HOW TO PREPARE FOR THE USMLE STEP2 CS?
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CSR
 C
 S: smile, silence(不打断病人), support(扶病人上下床，保护病人走路)
 R: response
 *一切根据 priority
Three critical thinking moments
 Doorway information: 30-45s, 整理思路
 Washing hands: 可长可短，不聊天，整理思路
 Chest & CV exam: 整理思路
One piece of paper
 Mental checklist
 3O + 2P + 2Q AAA
 PAMHUGFOSS WA
Most important DDx
 Life-threatening complication: 由缓到急
 Side-effect: 医源性
Important associations
 Diabetes mellitus
 Hyper/hypothyroidism
 Depression
 Gastrointestinal tumors
 Infections
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Some physical examinations
 Neurological exams
 Gait
 Romberg
 指鼻试验
 面部刺激
 Shoulder 刺激
 握拳
 抬腿
 Reflex
 Mini-mental examination
 Orientation (person, place, time)
 Memory (3-word)
 Attention (spelling)
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Family history (2): Family, close contact
Social habit (5): Smoking, alcohol, illegal drugs, diet & diabetes / hypertension
For the mini-cases, the focus with be on 4 separate sections:
1. Differential Diagnosis
2. History
 For the “Main” section, capital letter means a must ask question.
 3O =
 3O + 2P =
 3O + 2P + 2Q =
 LIQR =
 ABCO =
 AAA =
 WA =
 PAMHUGFOSS =
3. Physical Exam
4. Workups
---------------------------------------------------①-------------------------------------------------------
 Headache
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Differential Diagnosis
 Migraine (complicated)
 Cluster headache
 Temporal arteritis (giant cell arteritis)
 Sinusitis
 Tension headache
 Subarachnoid hemorrhage
 Meningitis (bacterial)
 Pseudotumor cerebri
 Trigeminal neuralgia
History
 Main：3O LIQr AAA PAMHugFoss
 Associated syndromes:
 Fever → confusion, rigid neck
 Confusion / loss of consciousness
 Weakness / numbness
 Visual change → nausea / vomiting
 Runny nose → tearing
 Pain with chewing
Physical exam
 HEENT exams
 Neurological exams
 Abdominal pain
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Differential Diagnosis
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 Nephrolithiasis
 Pancreatic cancer
 Acute pancreatitis
 Acute cholecystitis
 Ascending cholangitis
 Acute hepatitis
 Peptic ulcer disease
 Peptic ulcer perforation
 Splenic rupture
 Intestinal obstruction
 Mesenteric ischemia / infarction
 Ovarian torsion
 Diverticulitis
 Acute appendicitis
 Irritable bowel syndrome
 Pelvic inflammatory disease
History
 3O 2P LIQR AAA WA PAMHUGFosS
 Associated syndromes:
 Relation to meals
 Nausea / vomiting
 Domestic violence
Physical exam
 Cardio and pulmonary exams
 Abdominal exams (guarding, Murphy sign, psoas and obturator signs)
 Chest pain
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Differential Diagnosis
 Myocardial infarction (MI)
 Sickle cell disease-pulmonary infarction
 GERD
 Angina
 Pericarditis
 Costochondritis
 Pulmonary embolism
 Aortic dissection
History
 3O 2P LIQR AAA WA PAMHUgFosS
 Associated syndromes:
 Sweating
 Palpitation
 Cardiac risk factors
 Pulmonary embolism risk factors
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Physical exam
 Blood pressure (both arms)
 Complete cardiovascular exams (JVD, PMI, chest wall tenderness, heart sounds,
pulses, edema)
 Pulmonary and abdominal exams
 Joint / limb pain
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Differential Diagnosis
 Joint pain
 Systemic lupus erythematosus (SLE)
 Rheumatoid arthritis
 Psoriatic arthritis
 Osteoarthritis
 Septic arthritis
 Limb pain
 Domestic violence
 Carpal tunnel syndrome
 Hip fracture
 Hip dislocation-traumatic
 Stress fracture
 Plantar fasciitis
 Tennis elbow (lateral epicondylitis)
 Disseminated gonorrhea
 Peripheral vascular disease (intermittent claudication)
 Deep venous thrombosis
 Angina / MI
 Shoulder dislocation
 Rhabdomyolysis due to simvastatin or clofibrate
History
 3O 2P LIQR AAA PAMHUGFOSS
 Associated syndromes:
 Swelling, redness, warmth of involved joints
 Red eye
 Oral or genital ulceration
 Rash
 Focal numbness / weakness
 Recent trauma
Physical exam
 Musculoskeletal exams
 Relevant neurovascular exams
 Low back pain
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Differential Diagnosis
 Disk herniation
 Lumber muscle strain
 Lumbar spinal stenosis
 Malingering
History
 3O 2P LIQR AAA PAMHUGFOSS
 Associated syndromes:
 Context (moving furniture, trauma)
Physical exam
 Neurologic exam
 Back palpation and range of motion
 Hip exam
 Cough / Shortness of breath
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Differential Diagnosis
 Asthma
 COPD-chronic bronchitis
 Pneumonia
 Atypical pneumonia
 Lung cancer
 COPD exacerbation (bronchitis)
 Tuberculosis
 Congestive heart failure
History
 3O AAA WA PAMHUgFOSS
 Associated syndromes:
 Sputum
 Chest pain / heartburn
 Exposures
Physical exam
 ENT exams
 Cardio and pulmonary exams
 Lymph node exams
 Extremities exams
 Night sweats
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Differential Diagnosis
 Tuberculosis (Acute HIV infection, lymphoma, leukemia, hyperthyroidism)
History
 3O aaA WA PAMHUGFOSS
 *Severity, frequency, timing, pattern
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Associated syndromes:
 Cough → hemoptysis, chest pain
 Lymphadenopathy
 Fever
 Rash → itching
 Malaise
 Nausea / vomiting
 Menstrual history → peri-menopause
Physical exam
 HEENT exams
 Abdominal exams (hepatosplenomegaly)
 Cardio and pulmonary exams
 Dysphagia
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Differential Diagnosis
 Esophageal cancer
 Plummer-Vinson syndrome
 Achalasia
 Esophagitis
History
 3O 2P AAA WA PAMHUGFosS
 Solids or liquids vs. both solids and liquids
 Associated syndromes:
 Drooling
 Regurgitation
 Odynophagia
 History of Raynaud phenomenon
Physical exam
 Head and neck exams
 Cardio and pulmonary exams
 Skin exams
 Upper GI bleeding
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Differential Diagnosis
 Bleeding peptic ulcer
 Gastritis
History
 3O ABCO AAA PAMHugFosS
 Associated syndromes:
 Context (severe vomiting, alcohol ingestion)
 Nausea
 Abdominal pain
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Physical exam
 ENT exams
 Cardio and pulmonary exams
 Abdominal exams
 Blood in stool
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Differential Diagnosis
 Colorectal cancer
 Ulcerative colitis
 Diverticulosis
History
 3O ABCO AAA WA PAMHuGFosS
 *Melena vs. bright blood
 Associated syndromes:
 Abdominal / rectal pain
 Nausea / vomiting
 Trauma
Physical exam
 Abdominal exams
 Rectal exams
 Hematuria
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Differential Diagnosis
 Bladder cancer
 Polycystic kidney disease
 Renal cell carcinoma
History
 3O ABCO AAA PAMHUgFoSS
 Associated syndromes:
 Renal colic
 Dysuria
 Voiding symptoms
 History of vigorous exercise
Physical exam
 Lymph node exams
 Abdominal exams
 Genitourinary exams
 Loss of Consciousness (LOC)
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Differential Diagnosis
 Complex tonic-clonic seizure
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 Drug-induced orthostatic hypotension (causing syncope)
 Cardiac arrhythmia (causing syncope)
History
 3O aaA PAMHugFosS
 Emphasize on CONTEXT
 Associated syndromes:
 Preceding symptoms
 Nausea
 Palpitation
 Associated symptoms
 Tongue biting
 Incontinence
 Prolonged confusion
Physical exam
 Neurological exams
 Carotid exams
 Cardio and pulmonary exams
 Dizziness
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Differential Diagnosis
 Méniѐre disease
 Orthostatic hypotension due to dehydration
 Drug-induced orthostatic hypotension
 Benign positional vertigo
 Vestibular neuronitis
 Labyrinthitis
History
 Main：3O AAA PAMHUGFosS
 Lightheadedness vs. vertigo
 Associated syndromes:
 Auditory symptoms → hearing loss, tinnitus
 Visual symptoms
 Nausea / vomiting
Physical exam
 Neurological exams (Romberg test, tilt test, gait)
 Auditory tests (Hearing, Weber and Rinne tests)
 Cardiovascular exams
 Erectile dysfunction (ED)
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Differential Diagnosis
 Drug-related ED (Hypertension ED, DM ED, psychogenic ED)
History
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3O AAA PAMHUgFoSS
Associated syndromes:
 ±nocturnal erections
 ±libido
 Stress or depression
Physical exam
 Cardio and pulmonary exams
 Genitourinary exams
 Rectal exams
---------------------------------------------------②-------------------------------------------------------
 Other urinary symptoms
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Differential Diagnosis
 Benign prostatic hyperplasia (BPH)
 Prostate cancer
 Urethritis
 Acute pyelonephritis
 Stress incontinence
 Urge incontinence
History
 3O AAA WA PAMHUgFoSS
 Associated syndromes:
 Obstructive symptoms
 Hesitancy
 Diminished stream
 Sense of imcomplete bladder emptying
 Straining postvoid dribbling
 Irritative symptoms
 Urgency
 Frequency
 Nocturia
Physical exam
 Abdominal exams
 Genitourinary exams
 Rectal exams
 Fatigue and sleepiness
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Differential Diagnosis
 Depression
 Posttraumatic stress disorder
 Colon cancer
 Hypothyroidism
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 Diabetes mellitus
 Obstructive sleep apnea
 Sleep deprivation
History
 3O AAA WA PAMHUGFosS
 Associated syndromes:
 Sleep associated
 Snoring
 Witnessed apnea
 Emotion associated
 Stress
 Depression
 Work or life style changes
 Other associated
 Hypothyroidism
 Bleeding or anemia
Physical exam
 ENT exams
 Extremity exams
 Cardio and pulmonary exams
 Confusion / Memory loss
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Differential Diagnosis
 Vascular (“multi-infarct” dementia)
 Alzheimer disease
 Normal pressure hydrocephalus
 Creutzfeldt-Jakob disease
 Hypoglycemia
 Subdural hematoma
History
 MUST INCLUDE history from family members / caregivers
 Main：3OP AAA WA PAMHUgFoSS
 Associated syndromes:
 Fall → hit head
 Palpitation → weakness
 Depression
 Cold intolerance
 Infection → HIV, syphilis, prion
Physical exam
 Neurological exams
 Mini-mental status exams
 HEENT exams
 Nausea / vomiting
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Differential Diagnosis
 Pregnancy (gastritis, hypercalcemia, diabetes mellitus, UTI, depression)
History
 3O ABCO AAA PAMHuGFosS
 Associated syndromes:
 Abdominal pain
 Relation to meals
 Sick contacts
 Possible food poisoning
 Possible pregnancy
Physical exam
 ENT exam
 Abdominal exam
 Constipation / diarrhea
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Differential Diagnosis
 Colorectal cancer
 Low-fiber diet
 Irritable bowel syndrome
 Infectious diarrhea (gastroenteritis)-bacterial, viral, parasitic, protozoal
 Pseudomembranous (Clostridium difficile) colitis
 Traveler’s diarrhea
 Lactose intolerance
 Crohn disease
History
 3O ABCO AAA WA PAMHuGFosS
 Associated syndromes:
 Abdominal pain
 Sense of incomplete evacuation
 Diet (fiber and fluid intake)
 Sick contacts / recent travels
Physical exam
 Thyroid / endocrine exams
 Abdominal exams
 Rectal exams
 Numbness / Weakness
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Differential Diagnosis
 Transient ischemic attack (TIA)
 Stroke
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 Guillain-Barré syndrome
 Multiple sclerosis
 Diabetic peripheral neuropathy
 Myasthenia gravis
 Todd paralysis
History
 3O 2P AAA PAMHUGFosS
 LOCATION (unilateral, bilateral, proximal, distal)
 Associated syndromes:
 Pain → head pain / neck pain
 Visual changes → Eye pain
 Neurologic symptoms → loss of senses, slurred speech
Physical exam
 Orthostatic vital signs
 Neurologic exams
 Weight loss
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Differential Diagnosis
 Hyperthyroidism (cancer, HIV infection, anorexia nervosa, malabsorption)
History
 3O aaA PAMHuGFosS
 *Amount
 Associated syndromes:
 ±intention
 Body image
 Anxiety or depression
 Hyperthyroidism (palpitation, tremor, diarrhea)
Physical exam
 Thyroid exam (exophthalmos, lid retraction, lid lag, gland size, bruit, tremor)
 Cardiovascular exam
 Weight gain
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Differential Diagnosis
 Smoking cessation (drug side effect, hypothyroidism, Cushing syndrome, Polycystic
ovary syndrome, diabetes mellitus, atypical depression)
History
 3O aaA PAMHuGFosS
 *Amount
 Associated syndromes:
 Relation to medication changes, smoking cessation, depression
 Diet history
 Hypothyroidism (fatigue, constipation, skin changes)
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 Menstrual irregularity
Physical exam
 *Brief exam based on the diagnosis
---------------------------------------------------③-------------------------------------------------------
 Palpitations
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Differential Diagnosis
 Hypoglycemia
 Panic attack
 Social phobia
History
 3O aaA PAMHUGFosS
 *Gradual vs. acute onset/offset
 Associated syndromes:
 Context (exertion, caffeine, anxiety)
 Light-headedness
 Dyspnea
 Hypothyroidism symptoms
Physical exam
 Thyroid exam (exophthalmos, lid retraction, lid lag, gland size, bruit, tremor)
 Cardiovascular exam
 Sore throat
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Differential Diagnosis
 Infectious mononucleosis
 HIV, acute retroviral syndrome
 Pharyngitis
 Hepatitis
History
 3O aaA wA PAMHugFosS
 Associated syndromes:
 Fever
 ENT symptoms (ear pain, nasal or sinus congestion)
 Odynophagia
 Swollen glands
 Cough
 Rash
 Sick contacts
 HIV risk factors
Physical exam
 ENT exams
 Pulmonary exams
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Skin exams
---------------------------------------------------Ob/Gyn-------------------------------------------------------
 Amenorrhea
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Differential Diagnosis
 Pregnancy
 Polycystic ovary syndrome
 Amenorrhea secondary to prolactinoma
 Menopause
 Sheehan syndrome
 Anorexia nervosa
 Anxiety-induced amenorrhea
History
 3O aaA PAMHugFoSS
 *Primary vs. secondary
 Associated syndromes:
 Relationship to menstrual period
 Menopausal symptoms
 Pregnancies
 Eating disorders (anorexia nervosa, excessive dieting, vigorous exercise)
Physical exam
 Breast exams
 Complete pelvic exams
 Vaginal bleeding
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Differential Diagnosis
 Dysfunctional uterine bleeding
 Endometrial cancer
 Cervical cancer
 Spontaneous abortion
 Ectopic pregnancy
History
 3O ABCO AAA WA PAMHugFoSS
 Pre- vs. postmenopausal
 Associated syndromes:
 Relationship to menstrual period
 Discharge
 Pelvic or abdominal pain
 History of Pap smears
Physical exam
 Abdominal exams
 Pelvic exams
 Vaginal discharge
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Differential Diagnosis
 Bacterial vaginosis
 Vaginitis-candidal
 Vaginitis-trichomonal
History
 3O ABCO AAA PAMHugFOSS
 Associated syndromes:
 Vaginal burning, pain, pruritus
 Sexual activity + protection
 History of STD
 Sick contacts
Physical exam
 Abdominal exams
 Pelvic exams
 Dyspareunia
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Differential Diagnosis
 Atrophic vaginitis
 Endometriosis
History
 3O AAA PAMHugFoSS
 Associated syndromes:
 Vaginal discharge
 Painful menses
 Menopausal symptoms (hot flashes)
 Adequacy of lubrication
Physical exam
 Abdominal exams
 Pelvic exams
---------------------------------------------------Ped------------------------------------------------------*Some important things in Ped
√SID= Sick contacts + Immunization + Day care
√NO diabetes or BP is needed
√NO occupation information is needed
√NO sexual information is needed
√If younger than 9 years old, then social history is NOT needed
 Child with fever
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Differential Diagnosis
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 Neonatal sepsis
 Acute otitis media
 Measles (or other viral exanthem)
 Gastroenteritis (viral, bacterial, parasitic)
History
 3O aaA WA PAMHUGFS
 Associated syndromes:
 SID
 Severity
 Localized symptoms
 Rash
Physical exam
 HEENT exams
 Cardio and pulmonary exams
 Abdominal exams
 Skin exams
 Child with GI symptoms
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Differential Diagnosis
 Pyloric stenosis
 Hirschsprung disease
 Intussusception
 Somatoform disorder
 Colic
History
 3O 2P LIQR AAA WA PAMHUGFS
 Associated syndromes:
 SID
 Association with food
Physical exam
 Cardio and pulmonary exams
 Abdominal exams
 Rectal / pelvic exams (women)
 Child with red eye
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Differential Diagnosis
 Bacterial conjunctivitis (viral conjunctivitis, keratitis, uveitis, seasonal allergies)
History
 3O AAA PAMHUGFS
 Associated syndromes:
 SID
 Eye discharge / pain
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 Difficulty open of eye
Physical exam
 HEENT exams
 Child with short stature
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Differential Diagnosis
 Familial short stature (growth hormone deficiency, hypothyroidism, chronic renal
insufficiency, genetic disorder)
History
 3O aaA PAMHUGFS
 Prenatal and birth history
 Growth history
Physical exam
 Height / weight
 HEENT exams
 Cardio and pulmonary exams
 Abdominal exams
 Neurological exams
 Behavioral problems in childhood
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Differential Diagnosis
 Attention-deficit hyperactivity disorder (ADHD)
 Adjustment disorder
 Substance abuse
 Age-appropriate behavior
History
 3O aaA PAMHUGFS
 Developmental history
 Physical violence or use of weapons
 Substance use
 Changes in environment
 School performance
Physical exam
 Neurologic exams
---------------------------------------------------Psy/Consult-------------------------------------------------------
 Psychosis
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Differential Diagnosis
 Schizophrenia
 Substance-induced psychosis
 Schizoaffective disorder
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History
 Main：3O aaA WA PAMHugFoss
 Associated syndromes:
 Positive (Delusions, disorganized thought, disorganized behavior)
 Negative (Social withdraw, decreased motivation, decreased speech / thought)
Physical exam
 Mental status exams
 Depressed mood
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Differential Diagnosis
 Normal bereavement
 Major depressive disorder
 Bipolar I disorder
History
 Main：3O aaA WA PAMHUGFOSS
 SUICIDE risk assessment
 Associated syndromes:
 Stress
 Sleep pattern → Fatigue
 Manic episode
 Decreased social function, interest, energy, concentration
Physical exam
 Mental status exams
 HEENT exams
 Abuse
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Differential Diagnosis
 Domestic violence
 Rape
History
 *Establish Confidentiality
 3O aaa PAMHugFOSS
 Associated syndromes:
 Physical, sexual, or emotional abuse
 Fear
 Safety
 Backup plan
Physical exam
 Complete exam
 Insomnia
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Differential Diagnosis
 Stress-induced insomnia
 Obstructive sleep apnea
 Insomnia related to major depressive disorder
History
 3O aaA WA PAMHugFosS
 Description: trouble falling asleep vs. multiple awakenings vs. early-morning
awakening
 Associated syndromes:
 Medical problems keeping patient awake
 Arthritis (pain)
 Diabetes (polyuria)
 Daytime sleepiness
 Snoring
 Nightmares
 Depression
 Caffeine use
 Work or lifestyle changes
 Stress
Physical exam
 Mental status exams