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

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 !