Q: 
How to ask tenesmus?
A:
Do you have incomplete feeling after the bowel movement?
Q:

A
Typing is better than handwriting; however, make sure your spelling is 
correct. There is no proofreading function in the exam. A lot of ppls I know
chose typing. Be prepared for both, last time ,the computer system in LA 
down for 30 min , at that time, you don’t have any choice but writng.
Q
CS neuro cases question and more.
A
Focused exam. You should have enough time to finish, I will skip fundalscopy
exam in CN2-12 exam. It is only one mark and takes a lot longer to complete
compared with others. For dizziness, definitely you should ask pt to walk (
quick walk). But before doing anything, brainstorm it and clarify it is 
neuro case or cardio case, if you suspect orthostatic hypotension, don’t 
touch neuro at all. Don’t do both, you have plenty of time!
About the order, you are right.

Q
After you notice RLQ tenderness, how to check for rebound tenderness
and 
Rovsing's sign? Isn't that repeating painful maneuver?
A
Excellent question!
Don’t repeat painful maneuver, not the exactly the same place. That is 
the point. For Rebound tenderness , you should press the other site , For 
example, if it is appendicitis, you should press left site. NOT right site!.
Always leave rebound tenderness the last. And it is best time for you to 
show sympathy! I can imagine you are suffering a lot of pain (eye contact!),
but it is very important for me to make the Dx, I will be quick and gentle. 
I love this moment! 
Q
CS exam date change?
A
Be ready and take what day comes up in the schedule in the desired day, that
is my partner did, She only prepare for 20 days ! I noticed that the date 
is always available if you use Yeye’s method.
Q
Am I ready for CS
A
I don’t know the answer , that is the most difficult one…
Q
 A patient comes for fever and sore throat, but also 
complains headache and 
joint pain when you take HPI, do we need to ask LIQOR AAA about the pain?
A:
I will ask for LIQORAAA for both, but let the SP guide you, if you found pt 
show impatience during the conversation or he or she tell you,wow,Dr, it is
not that important, or not that bad, it is just like common cold, stop 
there, go ahead. The sp knows better than you regarding to the case. But if 
you have plenty of time during the PE, continue to finish you rest of your 
LIQORAAA.
Q
how to speed up in CS encounter?
A
You can’t fake the exam. You must wait for one full breath cycle. DO 
focused system. 
Abd exam: the gown is not yours, it belongs to the sp, only the tie is 
belong to you. Don’t touch the gown,” could you please raise up the gown 
for me, I can help you with that.” The sheet is yours; raise the sheet to 
make sure the sp’s body is not exposed inappropriately.
Q
 CS telephone interview
A
Good morning, may I speak to baby boy….’s mom? (According to door 
information).
After confirmation, I am Dr….I will physician to talk to you regarding to 
your son’s condition.
Q:

A: minimized exposed area. If 心肺 exam,yes all exposed . it is necessary. 
But remember, let pt to pull down the gown, you only help the pt untie the 
gown. This way, the sp will feel comfortable. When you listen to lung from 
the back, just untie the gown, you don’t need to expose the front chest. 
Minimized the exposed time and exposed area.
Q:

A:
If heart disease, full heart exam. That means: JVA bruit+ heart two position
(sitting and 30 angle)+ pulse . Pulse :one position is enough. For heart 
case, only listen lung from back. 

Are the SPs nice?

Some examinees said the SPs are very nice and friendly, and they went through the exam in a good mood. Unfortunately they failed the USMLE CS. Others said some SPs are tough and asked them to repeat the question they've asked, but they passed. The SPs are very experienced and well-trained. It is their job to deal with crowds of examinees day after day. I guess they have a clear impression that you will fail or pass after they talk to you and evaluate you. Therefore they may give you some tough time when they think you are good; and maybe very friendly when they feel you are not that great. So, do not be dominated by SPs. Do what you should do, say what you should say.

About communication skills

Communication skills is part of the CIS (Communication and interpersonal skills). CIS is a different category from SEP. Many examinees passed the CIS easily but failed SEP. Also there are others failed CIS and passed SEP. As long as some key points are taken care of and done properly, CIS is easy to pass. Standard patients (SP) pass you on CIS based on the following points:

) introduced yourself, now is your chance to show some smile
) make eye contact. Some say that they are not good at doing this, while it is just to tell the patient by your eye that you are involved in this conversation
) use patient's name Mr. Ms. Mrs.
) express empathy, never forget the patient is here to SEEK help
) conveyed nonjudgmental attitude, avoid judging words like good, great,excellent, instead use all right, okay, thank you
) drape the SP
) use open-ended and non-leading questions, and ask one question at a time

) paraphrase is said to be important to keep the conversation going
) better not interrupt the patient
) use transitional phrases

) use lay language ( imaging studies instead of CT MRI or X-ray, Electrical study instead of ECG)

) summarize history
) gave explanation during physical
) appropriate reassurance
) diagnostic impression in lay language
) discuss the diagnostic tests
) ask if patient had any questions or concerns
) patient educations

Are these difficult to do? Not at all after enough practicing. Show SP your confidence as a his/her doctor and the secret is: practice makes perfect.

two good pronunciation websites

Many people failed SEP. So English can be an issue.

http://www.uiowa.edu/~acadtech/phonetics/#

http://www.howjsay.com/

These two websites are good for self-learning.

There are many accent reduction services that can be googled. They charge big bucks but may not worth it for you. There is no general rule for everyone. Speech pathologists need to develop a treatment plan on a case-by-case basis.

USMLE CS study materials

I went through several materials recommended by the others. Personally I feel two of them are good: USMLEworld website and the book The ultimate guide and review for USMLE step2 clinical skills exam (wow, a long name).

If you just got started, I recommend the USMLEworld. It is complete with all the details from patient encountering to the up-to-date cases. Apparently this is a practial exam and it is not enough to just READ the website, you need to practice at least alone or better with partners.

The book is not just a long name, also a big book with 30 cases. These 30 cases is not even half of the cases on the USMLEworld website, but they are the most important ones. Keep in mind that in the real CS exam 90% cases are common ones and easily diagnosed. Those cases are tested again and again because CS is not a medical knowledge exam. It is a test of your manner as a medical trainee and your English as a FMG. The reason that this book can stand out of the other books is that it fits our learning curve. In each case, just like the exam, in the first place it gives you a door information and let you think what to ask and do after you go into the room. There is empty space therefore you can write down your answers. After that, a detailed answer is given to let you check out your own answers. Generally speaking you need to ask 70% of the history and physical.

There are two books that is smaller but I do not recommend. One is blueprint, which is very little book that can fit in your pocket. The other is Survival guide to the USMLE step2 CS. If you have time you can read it. Definitely you can learn some info.

One more point for Candian board examinees. The Qualifying exam 2 (QE2) is partly an oral exam. The difference from CS is that QE2 is evaluated by both the standard patient and an examiner sitting in the room. The examiners may also ask you correlated questions besides observing you. The book recommend for this exam is called OSCE study guide.

Speaking English Proficiency (SEP)

SEP is a separate category evaluated in USMLE CS. This is about your English itself, and has nothing to do with the content of your speech or your manner. People failed in this part are due to different reasons:

1. Pronunciation. Everybody has accent. Even if you do not have north American accent, it is not a big deal, as long as you can easily be understood, which is the basic requirement for a clinician. However, no matter what your accent is, you have to be accurate. This is everything about proper English, which is the way that English should sound. If you have pronunciation problems, the best way to treat is to see a speech pathologist. A speech pathologist knows how sounds are made by different organs in face, mouth and throat, therefore figures out the wrong sound organs that you used to pronounce. Different native language speakers used different organs to make sounds, therefore there is no general rule to cure everybody. You need to see a speech pathologist on a case-by-case basis rather than a English teacher in a class.
2. Words and grammar. If you read a lot in English, this should not a big problem anymore. However, when you speak out, you also need to speak with proper grammar. Otherwise, even if you pronounce right, it will still cause confusion to native English speakers.

1 and 2 gave strategies to conquer SEP. Bear in mind, language is used for speaking out and needs lots of practice. Neither speech pathologist nor ESL teacher can be your mother's tongue accompanying you. Therefore, the key to success is to find every chance to speak out.

Is Houston the best?

Houston center is so-called the easiest center for FMGs. We got to think twice before we believe some magic or easygoing personality in this center. ECFMG has standard criteria to assess the examinees in all its test centers. The outcomes of each center will be evaluated and statistically adjusted. Therefore the one who gives the final result is not Houston center, it is ECFMG.

Prepare well, behave well, speak well, then any center is the same.