Step 2CS All You Need to Know

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Patient Encounter
Overview
Physical Examination
History and Symptoms
Patient Note
Medical Therapy
Differential Diagnosis
Case #1
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Study Guide

For study purposes the patient will be called Wiki and the Dr. is Romero

Overview

Watch the USMLE website video first to get an overall idea of the examination.

The clinical skill component of Step 2, tests the fundamental clinical skills essential to safe and effective patient care under supervision.

Test Structure

The clinical skills assessed during this examination are:

• Taking a relevant medical history
• Communicating effectively with the patient
• Performing an appropriate physical examination
• Documenting the findings clearly and accurately and diagnostic hypothesis and ordering initial diagnostic studies

Things to bring to the Test Center

• Scheduling permit
• Confirmation notice
• Unexpired government issued form of identification (with picture and signature) such as current driver's license or passport
• Comfortable professional clothing
• Clean white lab coat
• Unenhanced standard stethoscope

Interviewing Process

Doorway Information

Mr/Mrs Wiki

Age BP HR RR Temp

1. Comes due to symptom (back pain/ sore throat)
2. Write down on given paper Name/Last-name, Age, Altered vitals, chief complaint
3. If possible write quickly 3 differential diagnosis for the chief complaint
4. Knock the door and enter the room

Introduction to Wiki-Patient

1. Hello Mrs/Mr Wiki-patient (Shake hands with the patient)
2. I am Dr. Romero I will be your doctor today, I will ask you some questions and perform a brief physical exam on you. Is that OK with you?
3. Is the room OK for you? (Dim light or adjust temperature if possible)
4. Let me make you more comfortable
5. How would you like to be addressed? (Wiki-patient says he/she likes to be called Wiki)
6. How may I help you today? (Wiki-patient describes chief complaint)
7. I am sorry to hear that. I will do my best to help you.

Asking About Chief Complaint

LIQORAAA for Pain

OCPDFAAA for Non-Pain

Review of Systems (ROS)

LIQORAAA (for pain) OCDPF ROS (IF PERTINENT) PAMHITSFOSS

Counseling

• Immediately when the patient gives you the information
• When washing your hands
• During closure

History

• HPI
• ROS
• ALL
• MED
• PMH
• PSH
• OBGYN
• FH
• SH

Patient Note

Avoid using medical terms when interviewing. Use Layman terms instead.

HPI

LIQORAAA (for pain) OCDPF ROS (IF PERTINENT)

PAMHITSFOSS ROS: negative except as above PMHx: previous symptoms like this or major medical condition Hipertension, Diabetes, MI. HOSP. NKDA, Medics: prescribed and OTC PSHx: TRAUMA, SURGERY FHX: none (only pertinent) OB-GYN Hx FMP, LMP, Period every 30 days, lasts 5 days, tampons/pads, GPA (gestation, pregnancy, aborption) SHx: Occupation. . Occupation. Support (SAFE). SEXUAL: active with. multiple Men/wome/both. Condoms every time. No STDs. HIV test. smoking (PPD: 1pack per day for 30 years, EtOH (CAGE 0/4), Illicit drugs, Travel history.

PAM HUGS FOSS WA FOR KIDS ON CALL IDIOT: onset number cry asociated sxs listless liquid (urine) inmunization diet, dehydration, daycare infection/ill contacts ORS:Oral rehydration solution Travel

Physical Examination

• Unable to examine due to pain
• NAD (hydrated, afebrile, tired, flat affect, tired, speech, movement)
• VS: WNL except: BP RR HR Temp.

• HEENT (head, eyes, ears, nose, throat)

Head: AT, NC (atraumatic, normocephalic) Eyes: EOMI, PERRLA, normal eye funds. No conjuctival pallor Nose: no nasal congestion. Throat: No tonsillar erythema, exudates or enlargement. Mouth: moist mucous membranes, good dentition

• Neck: Supple, no JVD, no carotid bruits, no cervical LAD, normal thyroid. (CAT ORGAN: Carotid, Abdomen, Thyroid)

• Chest/Lung: no tenderness, clear to percussion bilaterally, tactile fremitus normal, clear breath sounds bilaterally. (No wheezes, crackles, rhonchi, rubs)

• Heart: PMI not displaced, RRR,normal S1/S2 WNL, no M, G, R.

• Abdomen: ND, BS +, Soft, NT. (NO Murphy, McBurney, Rovsing, CVA tenderness, psoas/obturator sign "just one"). No Hepatosplenomegaly/ organomegaly.

• Extremities: No edema +2 +3, clubbing, cyanosis, hairless, asterixis, skin changes. Peripheral pulses (don't write it radial, brachial, dorsal is pedis, posterior tibilalis) 2+ and symmetric. No bruises. ROM (limited passive/active "abduction/adduction/flexion/extension/external rotation" MRS (motor, reflexes, sensation)

• Neuro

Mental Status: A & O x3, spells backward, recalls 3 objects. CN 2-12 WNL/grossly intact. Rinne WNL, AC> BC?. Weber not lateralized. Motor: strength 5/5 in all limbs except DTRs: 2/4 except (normal) absent ankle jerks. Babinksy - Left or right. Sensation: intact to pinprick and soft touch (sharp and dull). Vibration and position normal Gait: normal Cerebellar: finger to nose normal (dysmetria, diadococinesia) Romberg -.

• Skin: preserved turgor.

• Mental Status exam

Pt speaks slowly No hostile behavior toward interviewer Blunt affect with poor aye contact Inattentive to interviewer 3/3 registration, 3/3 recall at 3 times Distant memories are impaired Oriented to person, date and place Completed 3 step command Right handed 1/5 on serial 7s Poor judgement

Reporting Physical Exam Briefly

HEENT:

• NC/AT: normocephalic / atraumatic
• Ø LAD: no lymphadenopathy

Cardiac exam (CV):

• Ø M/G/R: no murmurs, gallops, rubs
• 2+ PT/DP B: 2+ posterior-tibial and dorsalis pedis pulses bilaterally
• Ø JVD: no jugular venous distension
• Ø LE edema: no lower extremity edema

Lung exam:

• CTA B: clear to auscultation bilaterally

Abdomen exam:

• NT/ND: non-tender, non-distended
• Ø HSM: no hepatosplenomegaly
• + BS: bowel sounds present

Back exam:

• Ø CVAT: no costovertebral angle tenderness

Neuro:

• EOMI / PERRL: extraocular mvmnts intact / pupils equal, round, reactive to light.

Differential Diagnosis

Give 3 to 5 differential diagnosis with pertinent positives or negatives from HISTORY AND PHYSICAL EXAM

Diagnostic Workup

1. Specific physical examination (rectal, pelvic, breast, genital) if applicable
2. CBC and electrolytes
3. Cultures
4. Imaging