u/Peppehoeni20

I passed my CSE with a score of 291 (244 needed to pass) after failing with a score of 218 previously. Here’s some stuff I did:

1. practice test are great, especially if they give you feedback back BUT: Practice test mean next to nothing if you aren’t supplementing them with books.

- Clinical manifestations and assessment of respiratory disease is a god send. (ISBN; 0323244793). The CSE heavily focuses on 3 pathologies (they’re definitely others outside of these 3 you may see).

CHF, COPD and COPD exacerbations, and asthma (especially in pediatrics).

Heavily study these 3, especially COPD, as the CSE will often give you patients with 1 of the 3 (or sometimes, a combination: COPD + CHF). Learn how to treat them with medications and ventilation.

*Tip*: The exam won’t always tell you what your patients is presenting with explicitly. IG is crucial in determining these mysteries. Have a strong knowledge on the hallmarks of the various common respiratory diseases. (Ex: “ground glass” cxr- think ARDS)

2. Know your scenario. If your patient presents to the ED with a COPD exacerbation - a pft test is very unlikely to be a correct answer during IG (unless it’s asthma and you’re looking at a PEF. *Note* This is usually indicated for a patient with a preexisting asthma diagnosis, not a pediatric patient in the ED with mysterious asthma like symptoms.)

The CSE will occasionally throw you easy points by asking you questions related to transferring a patient to a different care facility. Don’t send a patient to an acute care facility if the opening scenario already established this is an acute care facility.

3. Many scenarios will result in mechanical ventilation, NPPV, or some sort of oxygen device. It’s crucial you understand how certain conditions are handled on the ventilator in the NBRC hospital.

Ex: Asthma- because of air trapping/ auto peep, a longer Te is often needed. These patients are at a higher risk for barotrauma therefore pressures should be closely monitored.

COPD patients almost never need high Fio2 unless an extreme outlier. Often times 1-2L NC is what’s indicated for a COPD exacerbation in the wonderful world of the NBRC.

*Tip*: In my experience, the CSE really loves its HHFNC

4. For pediatrics, the most common scenario is asthma related. Knowing the following will greatly help you during information gathering and decision making:

- Continuous nebulizers

- IV and inhaled steroids

Be prepared to instruct asthma patients on how to use their medications and to identify an asthma exacerbation. Prepare for tricky questions like medication order, what medications require a mouth rinse after, and what medications require specific breathing techniques.

5. I always picked a CRX in non emergent scenarios, a chest X-ray will help you narrow down mystery diseases (crucial for CHF) and will alert you to underlying issues like a pneumothorax

6. The CSE is heavy on wanting you to titrate o2 for a target spao2 of low to mid 90s. This is usually a free point or 2 and often appears in COPD scenarios. Know your GOLD standards

7. Grunting, nasal flaring, and pursed lip breathing can be a strong indication that a patient is in need of additional flow (HHFNC) or pressure (NPPV) to reduce WOB. Nasal flaring and grunting in an infant is almost always an indication for a nasal cpap.

8. lastly, pay CLOSE attention. The test is littered with options that sound right, but upon closer inspection are wrong. They’re designed to make you click.

You’ll have questions that have numerous options and many will be wrong, unnecessary, or redundant. Don’t feel pressured to select more than you feel 100% confident in. Don’t go doing sweat test on patients who already have a diagnosis for CF.

Always go back and review all the information you’ve gathered and give yourself a small report before making large decisions like vent changes,l or invasive procedures; this is where you can cause harm and miss the most points. Don’t go inserting chest tubes without confirmation of a pneumothorax or effusion.

Don’t get alarmed if you get a response saying “Physician prefers”. This doesn’t mean you lost points, but you likely didn’t receive the max amount of points that question offers. You may have picked the second best answer over the #1 answer. “Noted” doesn’t indicate a pass or miss so don’t be alarmed, some questions will ONLY respond with noted. Don’t go picking wildly looking for feedback.

If you aren’t fully certain in an answer, ask yourself: “would I think to do this test if it wasn’t offered?”

Some easy test to consider during information gathering

- CXR

- Checking extremities (digital clubbing, cyanosis, pitting edema)

- ABG

- ECG

-BNP (this is often elevated in patients with CHF, above 100- heart failure)

Missing by a few points usually can be chalked up to: nervousness, small mistakes, under picking, and over picking. You have more than enough time to really sit through and digest each scenario and question, and for some, you likely won’t need much time at all. Doing your math: calculating VT, VE, P/F ratio (highly recommend as the exam will never announce ARDS for you) will absolutely help you.