MISTAKES OTHERS MADE:

Just got my results back yesterday after taking it in April in Philly, and I passed
thankfully no where near borderline and a star in SEP, let me tell you how my cases
went:
1. Nerves got the best of me and I spent too long on history. I didnt even finish it
because the 5 min warning went off so I did 2 brief examinations and started closing
before time ran out, so I didnt finish at all. On top of that I could only think of two
diagnoses and very minimal evidence for support.

2. Straight forward case, got some confidence back, but still forgot to ask some
questions, but luckily every patient tells you something you missed if you ask at the
end of your history if they have anything they want to add.

3. Phone case, straightforward.

4. Peds case, took a while to find out what the patient had, and I had a lot of dead air
thinking of questions, quite the awkward encounter, but after the initial awkwardness,
turned out just fine.

5. Forgot to ask some major questions again which made me nervous again and I was
running low on time. Again the patient helped out which helped me reach a diagnosis. I
didnt do two full major examinations I should of have.

6. Exact same thing that happened in 5, happened here.

7-12. The cases got easier and easier, much more basic. I had tons of time to spare
with the patient. I finished within 7 minutes for each.

Some huge mistakes I made with every patient though: I did not pull the footrest
once during my entire exam, not any patients, didn't do any neuro exams even when
warranted, and never used the ophthalmoscope.

After reading your experience, it seems like you did just fine, just don't over analyze
what you did wrong, but think about how many things you did right! did you greet and
introduce yourself to every patient? Did you properly handle their drape? Did you wash
your hands? There are a lot of small things that add up, so even if you missed a couple
of things for each case, that is a small portion of the whole grading scheme.
So I made quite a few major mistakes, mostly for ICE component. Is there any hope for
a pass from these?

1. Peds case - missed majority of past history questions not directly related to
CC (Got the history for the main complaint and all, but missed past
history/social/vaccinations/meds/allergies/etc) Diagnosis was fairly simple so confident
in DDx and Workup
2. Missed majority of neuro exam in a case that warranted it. Only did gait.
3. Missed abdominal exam in 2 fatigue cases (both definitely needed it) -
Didn't palpate thyroid either
4. One case in which I had no idea what patient had (didn't ask ROS)
5. Missed simple straight diagnosis in 1 case (got good enough history, but blanked and
realized diagnosis right after submitting note). Diagnosis I put were reasonable and
supported by HPI.
6. Completely messed up psych case. Patient had a couple of SIGECAPS, but I
asked about depressed mood (negative), so stopped inquiring without asking decreased
interest. Put it in my differential with appropriate workup though. Could have been
(stress?) so either way I messed up
7. Cancer diagnosis - Had cancer in my top 2 differential in 4 cases but for
some reason I didn't specify the type of cancer at all...I'm an idiot. I just put
malignancy and offered supporting evidence for it
8. Didn't palpate joint in pain case. Didn't do sensory or reflexes either.
9. Didn't ask sexual hx in everyone, just 1 person that I think needed it.
10. Didn't do HEENT or full lung exam (fremitus, palpation, percussion) in 2 respiratory
cases at all
11. Missed 2-3 major ROS and HPI related questions for 3-4 cases
12. Work up for CXR didn't specify PA or Lateral
13. Stupid differential as my 3rd in 3 cases

Things I did:
1. Though CIS stuff went overall fine. Maybe 2 patients I didn't really answer their
questions well enough. Didn't really show too much empathy for like half of them, but
was kind and did all the counceling/closing stuff for most of them.
2. Asked PMH/SHx/Allergies/Meds/Social (alcohol, tobacco, drugs, occupation) for
everything else but peds case
3. Summarized HPI, explained DDx, and plan for everyone. Asked if they had
questions/concerns
4. Notes were overall structured well except for peds case were I didn't ask majority of
HPI.
5. Confident in correct diagnosis in 9/12 cases
6. Workup was always appropriate except for one of the cases I missed diagnosis
(missed a major test)

Anyone have any idea if these mistakes will tank me?

EDIT: After a long wait in which I was a neurotic mess and was convinced I failed, I
passed with only one star in borderline region for ICE and Higher performance for CIS.
Hope this helps other people. Exam is definitely extremely lenient.

After several days of thinking about my errors I finally came up with a list that, for now,
seems to be all i can remember i screwed up on:

1. Ran out of time to write the tests i'd order for 1 patient
2. Put CT and Xray of head when i meant spine
3. accidentally wrote an incorrect abbreviation for a differential (cant specify due to
USMLE rules)
4. forgot to do a few key physical exam maneuvers i.e. heaves, thrills, pmi, when
required
5. didnt ask anyone about quality of life being affected/in what way its affected them
i.e. didnt ask if affects sleep or work, etc, never said im sorry about their chief
complaint, i would just kinda throw in random apologies and sorries when it fit
throughout the case or say things like

 we'll definitely try to help you now, thats the goal,

 we'll definitely try to get this fixed for u asap,
 i'll keep u in the loop,
 ill tell you the results as they come, etc etc etc

6. had 1 awkward moment with a patient that was unexpected during a left lateral
decubitus pt said well this is awkward but i apologized right away for it

7. Didn't document things like scars or tattoes but mentioned it to the patient
8. was running out of space multiple times on the HPI so if say a person didnt smoke,
drink, etc... i deleted those things from HPI so i can fit something more pertinent, so
basically seems like i asked an entire social history but will not get credit for doing so
because ran out of space to fit in other things and the things i did ask will not be known
now even thought they were done
9. multiple differentials seemed off to me, some i could not think of more than 1
because felt so obvious, other times (possibly 2-4) was completely boggled by what to
even put down as first one, and other times something i should have put on the list, i
didn't and didnt realize it after, just kinda hoping the ones i kept still can fit the HPI,
etc.
10. never put pertinent negatives into the differentials
11. several patients during the encounter (maybe 2) i forgot to ask a key question that
would have lead to a certain better test being ordered aka the patient gave clues to
something i, in my ever lasting nervousness and anxiety did not pick up on as hey
buddy u may wanna ask about this or inquire about that.

12. I never summarized the HPI/physical findings, i just did the closure and told them
what I think it can be/why i think its that/what tests id order/why id order them, not
sure if doing a closure but not a summary will kill

13. Provided counseling for whoever i thought needed it for things like alcohol... but in
case like alcohol i forgot to say the CAGE results... again something i did that won't be
in note

14. didn't put in vital signs for every patient... probably had em all for only half and
some of them i just put in w/e i thought was actually pertinent

15. Few times wrote "non-medical" terminology

16. scared **** out of patient by saying cancer.... but obviously wiggled around it
saying its not for sure we have to run tests, etc etc

17. when i did my abdominal exam... instead of pulling from the bottom... i figured if
the patient is already ungowned for the cardiac/resp exam, may as well help them lay
down and just pull gown down a little more and do abdomen

18. didnt ask every female about their obgyn history, menopause etc, only if it was
needed (or so i thought)

19. lot of my physical exams seemed kinda weakish, i did the typical heart/lungs...
+s1/s2 no murmurs rubs gallops regular rate rhythm clear to ausc bilaterally (never
wrote no wheezes rales or rhonchi tho whoops)

Im definitely gonna remember other things... but as it stands... it seems like i failed
ICE or CIS or both
19.
our mistakes don't seem so major compared to mine IMO. But then again, we all think
that we did worse than the others, so I don't know.

Took it on the 15th of July, also waiting for results next week. I'm a US IMG and
hopefully my American accent covered up for some of the mistakes I made:

-I had time management issues for 3 patients (Left in the middle of physical for 2, and
in the middle of closure for one). In one of the incomplete cases, I could not make a
diagnosis without the physical so I had to type in very general differentials.
-2 vague diagnosis cases where I had no idea about the most likely differential
-Did not ask SIGECAPS for an insomnia case (Technically it would be warranted here I
believe but I sort of got a diagnosis from the HPI so I forgot and didn't ask)
-Forgot to counsel about smoking and/or alcohol on probably 3 cases where it was
warranted. Like I did a closure but the counseling slipped my mind
-I had an awkward moment with palpating PMI in a female with a huge bra (like its
support band was extremely thick and went below even the 6th ICS, so I had to have
her move it upwards and just plain awkward. Definitely a screw up there, we're not
supposed to expose more than needed or palpate there? I don't even know why I
attempted to palpate PMI in her case.
-Rest were fine, I finished a min early and got a head start on the note. I always smiled
for normal looking patients and kept a concerned expression if they were evidently in
pain or anxious/distressed, and was calm and maintained eye contact throughout all of
my encounters, and answered challenging questions properly. Washed hands in every
encounter and was respectful while performing physicals, and only exposed what was
needed (with the exception of that one female).
-What I did with my notes: I always wrote the differentials first (2 dx on most, only 1
dx on an extremely straightforward case, and 3 dx for only a couple cases), then the
workup, then general P/E (at least the "pt is in no acute distress, VS WNL" or the
distress state/abnormal vital signs as needed). Then I would write the HPI, and copy
paste supporting HPI findings as I would go, so that I wouldn't lose points if time ran
out, then the systemic exam findings and copy paste as I go. ---For a couple of cases, I
had to leave the HPI incomplete (social history left out), and on a couple I couldn't put
in the systemic physical exam. For a large majority, I forgot to type in CAGE negative
even though I asked it, and in one I completely forgot to type in the alcohol intake even
though I asked it. In one of my first ones, the second and third differential had no
specific supporting evidence (Like just the same major complaints that I copy pasted in
all 3).

Basically, I just don't know if I passed ICE or not and the wait is killing me. Anyone
with similar mistakes? Good luck to everyone else who posted on this thread, lets hope
we all passed.
ello guys,
(yes, I just joined this forum to meet similar freaked out peers like me). I had my step
2 CS in august and I am literally freaking out after the exam.
I am an international med student, have not taken my step 1 and step 2 CK and here
are a couple of things I did wrong.
1-In my first station, I made my female patient very uncomfortable by asking sexual
hx(which i thought was pertinent) and when I asked OB/GYN, she questioned my
rationale for asking it and I flustered and I auscultated her over the breast which was a
huge screwup (although her breast were small) ! and given the fact that it was my first
station, I forgot to counsel her on relevant aspects.In all, I forgot counselling on 2-3
cases, but other times i did it on pertinent aspects
2- I mishandled one of the challenging questions hugely.
3-There was a difficulty in comprehending 1 patient in the question which was really
important for diagnosis and I think the patient was a bit angry about me repeating my
question
5-I forgot to document some of the examinations I had done on the patient, including 1
supporting finding and thyroid exams
6-My top differentials on most cases were strong but the 2nd diff on 2-3 cases were
plain brain farts.
7-I never asked any patients if they understood me, I just asked if they have any
question for me.One of the patient actually said I was speaking fast.
8-Some of the patients had no challenging questions for me.
9-My patient notes were fine I guess, except for few times when I forgot to document
few things.

I am majorly concerned about my empathy part (CIS), I think 2-4 patients might not
be happy with me .i TRIED SHOWING EMPATHY EVERYTIME, I did all standard things. I
hope I hope I hope I pass.

Anyone who has similar history or is undergoing similar agony please hit me up. Could
really use some comforting words.

Hi guys!
I took my exam a while ago and expecting results very soon.
Despite trying very hard I can't focus on anything.
I've read pretty much every booklet and according to them I'm doomed.

I'm an IMG with no problem with English. I was very nice, empathetic, I believe.
I tried to talk to them as if they were my real patients.

My point is I didn't summarize the history. I didn't counsel on HT and weed/etoh (used
very rarely but it was a tenager).
I also never asked: How does it affect your life?
I remember talking about work in case of fatigue, diarrhea etc but some cases I just
asked qs related to the cc. That's it.

I always thanked, said sorry and was calm, confident.

I'm really afraid I failed the CIS portion

Is there anyone here who had similar problems and managed to pass?

Thank you

had similar problems and managed to pass.

On a more serious note, CIS (unlike ICE and SEP) can't be objectively (and more
importantly, realistically) evaluated by the people you've been practicing with. The
entire grading system for this component is so vague that the best you can do is
assume that if the patient didn't "rage quit" on you - you've performed fine. Just like all
of your predecessors - I missed questions, forgot to force myself into displaying
ridiculously obvious empathy and didn't bother asking about the way one's diarrhea put
him/her into an existential crisis.

The common wisdom is to acknowledge that nothing can be done at this point and try
to suppress anything CS-related until the score arrives. Best of luck along the way, you
passed. (If you're really freaking out, there's another USMLE-forum(s) which will
remain unnamed in which there's an entire subforum dedicated to the sharing of "what
did I do wrong on the exam and what was my outcome")

Hi
1- I was nervous, ( case of neuro) did'nt ask many important questions lke CONFUSION
AFTER LOC ( thought it was not seizure case), other qs, didn't do Full CN just did form
2-7 ( I write in the note CN 2-12) intact., ( I did MMSE) forget to write t in the note, forget
to write DTR in note, explained my ddx and workup badly, didn't have time to answer any
questions

2- ( forget to write about Diet ( I asked about it , colonscopy) , put only ddx, did my
closure and counselling my sound was shaking( as if I had panic attack ) was not confident

3- LIGHTHEADEDNESS : ( did full neuro ( didn't write MSE in note again ) ,

 Listen to CAROTID & HEART (Aortic stenosis?; No carotid bruit)

 o I liistened to carotid and only 2 places in the heart. ,
 Counsel to STOP DIURETIC USE….I didn't counsel pt to stop diuritcs, though I
wrote it in my note.

4-pt COUGH BLOOD ( Female) just listen to lung in one place from front ( b/c ) I thought
not to touch the breast , from back was complete, didn't do HEENT.
forget to write her MEds( vit and CA) in the note

 “Cough” = do
o HEENT; LUNG; CVS

5- CHRONIC GASTRIC PAIN ( forget to do murphy's, write chronic pancretitis in my ddx )

only 2 ddx, write rectal exam in the noet

 GI CASE:
o Check Gallstone (Murphy)
o Chronic Pancreatitis sx? Pain radiates to back; fatty-greasy stools “floats”
o RECTAL EXAM

6- PIN POINT KNEE PAIN ( ddx were wrong I/m sure) thought PE : were good, pt was
limping in PE but I wrote Gait : normal (

 DIAGNOSIS?

7-MSK : went good

8- PEDIATRIC CASE : MILD IRRITABILITY ( forget to ask many qs as no of dipers

changed per day etc, put only 2 ddx

9- ANOTHER PED: WENT GOOD ( note were not perfect forget some points like diet (
althought I asked about it ( it was regular )

10 - SORE THROAT ( forget to write sexual Hx in the note ), put 2 ddx,

11-URINARY CASE ( forget to ask important qs) ( sexual hx )

12- I THINK DEPRESSION ( put 5 of 9 SIGECAPS) but forget to write depressed mod (
stupid mistake,
in addition : many pts I forgot to write their medications.
one pt has fever , but I wrote VS :WNL
1) Patient who needed both complete neuro and cardiovascular exam, I did only full
cardiovascular.

2) Didn't do Kernig/Brudzinski in a case that was clearly needed..!

3) Didn't do Heart/Lung exam in every case (don't know if this is a mistake but just putting
it here).
4) Exited the room quite early in 2 cases (9.5 minutes in one and 10.5 minutes in another
one). I really didn't have anything else to ask or do, they were pretty straightforward, but
still it seems weird...
5) I put a little bit too invasive tests on work-up in 2-3 cases (for example CT and
bronchoscopy and ABGs and other stuff). They were all relevant but I don't know if that's ok
with them.

There are my ''BIG'' mistakes. I think I asked all important information in all cases (but for
example I didn't ask about diet in a diabetic patient) and I always knew what was
happening and what was the top 2 differential. My English was pretty good (nobody had a
hard time understanding what I was saying) and I think I did pretty well on CIS, I always
did a nice introduction, summarized, showed empathy (I think), did full closure with
counseling and everything. The only part that was kinda short was my physical exam and
that's the only thing that scares me (it was pretty focused and forgot the stuff I mentioned
above).
My patient notes were also very good, I didn't forget to type any information I collected, I
put at least 6-8 supporting findings in my differential and I put 3 DDx in ALL cases (they all
made sense I think, I didn't just put them to fill the gaps).
So actually the only thing that scares me is the physical exam (plus some minor stuff I
might have forgotten here and there).
I would appreciate any feedback thank you.

Hi,
So I'm in that phase right now where I've already just recently given the test. but now
I'm under the impression that it wasn't as easy I thought it was after coming out of the
exam.
1. First case, I didn't get to do a closure.
2. In one patient note, I left out the whole allergies, meds, PMH, psh, fh, sh, ros....I
finished everything else perfectly for the case...I thought I was done when I scrolled up
and realized that I had left that part to come back and finish.
3. couple of cases, I forgot to pull out the leg rest.
4. I asked eldery pt about help at home/support. however, I didn't ask everyone.
5. There was a pt which I wasn't sure about domestic abuse...but I just didn't really ask
about it at the time, I was only thinking this pt is behaving weirdly. However, I wasn't
thinking of abuse.
6. I forgot to explore drug abuse issue.
7. I'm most worried about this. A lot of my friends say that you must write a lot of
supporting evidence from history when writing under the differential diagnosis. I wrote
a couple of things for each differential. And sometimes, even only had one supporting
evidence. This is what I saw in First Aid, so I thought it might be okay...however,
others are saying you need a lot more evidence???? Should I be worried about this, as I
did this for almost all of my patients.
8. In once case, 1 differential was rock solid good. The other differentials on patient
note were vague and unclear diagnosis. Like...possible injury from past surgery? I don't
know if they count/are good.
9. One or 2 cases, in the hindsight, I think I might have messed up the primary
differential.
10. in a couple of cases, i forgot to mention physical exam to be done..like pelvic exam
or breast exam....which were pertinent.
11. I was only able to do one or 2 systems for physical exam. The pertinent and a
secondary one. Or sometimes only pertinent.
12. I didn't really have any phsyical findings that were positive during physical
exam...so I didn't have any supporting evidence for physical except for like vital signs.
13. I thought one of the patient was pretending to be wheezing...but I disregarded
because it seemed fake. -_- I think it was a mistake.
14. I didn't finish full neuro exam during one case because I kept repeating the same
pinprick questions because it seemed the patient himself was confused. I don't know if
he was making it up or it was seriously messed up...fml
15. one of the diagnoses, i misspelled it. so it might not sound like a real diagnosis.

I'm just really worried about my exam. Can you guys elaborate if you had similar
problems or concerns or made mistakes...and what happened...did you pass?

I'm just in the limbo right now and there's no definite answers anywhere. I hope we're
not expected to write like 8 supporting evidence for each differential. Because for some
I only had one or 2. I'm too nervous.
How do they remove 2 cases? are they just your worst case grades?

ICE portion is graded on physical exam, differential, and how you support it. Physical
exam is actually graded twice. Once how you perform and then how its documented in
the note. So anything vital physical exam wise is counted against you twice in ICE. Not
doing a good physical exam can basically fail you for that case even if you write a
good note. Also with your differential you get a few points by a listing diagnosis
but you also get points for supporting it. If you just a list a diagnosis without
support, you gets points taken off. Say you list the correct diagnosis and support
it, you get the full 30% (hypothetical number). However if you list three
differentials, and only the first is right, the other two are wrong or badly
supported, you only get 10%. The other diagnosis's count as 10% each and so the
30% gets spread out thin. So only list differentials that are most likely and
supported and you can get full 30% since it might be accepted as a alternative
diagnosis. Basically listing two or three diagnosises, is kinda like hedging your bet if
your primary diagnosis isnt the most likely on the exam. Also, how you support the
diagnosis is formulaic. There is a way you are suppose to fill in those date entries lines
under the diagnoses. Step 2 cs book has is all wrong. They don't tell you this. The test
is very very poorly understood. Probably one of the most if not the most poorly
understood exam out there. Its really crazy.