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Jefferson Medical College Alpha Omega Alpha Guide to USMLE Step II: Clinical Skills and the OSCE

Your Exam Day

Step 2 CS consists of 12 patient encounters.  The OSCE has 11-12.  Both last approximately 8 hours.  Sitting at a computer for Step 1 or Step 2 CK for 9 hours is a long day.  However, if you've been on rotations, you're used to seeing patients for 8 or 9 hours.  The exam day often feels like a light day depending on rotation you're on!
You have 15 minutes to see the patient, take their history, and complete a clinical exam.  Each exam room door has a sheet with instructions and pertinent information on it.  You may look at the sheet as soon as the overhead announcement tells you to begin the case.   The sheet lists the patient's name, chief complaint, and vital signs. 

Do a focused history and physical.  In general, only repeat the vital signs if they are abnormal or relevant to the case (ex. hypertension, orthostasis, dyspnea).  You are NOT allowed to perform a rectal exam, pelvic exam, breast exam, or male genital exam.  Announcements tell you when 5 minutes remain and when the encounter is finished.  If you complete the patient encounter in less than 15 minutes, you may leave early.  However, you may not re-enter the room.  Any extra time can be used to start your patient note.

On case will not actually have a patient.  This is usually a pediatric case because they can’t use child actors.  It could also be a scenario where a patient calls you in the middle of the night.  You may walk in the room and see a phone—you will talk to the “parent” of a pediatric patient or an adult patient over the phone.  You might also have someone to talk to in the room, but it may be the “parent” of a pediatric patient.  Obviously, you won’t do an exam, but you can ask about subjective appearance.  You won’t have an xam to right up. 

You have 10 minutes (plus any extra time from finishing the encounter early) to write your note. During the OSCE, you’ll type everything on a computer next to the exam room.  You’ll need your campus key to log in at the beginning of each write-up.  For Step 2, you can either use their computer or hand-write it.  The keyboards at the Step 2 site are old and bulky, and some people might find they can write everything faster and still have it be legible.  You don’t have to only type or only write all the cases, but you can’t switch in the middle of an individual case.

The computer interface looks like this: You need to write the history, your physical exam findings (include the vitals from the door), differential diagnoses, and diagnostic work-up plan.  The history and physical are things you should be used to writing up.  Record what you find on exam, not what think you should find on exam based on the history (more about this in “Quick Tips”). You may use standard abbreviations in your note: the National Boards have a list of accepted abbreviations.  There is a character limit if you type at Step 2, so you may need to abbreviate some words if the history or exam is a bit long.  If unsure, just be safe and write it out. 

The differential diagnosis and work-up fields each contain five lines.  Write up to 5 differential diagnoses in order of likelihood.  Base this on the history more than the exam for the reason just discussed!  Write up to 5 things you would like to do next (i.e. the next best step) for your diagnostic work-up.  These can include individual lab tests (CBC, chemistries, UA, blood cultures), imaging (RUQ ultrasound, x-rays, dopplers, CTs), or parts of the physical exam you are not allowed to do during the encounter (pelvic exam, breast exam, rectal exam).  Don’t list ordering consults, patient education, or therapeutic interventions. 

There are two breaks.  The first is 30 minutes for lunch, and usually happens about noon (after 5 cases).  Food is provided.  At the OSCE, it's typical Jefferson brown-bagged lunches.  At Step 2, it was a spread of sandwiches, potato/tuna/egg salad, and deli platters.  You may bring your own food, but you can't leave during the break to get it.  The second break follows the next 4 cases, and it is 15 minutes long.  Your day is then finished after the last three cases and a short evaluation of the test day.  You can only use the bathrooms during the breaks for Step 2.

Note:  you are graded on your write-up AND your performance in the room with the standardized patient.  Treat them as you would a real patient, not an object to extract facts from so you can do your note.   

Last updated: January 2007

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