Hi there. Here’s whatever is worth of my USMLE Step 3 experiences. CCS cases in particular. Sure hope they’re of some help!
If you are crossing time zones, try to get to your venue a couple of days earlier so as to adjust. USMLE is long, tough and requires a lot of concentration.
The first day is tough. That’s my feeling. Seven 1 hr. sets of MCQs. Either way, it’s 1 min. 15 secs. for a question and by Jove, you’ll need it. The questions are long.
If I were you, I’d read the answers first. Makes it easier when you scan the question. For instance, the real choices may be about the required ethical decision. But the question will be full of technical fluff.
Concentrate on Office/Satellite settings. That’s about the size of the exam. Those with experience in family practice will just love Step 3.
Second day – three shorter sets of questions. CCS follows. And CCS is what this posting is really about.
CCS is actually fun! Immensely enjoyable. Nine cases on the whole, easily diagnosable. How u manage them is the crux of the matter.
You must do the five samples given by USMLE. Also do the practice scenarios and think through the case. This is before doing the real exam. A MUST.
At the beginning you’re given a very short introduction. Something like “a 45 aged white man comes with a complaint of severe chest pain. Then you’ll be given the history of the complaint and additionally PMH, Allergies, DH, ROS and FH etc. You have no alternative except to read through all the material.
Before you move on, these are what you should do:
- Try to come to a narrow differential diagnosis – even before the physical exam
- Note down any allergies (in case you administer the wrong Rx accidentally).
- Note down risk factors like obesity, hypertension, smoking etc. You could get extra points if you counsel the patient on these at the end of the case.
- If pertinent and necessary, you can sign off with a order for some sensible screening tests such as pap smear or mammography etc.
Right. Now that you’ve gone through the complete history and come to a conclusion on the differential diagnosis, your next important query would be:
Is the patient stable? That is, is there anything to be done immediately? If the answer is yes, no point in doing a physical. It would be inappropriate. Imagine you’re on the spot. You’ve a patient with severe chest pain. Would you waste your time doing a through physical? No! You’d straight away go in for oxygen, iv access (for pain relief or otherwise), pulsox, EKG and portable CXR and ABCs. If there is any indication, don’t forget to get tests such as ABG, serum glucose, PEFR and urine analysis done. These are just routine that you might just forget them.
Another essential point; what if this took place in an ‘office’? Application of oxygen and perchance an IV line might be possible, but you’ll soon have to do a move location to an ER for further management.
If the condition of the patient is severe and the situation warrants it there will be justification in carrying out all these emergency actions before the actual physical. Once a semblance of normalcy is established move on to the PE and click on the systems that you wish to examine. A cardio/respiratory/abdominal exam is essential and shouldn’t be missed. Also any other appropriate ones.
Once you go through the PE findings, your differential should be narrowed down even more further. With the coming in of the EKG, the CXR and the blood results, you should have a preliminary diagnosis.
This is when you start on a specific line of management.
If you had ordered a number of tests and are waiting for the results, you can try to obtain those results earlier. In case your method of management is correct, feedbacks like “the patient is more comfortable” or “is less breathless” will come in. In case you are wrong, the feedback would more possibly be “your patient’s breathless is increasing”, etc.
Keep firmly in mind the venue. If your patient is unstable, that is he/she is having acute heart failure, DKA, MI or Pneumothorax, move him/her to the Intensive Care Unit (ICU) immediately. In the US of A, pneumothoraces and DKAs are usually taken care for in the ICU. If necessary, a central line, or an arterial line or a PA catheter might be given. If immobile, keep heparin in mind.
If the patient is in your consulting rooms, with some minor complaint, there is no necessity for a rush. You can take your time to examine your patient. You can then order any tests that are relevant. And if you need those results to confirm your diagnosis, get your patients to undergo them without any delay.
The CCS will show you when the results of the tests that u ordered will be made available. In a consulting room, blood tests will take about a day. You can send the patient home with a pain killer, if necessary, and ask them to come back with the test results.
Specifically in a consulting room situation, you may have to see the patient a couple of times over a week or two or more to see if he/she is getting better. So, if for instance, it is a patient with Iron deficiency, don’t just prescribe ferrous sulphate and some counseling and forget about them. But do counsel them if required. For instance for drug compliance or cessation of smoking.
Location change is also important in the reverse. If your patient in the ICU is much better, shift him/her to the general ward.
Over-treating will not get u extra points. You just might end up losing some. Like, for example, if you do an unwarranted expensive or invasive procedure.
In a CCS setting you are the patient’s primary physician. Usually you’ll not be allowed to perform an specialized procedure like evacuating a subdural hematoma. If such a procedure is deemed necessary, you’ll have to refer the case to the specialist concerned.
Clicking “consult” in the orders page will list out the choice of specialists.
If you do not have sufficient grounds for a referral, the specialist will not put in his appearance. For example, for a cough, you’ll most probably get a refusal from the Pulmonary Specialist. But if you did an imaging on the chest that turned up a discrete lesion, not only will the pulmonologist but also the oncologist will evince interest. The point is, have solid evidence, like imaging. Once the problem is identified then the operation on the patient can be carried out.
Right! Here it goes!
Had my exams for two days January 16th and 17th. My results came out last week.
Prep. Time – 2 weeks.
Books – None. No time for books.
Other than books material used – UW CCS cases and UW Multiple Choice Questions. No time to complete the UW questions. Answered about 800 or 900 questions; all in timed mode. Got an average score of 58%.
Went through the UW cases once. Tried the five practice cases so many times that I’ve lost count. Learnt how to use the Primum software and tried out a few UW cases on it.
NBME – Tried it out for the sake of trying it out. Got a decent score of 420.
Right! Now for the real thing. Very hectic day one. Very long questions. Lots of them in Geriatrics. Patients on multiple drug and with some 60 or 7 diagnoses. Usually these questions would test issues of drug interaction or ethics.
Some of the questions were straightforward some were ambiguous. I’d say that on an average, I’d be sure of some 60% of the questions for each block and sort of sure for about 10 to 20%. No inkling of the rest.
Lots of pictures of skin – some easy, some indistinguishable. Dermatology questions were tough as the history of the patients were vague.
There were only a few X-Rays and just a sole EKG.
Questions seem to be in the UW pattern though whether they were similar or not is quite difficult to say.
The second day moved like lightning. But a block of questions out of the 36 was singularly hard. Can’t say if I was fagged out or otherwise. Couldn’t really concentrate in the final block. Just wanted to finish the whole thing and walk out. Felt smothered.
CCS cases – Just snapped through it. Eight minutes per case, no more. Fact is, the last one lasted only 4 min. All the patients recovered. First case was a failure. Couldn’t figure it out. Even took 20 min. Just didn’t recover.
Final Score was 86%. Couldn’t be better satisfied.
Studying successfully for Step 2 of the USMLE
As you get ready to study for USMLE Step 2, have no doubt in your mind that it is going to be tough and that you will be under immense pressure. The pressure may not be to the extent that u faced when preparing for Step 1, but there will be some. Some study procedures that might help you score the marks that you expect are given for your benefit.
First Procedure : First of all you have to have a plan of study. Ensure that there is sufficient time to study so that you do not finding yourself cramming at the last minute before the exam. You must have heard of some kind of scheduling that is required. You may also have heard that though it requires 2 months of study for Step 1, 2 weeks would be sufficient for Step 2. Take it to heart but do not stick to this plan as you will require more than two weeks for preparing for Step 2. Two weeks just will not do.
Second Procedure : The First Aid book is an absolute necessity for Step 2, if you want to get off on a flying start and be successful in getting through its examination. If you are used to the First Aid series for Step 1then this will be the format that you will also get for Step 2. You can get the most of the book by reading it a more than a couple of times. Schedule yourself a plan of study and try to extract all the information that you can get in the first read itself. Utilize the same kind of methodology of studying in the subsequent readings as you are bound to leave out some information in each read.
Third Procedure : Make it a point to consult a number of sources when preparing for an exam or for anything else for that matter. Every time u read another fresh material, you will find that there is something new that u did not get in the previous source. Once u have gone through the First Aid for Step 2, you can move on to the next Crush Step 2 material. As u read new material from different sources u will find that the presentation is also different so that you will not get bored with repetitions. The Crush Step 2 will be a fresh format.
Fourth Procedure : Step 2 Secrets will definitely complement your study for the USMLE Step 2 exam. You will not be learning anything new, just that you will be reviewing what you had already studied and finding out the stuff that you had missed out. Step 2 Secrets is excellent resource material since it permits you to test yourself. It is also perfect for a fast recap prior to the exam, that is if you really get the top 100 secrets correctly.
Fifth Procedure : You have only two choices when it comes down to databases – the Kaplan Q-Bank or the USMLE World. Which are you going to choose? Even though the choice is yours, many people who have passed out successfully swear on the USMLE World. The reasons are that a. It is only a one month $60 subscription and b. The questions are more deep. If you want to guarantee yourself a success and have the means to do so, then purchase both. If you do not mind the expense, then also purchase both the databases.
Even either one of the databases might just overwhelm you. To make it easier for you set it up in sections of 46 questions each to be done in the timed mode. By doing so you are setting up a mock exam session and so there will be no surprises on the real exam day. Don’t try to go into the tutor mode and cut down the 46 question format just to relieve yourself. You have to get used to the atmosphere of the exam that you’re going to sit for. But whichever database you use, make sure that you use it completely and thoroughly.
Ensure that you review all the material, both the ones that you got right and the ones that you got wrong; with more concentration on the wrong ones. This is the only way by which you can identify the reasons why you gave the specific answers to the questions.
As you go through the First Aid for Step 2 book, make marginal notes. You’ll find that these notes are really helpful when you do the review just prior to the real exam. Use all your resources.
If you conscientiously followed the five procedures spelt out and reach the end of your study, there is little doubt that you will get through the Step 2 exam and come out with flying colors
I am very happy. I just received my IMG score. I wanted to give my advice, the advice that I wished I had received before I began studying for the United States Medical Licensing Examination (USMLE). But this is the rough outline of the way I would prepare for the exam.
1. You will require three to six months preparation time depending on your current level of your studies. If you know your pharmacology, pathology and microbiology, then three months should be sufficient. If not then you’d need nearer to six months. You would need lesser time if you are going to medical school in the United States.
2. Start by going through the A rated books on FA (physiology, BRS pathology etc.) Ensure that you understand everything; when I say “understand”, I really mean “understand”. This examination really tests your understanding. Just learning the facts is not sufficient.
3. As you study and understand each subject –
- Annotate your First Aid book so that you can understand every fact in it clearly. On its own, first aid is not interesting and unless you read it over and over again during the last two to four weeks you cannot prepare for the exam efficiently. You should be so familiar with the subject that you should be able to review it completely in just one day.
- The record of all the topics given at the beginning of each of the chapters is of great use it is advisable to cover all of them at the very first time that you read it.
- Make a note of those subjects that seem to be theoretically difficult. This will be helpful when you revise so that you can go straight to the topic. It is important as revising for this exam is tiresome and boring. When you revise, do the difficult subjects first so that at the end of the day you can concentrate on the easier subject. It is difficult to read about epilepsy management, anti-cancer drugs and renal pathology when you are tired.
- See that you are strong in those areas in first aid that are important – microbiology, endocrinology, autonomic pharmacology etc.
4. Once you have finished reading all the subjects, I would attempt all the Board Simulator questions and or the medrevu.com questions, subject by subject. This will reinforce your knowledge. As far as I am concerned, these questions are good for teaching purposes by not good from the point of view of the exams as they are too choosy. You should do it only because the analysis of your answers is automatic.
5. If you have finished the medrevu.com questions then you should check out those areas in which you are weak. No point in doing a repeat on those subjects that you are well versed in. Focus on the subjects that you are weak in. Use the results of your medrevu.com analysis of your answers and the notes that I told you to make previously. This is more essential, especially if you happen to be weak in those subjects that will give you a better score. Don’t waste your precious time on subjects in which you will probably get only one question, the one question that you’ll probably get wrong. Some four months would have gone past by the time you get to this point. From this point onwards use “kaplan qbank” and shift your focus to all areas. That should leave you some two more months to prepare. Read a couple of subjects more for the next three days or so, for example, behavioral science and microbiology and then repeat the qbank questions. Do this again and again until you have completed all the subjects and all the questions in qbank. This should take another month. Leave the last month for a complete review, concentrating on the weak areas. You should be able to review FA in a day with the exception of pathology, perhaps.
Some General Points For Study : Learn the subjects from a clinical angle. You have to be strong in pathology because one of USMLE’s favorite question id to ask you to describe a disease and then quiz you about its immunology, pharmacology, microbiology etc. If you haven’t studied your pathology, you’re bound to get stuck. No point in looking up the previous questions that have been asked or the question that others have been asked. They are all different. FA is a better guide. And don’t go about comparing your scores with those of others; your standard of preparation will be different from theirs. Focus on your scores and they will gradually rise to the place where you want them to be. Do your practice questions a couple of weeks before the actual examination so that you will have time to rectify your mistakes.
Make an attempt to score some 70% and above in realistic examination standard questions. Kaplan simulated USMLE exam CDs would be the best for practice. Though there is no guarantee to success, scoring 70% in the Random Tests should do the trick. To my opinion, anatomy is the least important simply because there is so much to study. Keep in mind that each individuals exam is different and everyone gets a bombshell to blast them out of the exams. Frankly, mine was in molecular biology. So many questions! If there is any subject that you intend to gloss over, make it anatomy. From what I can make out, that is the subject that is not likely to come up with many questions. There is also ne necessity to look at too many slides in histopathology. You can make out most of the histopathology slides just by looking at them.
What I am now imparting to you is an improved version of the study methodology that I followed. I did not prepare as well as I have advised you to. Make alterations to this pattern of study to suit your temperament and your time schedule. But on the whole I believe this will be useful. That is Understand FA. Answer a lot of test questions. Put your focus on weak areas! Do Not Give Up!
The scores that you should aim are :
ü Qbank 69% (a month prior to the real exam)
ü USMLE CD 39 to 45%
ü Kaplan Simulator CD 73% ( a week prior to the actual exam)
ü Books to read up : BRS Pathology / Physiology / Behavioral Sciences(BRS pathology is the best), Microbiology Made Simple(the best), Lippincott’s Biochemistry, Pharmacology, Immunology and FA for all subjects.
If I think of anything else, I’ll post it. Bye for now and Good Luck.
PLAB Exam overview
This is a detailed an excellent experiece in plab 2 exam written by a plab exam candidate
- Bimanual Examination
I explained the procedure to the patient and had taken the consent. I had some sensation of cystic swelling at the cervical opening. Palpation of the fornices was also difficult. In my opinion, the uterus was retroverted. I completely forgot about the lubricant or the KY jelly. My examiner was pressing me for the differential diagnosis but the finding at the cervix was occupied in my thoughts. So I was repeatedly telling him about the swelling at the cervix. He was not happy with my answer.
- My experience in next station was meeting with a post partum lady with some kind of depression
She was 4-6 weeks postpartum and visually looking depressed. Anybody could have diagnosed a case of postpartum depression. When I asked further, she was in a mood to commit suicide and harming the baby as well. My recommendation was hospitalization for both of them.
- Art of taking a history of constipation from a nurse
Initially I thought it would be an easy station. Actually during my preparation, I always neglected it and did not practice it so well. Therefore, the net result was always it had to be. My performance was worst there. After the foreword questions, I was having difficulties and was thinking the way out. I maintained silence for about 20 seconds. When I started again, I was trying to exclude malignancies and any emergency condition. I was sure that the effects were due to drugs as the patient was admitted with fracture femur for a long time. He must be prescribed codeine and calcium supplements. But I was having a hard time to ask appropriate questions from a third person to exclude the differential diagnoses. If you can do so, you can expect more marks than merely sticking to a single diagnosis. It is my advice here to practice everything well in advance and not to think to make up in the stage.
- How to talk to a mother of 18 months child with history of epilepsy
The station was a mixed history and counseling type. He gave the history of febrile fit for the first time. As I used up much time to take the history, therefore I had little time to counsel her. I had just the time to explain that it was a simple febrile convulsion and it normally occurs in children. When I said that it was a normal condition and she looked very much surprised. I consumed the stipulated time as I explained her about our next course of action.
- My next station was talking to the daughter of an 83 years old lady who was suffering from CA ovary. We were discussing about pain management in this disease. The lady was sitting comfortably in that room with a pen and paper. She was asking about medications we prescribe during pain management of CA ovary.
- Suture materials
Primarily, I explained the procedure to the examiner, taken the consent but not anesthetized the wound. I was provided with prolene suture and was struggling to make a knot. Add to my bad luck were the instruments. They were not of good quality; needle holder was not locking properly and I was provided with tooth forceps. Finally I gave up and made the knot with my hands. I had the time to make only one suture. As I was leaving the room, I did not forget to drop the needle in the bin placed to discard the sharp objects.
- Speaking to a lady about medications who had a MI 6 weeks back with heart failure
I was not sure about the patient. I managed to realize from the primary questionnaire that she was taking medicines irregularly as she was not reviewed her prescription from the GP after 2 weeks. I preferred to start with general advice. Gradually I explained her about each and every medication. She was keen to know about side effect of all the medicines. I informed her about lifestyle modifications and also told her to control her weight and edema of the legs. At the last stage of the station, I thought that I should inform her about frusemide. So, just before the final bell, I told her to take water pills.
- My next station: Speaking about MMR
I was talking to the father of a child about MMR. He was young and cordial. He had some idea about the vaccine and was speaking continuously. All I had to do was to add some points filling his conversation.
- Convince a lady to stay at the hospital having suspected ectopic pregnancy
It was one of my toughest jobs. She was continuously pleading to get a discharge and my duty was to convince her to stay. I understood her point as she had a job interview, but she was not a case to be discharge. I told her there might be bleeding per vagina and out of that she may die. Could a job be more important than a life? I gave her telephone number and some letters from the hospital. I also inquired about her other children and her family. She was repeatedly pleading to get a discharge. Later, I thought that I should have revealed some facts about infertility and future ectopic pregnancies.
- Clinical examination of a shoulder
Next patient was a Painful Arc Syndrome; at least I had this diagnosis. To my contrary, the examiner was not happy with the diagnosis and pressing me for the differentials. I was informed that the patient had injury to supraspinatous. So I thought it could be tendonitis. It never seemed like simple muscular injury as he was having pain and difficulty in abduction after 90 degrees.
- Examination of respiratory system (PEFR was part of the job)
I failed here and could not able to complete it. I also forgot about percussion of the back side. I missed face during General Physical Examination. But at the last moment when the 30 seconds bell was there, I managed sometime to take 2 PEFR readings.
- Examination of a patient having diabetic foot
I was checking the vibration sense when I heard the 30 sec bell. I thought that I would check the reflexes ideally and asked the patient to stand up and walk. Noting down the gait was so important in this kind of examination. The patient was not having any vibration sense below his ankles. All other sensations and the gait were normal.
- Next station: a lady with abdominal pain.
My next patient was a young lady lying in right lateral position. She placed her hand over the left lumber region and gave the history of radiating pain from loin to groin. She was also having vague complaints regarding her urinary system and some flu like symptoms. I had to take history and discuss the differentials with the examiner.
- Demonstration adult CPR
To my surprise, I did not forget to check my watch before starting the procedure as I always failed to remember it during practice back home. To me, I did not miss anything. As I finished the station, my examiner told me that the next station is rest time. So I kept sitting till the second bell.
- Rest station
- Next station: patient with Temporal Arteritis
I had to examine the patient and inform him about short and long term management. This time I had an Asian examiner. He was nice. My patient was middle aged and understanding. I asked him whether he had any idea about his present disease and informed about it as he was asking about it. Then I told him about high doses of steroids just to save his vision. I also mentioned about long term steroid for 2 years. The examiner was asking about the long dose schedule but I did not remember it. I informed that I would check the BNF.
All my intention to write this article was to share my experiences in PLAB 2. I know, I am not a writer and this article is not well written. But I think it will benefit the new candidates to have a general idea about how the PLAB 2 is conducted.
My best wishes to all aspirants.