheet, Patient Note)

H-Study Partner …………………... (importance, alternatives)

I-Pre/EXAM/Post …………….…… (preparing, actual day)

J-Acceptable mistakes…………… (passed despite them)

K-Being Different ………………..... (what to do/say)

L-Whether to Retake the CS ……..…. (reasons why you should)





A- USEFUL LINKS:


1- usmle.org/Examinations/step2/step2cs_content.html
Please be careful to read the whole Orientation Manual & watch the Orientation Video (worth watching a couple of times to familiarize yourself with the exam environment- helps decrease anxiety).

2- ecfmg.org/usmle/step2cs/index.html
Please be careful to read whole Information Booklet. Especially read Application requirements if you’re a non-US graduate, to get your papers ready in time.

3- csprotocol.blogspot.com/2007/12/usmle-step-2-cs-study-plan-for.html
THIS IS THE MOST COMPREHENSIVE & VALUABLE SITE FOR CS!! Please be careful to check all the links in the right & left margins, especially Study Schedule, Most Common Errors, CS Experiences, Atlanta Exam Tips & Experience, Visa Issues (if relevant).

4- www.usmle.net/csa/
To help find a Study Partner & read others’ Exam Experiences.

5- forums.studentdoctor.net/forumdisplay.php?f=137
To read Exam Experiences.

6- www.valuemd.com/usmle-forums/
To read Exam Experiences (scroll down site to Step2CS).

7- usmleforum.com/forum/index.php?forum=3
To help find a Study Partner & read Exam Experiences.

8- www.usmlesource.com/usmle_forum/
Please watch all PE Videos & you’ll find useful Exam Experiences.


It’s extremely important that you dedicate time to check them all out & read them thoroughly- it’s part of the guarantee to pass! Each link provides valuable information & exam experiences.






B- RESOURCES USED FOR STUDY:


1-First Aid for Step 2 CS

Read very early from COVER TO COVER, especially study & practice the ‘30 Long Cases’.


2-Kaplan Step 2 CS Book

Read at least the Communication Skills, Rapport, Phrasing & Data Gathering.


3-USMLE World Step 2 CS Material

Read at least the Tips section & MUST watch the Videos



Needless to say, you can buy the books used, for a lot less than retail price, or get them for free from a friend who's done the CS.




C- THINGS TO MEMORIZE:


1-List of Differential Diagnosis (DD) for common symptoms.

See First Aid Step 2 CS book- Mini Cases section, choose maximum 6 DD for each symptom.


2-List of History-taking Questions (Hx) to ask the patient to exclude/confirm each DD.

There are questions to be asked to every single patient (easily remembered using the mneumonic “PAMHUGSFOSS” , see below for further explanation) & other questions specific to the complaint/DD. It’s important to know how to communicate them clearly to the patient to get the relevant info.

See Kaplan Step 2 CS book- History section, for what to ask & the wording how to ask it.


3-Knowledge of Physical Examination (PE) maneuvers to examine each Body System.

Know which System to examine for each Symptom or DD, to keep it focused due to time restrains. Also, how to communicate the commands properly for the patient to cooperate, so you can establish physical findings that will exclude/confirm your DD.

See KaplanStep2CS book – Physical section, for proper wording, & Focused Exam section for examination steps & which system to examine for each complaint.

PLUS Watch USMLE World material- Videos section,
OR from USMLE Source website- Videos section.


4-List of Investigations to order so you can further exclude/confirm your DD.

See Kaplan Step 2 CS book- Focused Exam section.


Will try to include all four lists here in the future, to be ready to copy, paste & print ….






D-SCORING THE CS:

3 categories- each must be passed ‘separately’;

IMPORTANT! Please copy/ paste & print the below as is, to use as a checklist for evaluating yourself during case practice. It’s interesting how we usually ignore doing some of these points in the exam, when they are so clearly stated as scoring points on the official website!

See the official USMLE website, p.10 of online PDF Information Manual
download.usmle.org/2009/2009CSinformationmanual.pdf).


(>>>>BEGIN COPY/PRINT)


1- Communication & Interpersonal Skills (CIS) assess:


*Questioning skills;

-use of:
open-ended questions,
transitional statements,
facilitating remarks

-avoidance of:
leading or multiple questions,
repeat questions unless for clarification,
medical terms/jargon unless immediately defined,
interruptions when the patient is talking

-accurately summarizing information from the patient


*Information-sharing skills;

-acknowledging patient issues/concerns and clearly responding with information

-avoidance of medical terms/jargon unless immediately defined

-clearly providing:
counseling when appropriate,
closure, including statements about what happens next


*Professional manner and rapport;

-asking about:
expectations,
feelings,
and concerns of the patient,
support systems and
impact of illness, with attempts to explore these areas

-showing:
consideration for patient comfort during the physical examination,
attention to cleanliness through hand washing or use of gloves

-providing opportunity for the patient to express feelings/concerns,

-encouraging additional questions or discussion

-making empathetic remarks concerning patient issues/concerns

-patient feel comfortable and respected during the encounter



2- Integrated Clinical Encounter (ICE) assess:


*Data gathering;
-patient information collected by history taking and physical examination

*Documentation;
-completion of a patient note summarizing the findings of the patient encounter, diagnostic impression, and initial patient work-up



3- Spoken English Proficiency (SEP) assess:


*Clarity of spoken English communication within the context of the doctor-patient encounter;
pronunciation,
word choice,
and minimizing the need to repeat questions or statements

*Based upon the;
frequency of pronunciation or
word choice errors that affect comprehension, and
amount of listener effort required to understand the examinee's questions and responses.


(>>>END COPY/PRINT)


Also, here is the scoring in points according to one of the forums (copy/pasted as found)
(SP means Standardized Patient, PAMHUGSFOSS will be explained later):

there are a few points and sp marks u ; bad /average/ good /excellent

*history of chief complaint (1-5 point for this depending on the chief complaint)

*pamhugsfoss; each carry 1 point (so around 7 points for them)
so we have to place a lot of importance on pamhugsfoss. Usmle Source uses this approach using PAM HUGS FOSS in all the cases which is very useful

*now on ur manners
1 point for knocking on door
1 point for behaviour in general (was he nice)
1 point for washing hands
1 point for draping
1 point for asking permission before examination
1 point - were u able to understand him

*and finally 1-4 points for proper physical examination





E- COMMUNICATION SKILLS:

Important tips which were useful from friends & forums;

1-Knock, then poke your head into the room, inquiring “Mrs. XYZ?”. She’ll say “Yes”, then you enter the room… it was originally mentioned on the forum to be able to discover Dementia patients, since they will not respond to their name, so you know they have Dementia even before entering the room. But I also found it very useful in breaking the ice, instead of barging into the room! And familiarizing the patient with how I look & more importantly, familiarizing myself with the patient, without having to be in their face directly. You can get a quick impression & register critical information in this moment, like how are they sitting (in pain, not), what is their character(friendly, aggressive, shy) etc..

2-Enter with full eye contact to the patient, smile, greet them & confidently shake their hand while introducing yourself, stating: “Hello, Mrs. XYZ, I’m Dr. (Last Name), I’m a physician here at the hospital/clinic. How can I help you today?”. It’s important to identify your role to gain their trust. Asking how you can help them is better than “What brings you here today?”, or “What seems to be the problem?”, since “How can I help you today?” reflects compassion & care for the patient. I think you should smile, regardless of how grave the patient’s condition is, because you get a reflex social smile & dissipate some of the patient’s anxiety. It also helps them feel comfortable with you & confide in you. Then you can appear more serious if they are distressed or have a painful condition for example.

3-While the patient is answering your initial question, do absolutely nothing but look straight at the patient, giving them your full attention & maintaining eye contact. It’s worth the 2-3 seconds, to gain the point of eye contact & to make the patient feel you are listening to their complain. You should follow up asking about (onset/course/duration of complaint) while still looking at the patient & being attentive. You won’t forget 2 sentences so soon, & you can repeat them to the patient as soon as they are done, since paraphrasing also gets you points & makes the patient feel they were heard.

4-Now put down your clipboard & pick up the drape- while draping the patient, ask them “Is everything in the room as comfortable as possible for you?”. This will earn you more points & make them feel respected & comfortable. It will also give them an opportunity to tell you if they are bothered with the room temperature (Hypo/Hyperthyroidism) or the light (Meningitis).

5-Then pick up your clipboard & tell the patient “OK Mrs. XYZ, what I’ll do is ask you some more questions, then we’ll do an examination & according to the findings, we’ll discuss the possibilities causing your complaint & what we can do about it. I’ll be happy to answer any questions in the end. Is that OK?”. Clearly stating your plan from the start helps make them feel involved & develop trust that you know what you are doing – getting them to affirm in the end with a “Yes” gets them in a cooperative mode! Then ask them “Do you mind if I take notes while we talk?”, this will automatically excuse you if you have to look away from the patient while writing your notes & will prevent the patient from feeling ignored or offended.

6-Using transitional statements as you go through your History questions scores you points & is important in keeping the patient involved. It is easy for the patient to start wondering & questioning a physician’s competence, if they come in complaining of Diarrhea & you start asking about your last menses or occupation. The patient doesn’t know any better. Especially before asking about their Sexual History, you must reassure them about confidentiality & ask the questions in a neutral, nonjudgmental, unassuming way.

7-At the end of the History taking, thank the patient for sharing their information, then summarize in 3-4 points the History, which gains you points & informs the patient that you were listening.

8-It’s very important to ask in the end “Do you have anything else to add?” & “Do you have any concerns to discuss?”. So you give the patient a chance to fill you in on anything you may have skipped in the History, & to ask you their challenging question.

9-When answering the challenging question, you should acknowledge & address in an honest, diplomatic/ indecisive manner. Like “Yes, cancer is a possibility, but we will not know for sure till we do an examination & run some tests”. Do not downplay the possibility or offer the patient false reassurance or give a final diagnosis, you will lose points! Instead, you can assure the patient “Whatever it turns out to be, I want you to be sure I will do everything possible to make you better & I want you to feel free to contact me if you need to”.

10-It’s very important to use the patient’s name at least 3 times. You should also use open ended questions at least 3 times. So it’s easiest to fix those 3 questions when you are practicing & to use the patient’s name with them each time, so you don’t forget doing either & you earn double points. The questions I used were;

“Could you tell me more about your complaint, Mrs. XYZ?” or “How do you feel about this, Mrs.XYZ?”
(asked in the very beginning of the encounter)

“How are things at work/home, Mrs. XYZ?”
(asked at the end of the History taking, before the Physical examination)

“Do you have any more questions or concerns, Mrs. XYZ?”
(asked at the end of the Physical Examination or at the very end of the encounter after counseling)

11-If during the History taking, the patient goes off point & starts wasting time, gently redirect the discussion (without interupting if possible), while acknowledging what they were saying. Like “ Excuse me Mrs. XYZ, I understand the importance of what you are telling me, now I would like to focus on your complaint to help make you feel better”.

12-While washing your hands, must use soap & deliberately stand sideways to still be able to look at the patient & to let them see you doing it to score a point! Very crucial- this is the best time to make a ‘personal’ remark that will help you connect to them as a human being, rather than just a patient. It makes them feel important to you, respected & generally helps them ease up the anxiety of being examined. Topics that are generally safe, easy going & not too personal are along the lines of;

*Commenting about the weather/ any important or current events happening in the US, as elections, traveling, their major holidays

*Commenting on their field of work/studies, showing interest in it, or asking if it’s stressful …

*Comment about their children/partner, or ask about their kid’s age, or about living conditions at home

13-Ask permission before examining the patient, & explain ‘why’ you are doing each step, as you are performing it to avoid wasting time. Tell the patient to notify you if they feel any discomfort. Establish eye contact with the patient while examining them as much as possible, instead of just looking at their abdomen, limbs etc..

14-During physical examination, some points to remember; use of transitional statements, proper draping, modest exposure, do not repeat painful maneuvers, warm your hands by rubbing them together, turn lights off for Meningitis patient, pull out leg rest when patient lies down, help them get up/down, un/tie gown, don’t forget to do maneuvers bilateral for limbs, ask if patient is comfortable/in pain, pull out foot step, thank patient at the end for their for cooperation!

15-Before leaving, be sure to tell the patient “It was nice meeting you, I’ll see you as soon as the tests come back, take care Mrs.XYZ”, with good eye contact, a warm handshake & smile.

16-If the final bell rings & you haven’t finished the encounter, immediately excuse yourself telling the patient “Mrs. XYZ, I can hear them paging for me, I will see if it’s an emergency & come back to you as soon as possible”. It totally acceptable & will save you from a very akward end to the encounter.

NB; Great advice I heard from a specialist in the field of Dr-Pt Relationships, is to always keep in mind that the encounter should be about 3 things; information gathering + rapport building + information sharing. It is a 2 way conversation, not a download of info onto the patient!





F- IMPORTANT ADVICE:

1-The SINGLE MOST IMPORTANT piece of advice is that you write down your DD (& your draft sheet) BEFORE entering the patient’s room…. It might cost you a whole minute of the encounter, but trust me it is a minute well invested!! It will allow you to enter the room with a plan & very focused! It eliminates the possibilities of brain block or being at loss as to what to ask for next or what to do next… You will appear confident & you will be efficient!!

2-Also important, is that you practice, practice, practice! Take it easy at first, focus on mastering each part of the encounter, then start timing yourself through the whole encounter, do this for most of the 30 practice cases- the more often you do it, the better. Remember, 15 minutes is a long time! Although it doesn’t seem like it, with practice you will usually get everything done on time, or at least know what to leave out..

Here’s a time-line to work along;

Doorway= 1 minute

History= 7-8 minutes

Physical= 3-5 minutes

Closure= 2-3 minutes

Pt. Note= 10 minutes






G- LEARN TO WRITE:


1-a Draft Sheet, written before going in to see the patient.
(see below for recommended draft layout.)

2-a Patient Note (PN), written when you finish each patient encounter.
(typing is also an option.)




1-Draft Sheet;

I will explain how to lay out the info you need to ask on the draft sheet, in a way that makes it easy to remember, includes all the points to be asked & allows you to briefly write next to them, so that when you transcribe your draft to the Patient Note, it is easy & efficient!

Follow the clear & simple steps below, with a pen in your hand, using a blank sheet.

IMPORTANT: Draw 2 horizontal lines at the top of the paper, to create 2 long & narrow boxes to write in. Then draw 3 vertical lines to divide the rest of the page into 4 equally wide columns to write the mneumonics in, by putting the letters underneath each other. With practice, you’ll know how much space you’ll need for each part of the page.


i-First Horizontal Column- write in it these words NEXT to each other;

pt’s LAST name, age, abn vital data, DD (3-5 maximum)


-writing last name in CAPITAL letters will help you remember it, because you must address the patient by name at least 3 times in the encounter. It will also be easy to spot from the corner of your eye in case you forget it!

-writing the age before you go in will help you make a mental note of what to expect when to enter the room & of particular vulnerabilities of that age group. For example, older patients must be probed for dementia symptoms & elder abuse.

-writing abnormal vitals will remind you to ask about them in your Hx

-writing a few DD (based on the Chief Complaint & patient’s age group) before you enter the room is THE MOST IMPORTANT step in the whole exam!! Use the DD as a guide in asking questions that exclude/confirm each DD, so your Hx is focused due to time restrains. It also helps you get flowing in speech, to avoid any brain blocks or akward pauses infront of the patient. Basically, having the DD ready in mind provides you with a plan. Time will not allow more than 3 DD to be explored, if you put down 5, the remaining 2 will quickly be ruled out from the first couple of questions.



ii-Second Horizontal Column- write in it these words NEXT to each other, with a space between them;

2nd C/O, Inv.


-a second complaint may appear during asking the patient about their Hx, so write it in the second horizontal column to remember to analyze it properly & ask it’s related questions. For example, if the patient comes in primarily for abdominal pain, then while asking the Hx, they mention they have a cough too- don’t just let it pass, you have to analyze the cough too (non/productive? timing? positional? Remember also to analyze sputum if applicable!)

-writing 1-2 investigations will remind you to mention them to the patient during closure on what’s next



iii-First Vertical column-write in it these letters directly UNDER one another;

O C D F P C T L I Q O R A A A S A B C C C O


(= onset, course, duration, frequency, precipitating factors, content, timing, location, intensity, quality, onset, radiation, associated symptoms, alleviating factors, aggrevating factors, similar past episodes, amount, blood, character, consistency, color, odor.)

-OCD are the first 3 simple questions concerning the Chief Complaint (CC)

-FPCT are questions further analyzing the CC (if applicable to CC)

-LIQORAAS are the questions for any PAIN symptom, whether it’s abdominal, joint, cardiac,etc - always ask these set of questions

-ABCCCO are question for analyzing any body fluid/discharge (if applicable to CC), like sputum, vomit, stool, vaginal secretions.

-obviously, you usually won’t have to ask all these questions, but always write them to remember them when applicable, if not, then just skip to next relevant question. There’s no chance to depend on your thinking & memory abilities- you have to be able to go over these questions fast & efficiently, due to time restrains.



iv-Second Vertical column-write in it these letters UNDER each other, with spaces between them;

System, Specific, Mneumonic, Complications


-Systems;
briefly ask about these ‘overall body systems’ through simple questions:
General- fever+ chills, nausea+ vomiting
GI & GU- bowel+ urinary habit changes
CV- chest pain
Resp- shortness of breath
Ms.Sk.- pain anywhere in body


-Specific Qs for ‘the system' of the chief complaint;
for example if the patient complains of frequency in micturition, then you should ask all other Qs related to Urinary tract system- like difficulty starting/stopping, dribbling, discontinuous stream, straining, incontinence, painful urination, blood in urine, etc..


-Mneumonics;

if the patient complains of Shoulder Pain, you should write down it’s mneumonic: SPORTS
(=Septic arthritis, Pseudo-gout + Patello-femoral pain syndrome + Psoriatic arthritis, Osteoarthritis, Rheumatoid arthritis+ Reactive arthritis (Rieters syndrome), Tophi (Gout) +Trauma (Fall, Elderly Abuse and SPORTs!), Sac Inflammation (Bursitis))


OR if it’s a Pediatric Case- write it’s mneumonic: ONCCCCCALLIDDDIIOT
(=onset, number of times,content,consistency,color,crying,cramps,assoc.(fever-rash-nose/ear discharge-cough/vomit-shortness of breath/sore throat), lethargy, liquids not passing, immunizations, diet, dehydration S/S, developmental milestones, ill contacts, infections , oral rehydration solution, travel.)

(ps; of course also ask these which you’ll find in your other columns; Birth Hx + Past Hx + Family Hx + Allergies + Meds)


Or if it’s a Medication Refill visit; DDDCMEDEM
(=drug, dose, duration, complications, monitoring, education, diet, exercise, medications)

-Complications;
Like if it is a case of Diabetes, don’t forget to ask about the expected complications of Diabetes, as visual changes, tingling/numbness in extremities, etc..



v-Third Vertical column- write in it these letters directly UNDER each other;

S A W D E P A M H U G F O S S O D A M T


(=sleep, appetite, weight, diet, exercise, past Hx(medical diseases & surgical operations), allergies, medications, previous hospitalizations, any urogenital S/S, any gastrointestinal S/S, family Hx, obsgyn Hx, sexual Hx, social Hx which includes these letters- occupation, drugs, alcohol, married/children, travel.)

-SAWDE are about the patient’s lifestyle- asking them will tell you if the underlying disease is affecting them & will also reveal any bad habits the patient has, which you will have to counsel them for at the end. For example, if patient’s CC was fatigue, & they say they have been waking up early/loss weight/lost interest in exercising.. this could lead you to confirm Depression as one of your DD. Of course, you will now need to ask further questions relevant to Depression, like suicidal attempts/ideations, etc…

-PAMHUGFOSS/ODAMT are everything related to the patient’s past, which means anything other than the History of Present Illness (HPI).

These third column questions are asked in EVERY encounter, whatever the patient’s CC. They will always help you exclude/confirm your DDs & sometimes even draws your attention to something you were completely missing in the DD!



vi-Fourth Vertical column- write in it these words UNDER each other;

General, Chest, Heart, System ,Counsel


-General examination for every case:
pallor, jaundice, cyanosis, nails, LN enlargement, LL edema, rash
(remembered using P.I.C.K.L.E.S.= Pallor, Icterus, Cyanosis, Koilonychia, Lymph nodes, Edema, Skin)

-Chest:
basic auscultation of every case

-Heart:
basic auscultation of every case

-System of chief complaint:
complete examination of H&N or Chest or Heart or Abd or Neuro or Extremities

-Counseling:
in 3-4 lines maximum try to cover most of these points-
.show concern,
.warn of possible complaints,
.explain treatment options,
.offer support (through social worker to give ride home/ pick up child at home, support groups in clinic to quit drinking/smoking/loose weight etc),
.discuss effect of their negative habits (eg.smoking)/encourage their positive ones (e.g.they exercise regularly)!,
.show sincere willingness to help, & most importantly,
.explain to them what is going to happen next…





2-Patient Note:

I first wrote down the headings, under each other, along the left border of the PN, to avoid forgetting anything. It takes a whole minute to do it, but it’s well invested to get as much points on the PN.

Write below each other:


*in the History section;

CC, HPI, ROS, Allergy, Meds, PMH, PSH, FH, ObGynH, SexH, SH.

(=chief complaint, history preset illness, review of systems, any allergy, medications, past medical history, past surgical history, family history, obstetrics & gynecology history, sexual history, social history)


*in the Physical Exam section;

Pt. is …, VS, Gen., Chest, Heart, System.

(=patient’s condition whether stable/distressed, abnormal vital signs, general examination findings, chest auscultation findings, heart auscultation findings, other system examination findings)


Then I started to fill them out in the following order;

1st- DD
(in order of most likely to least likely),

2nd- Investigations
(make a mental note of ordering the following according to relevance)
a-Pelvic/Rectal Exam,
b-CBC with differential/Electrolytes,
c-Xray/CT/MRI

3rd-History
(it’s very tricky to manage the space for History, so practice it well to avoid writing in a clumsy way),

4th-Physical findings.
See Kaplan Step2CS- Focused Exam section, for how to document PE findings on the PN
(brief phrases for the +ve/-ve findings of each system examined).


Please stick to this order, even if you start getting confident with your timing, because there will always be a case where you run out of time, so always be sure you got as much points as possible…

See USMLE website’s online Information Manual for Template of PN
(print 30 copies to use while practicing long cases)
usmle.org/Examinations/step2/cs/content/appendixA.html

See USMLE website’s online Information Manual for Common Abbreviations allowed on PN
(print for reference)
usmle.org/Examinations/step2/cs/content/abbreviations.html

See USMLE website’s online Information Manual for Samples of PN
(showing acceptable writing styles)
usmle.org/Examinations/step2/cs/content/appendixC.html


Both empty draft sheet & patient note are provided to you in the exam for each patient.






H- STUDY PARTNER:

This is one of the most crucial things for the CS exam… finding a study partner & practicing the cases with them. There is much anxiety involved since this is face-to-face interaction, plus the time is very limited. So practicing with a partner will give you the confidence & speed you need….

There are many options, one or more will suit you throughout preparing for the exam;

1-Find a colleague studying for the exam as well, obviously this will be the most efficient form.

2-A study partner who understands medicine, but is not familiar with the CS exam, will still be helpful

3-A study partner who is not in the medical field but willing that you ask them the Qs & examine them.

4-A partner who will role-play through the scenario (but won't feel comfortable being examined).

5-A partner who talks on the phone with you for the Hx part of the encounter.

6-Making a life-size doll, including face & limbs, to practice on! I did this by putting a shirt on a clothes hanger (for support) & attaching pants using a lot of safety pins. Then filling them with crumbled sheets of newspaper (to give support), attaching a stuffed bag upside down or attaching a balloon for the face, drawing eyes & mouth, sticking on it a nose, tongue & ears (to be able to hold during examination). Feel free to be creative & add strings of paper as hair etc … Using an medium-sized empty box under the shirt for the torso, will allow the doll to sit up easily & also simulates the resonance of the chest cavity on percussion! And you can cut out the lower part of the box & put in a balloon for softness of abdomen, allowing light & deep palpation.

7-Using a pillow to practice on as your imaginary patient..

Other ways to help you simulate the exam is to practice examining the patient using utensils from around the house as your instruments. The ones provided in the exam room are: torch, otoscope, ophthalmoscope, tuning fork, stethoscope, tongue depressor, prick stick, cotton swab, reflex hammer





I- Pre-/EXAM/Post-:


Pre Exam Checklist:

Hotel & flight reservations

2 photo IDs, your name spelling MUST be identical as your ECFMG records

exam permit & confirmation notice

white coat & stethoscope - can be provided at the exam, but highly recommend to take your own

professional & comfortable shoes & outfit


Exam Timeline:

8 hour day , allowed to check instruments during orientation ,

1st break=30 minutes, 2nd break=15minutes, light meal provided
( I recommend you bring your own, especially if you have dietary restrictions)

11-12 cases, only 10 are scored

cell phone/digital watch/pager/ PDA/notes/study materials- all are put away in small storage cubicle


Post Exam:

Try not to obsess about what you forgot to do! The score is of your overall performance anyway…. It’s a long 2 month waiting period, so ….relax & enjoy the post-anxiety euphoria!

Most importantly write down your advice to share with future CS takers. It’s good karma! If you benefited from reading other people’s experiences, it’s the least thing you can do to contribute to the overall good of the medical professionals & their patients.

I’m sure ECFMG or NMBE just want to be sure examiners have the necessary skills, they don’t care if you pass the first time or not, as long as you acquire the skills. So why not help your colleagues learn them before the exam, not after!






J- ACCEPTABLE MISTAKES:

These were mistakes I made, which had me second guessing if I would pass. Thankfully, it seems they were OK !

-the exam supervisor knocked on the door after the final bell rang, as a warning to leave the room in two of the cases. I was worried this would be reported as irregular behavior, though I didn’t stay extra-time, the bell had just went off & he was behind the door knocking on it immediately…

-there is a questionnaire they ask you to fill out at the end of the exam, one of the questions was about how much of your clinical training was supervised by senior residents… in my training, it wasn’t much & that’s the answer I chose, which had me worry later if that would affect my score

-was a bit clumsy with one obese female patient, as I was helping her lay do wn on the examining table, her gown accidently uncovered her, because I hadn’t properly unfolded the drape on top of her, so thought I’d lose points for not draping her properly/completely

-didn’t complete the patient note on one of the cases, ran out of time, because was getting too confident & didn't stick to recommended order of filling out PN

-had no idea what was the diagnosis of one of the cases, which I honestly told the patient ! I had a Differential, let him know it & said we’ll learn more from the Inv., but was not sure what it was he had… although I ruled out the possibility of HIV from the History, I still wrote it as in the DD & asked for its Inv. anyway!

-didn't ungown some patients (if they weren't chest/heart cases) when listening to their heart & chest, just stuck my stethoscope under their gown to save time... wasn't sure if I would loose points for that, i guess the important thing was not to place stethoscope over gown while listen to their heart/chest...

-forgot to counsel a patient on proper care & rest of his sprained heel.

-made a sincere attempt to add a little humorous remark during the History taking, some patients laughed, a few stubbornly gave stares or kept straight faces…

-most of the patients seemed very tired, thought I was boring them to death! I actually asked the supervisors if these patients were the same from the morning session to be sure, they were not…

-was always the very last person standing in the hallway before going into the room… scribbling down my DD & Draft Sheet… was worried the patients would think I didn’t know what I was doing, if they did, as soon as I entered the room, I changed their minds!

-was usually leaving the room at the final bell ring, the times I would finish early, I’d tell the patient I will sit down & write my comments/recommendations while still in the room, in case I remembered to ask something or they remember to mention anything…

-forgot to examine a patient’s right limbs, to compare & contrast to the left side which he was complaining of

-one of the cases was a consultation/follow up, the patient was fully dressed, no examination required- I wasn’t too sure of the questions to be asked, felt like I was kinda just chatting with her…

-there is this formula students on forums use as a psyche booster, which is that the pass rate of the exam is about 65%, ie 8 out of 12 exam takers pass... so they would enter the orientation room & pick out the 4 most misfit people & convince themselves they weren’t one of the 4 who will not pass that day! I tried to find 4 people who looked misfit, was doubting I was one of them, but thankfully & obviously was not!






K- BEING DIFFERENT:

Rule no.1- it’s OK to be different! Whether in appearance, ethnicity, religion, background, culture etc.. America is made up of immigrants, it has a very diverse mix from all walks of life.

Rule no.2- if English isn’t your first language-as long as you use simple sentences, proper grammar, clear pronunciation- you’ll be fine… Chinese accent is considered the trickiest & I heard of some of them who have passed 1st trial.

Rule no.3- it really helps to be aware of US current events & American values & lifestyle. You can use it in the ‘personal’ question you ask while washing your hands, in an attempt to connect to the patient on a humane level. Before I came, I got a lot of insight from Yahoo news, while checking my mail…& once I was here, I was tuned in to the news channel.. Also this knowledge will help you sound less judgmental towards their life style habits, while asking about their social & sexual history & during counseling them on these.

Rule no.4- I think the most common mistake of foreign students, is when they do not take into consideration that in the US, doctors are at the service of their patients & expected to act that way… being courteous & mindful, giving them a chance to talk & say their opinion & be involved in decision-making by giving them options.. & that they usually educate them about their illness, so will always have questions concerning it..

Rule no.5- ideally, in a clinical setting, you are the one with the knowledge, wanting to help the patient. So you must act in a way to reflect that- via appearing confident & compassionate.

Rule no.6- FORGET that they are actors! That is another common mistake, going through the exam in a robotic fashion, assuming they are there only to give you points for things you ask/do. You must act out your part, as they are acting there’s!



Personal Note; I wear a headscarf & cover up as part of my religious belief in modesty & chastity- just like Virgin Mary, Christian nuns & also devout Jewish women. Especially on the exam day, I was wearing a wide & long one, in no attempt to compromise or be apologetic about it. So my message to all female Muslim* foreign physicians, wear it modestly & proudly and always do your best to live up to its honor!






L- RE- TAKING THE TEST:

If you understandably feel hesitant to go through the burden of the exam again, I would like to share valuable feedback posted on forums, from those with a similar experience;

forums.studentdoctor.net/archive/index.ph /t-232194.html

forums.studentdoctor.net/archive/index.php/t-334059.html

forums.studentdoctor.net/archive/index.php/t-361232.html


Sometimes, life will knock you down- it’s OK to feel dazed & off balance for a while- but the only thing to do is get right back on your feet! I’ve been challenged by other exams, & found the only thing that makes it better is to have faith in yourself, change your approach & make another attempt! Don’t let a test tell you what you can/not do… After all, in our field, it’s just one of many tests…

If at any time you start to doubt your abilities & need inspiration, check out this amazing dude;
www.maniacworld.com/are-you-going-to-finish-strong.html





As a Muslim, I felt both obliged & blessed to share this hopefully beneficial information… I would similarly like to share with you something MUCH more important, because passing the CS is a happy & significant moment in time, but passing life’s ultimate test is happiness for the rest of your life!

My religion, Islam, teaches us not to withhold this precious information, within which lies its answer to every question & the solutions to all your problems. If you are reasonable enough to look beyond the false/negative propaganda in Western media….. if you are clever enough to summon some curiosity about the fastest growing religion worldwide, then I invite you to check this link; www.sultan.org/

Oh , & congratulations in advance on passing the CS!! :-D