Typical USMLE Step 2CS encounter 'pro forma'



While waiting in front of the door


Use this time to note down the following things on your scribble sheet


Name (Make an effor to remember it when you write it. Don’t confuse it with your previous patient!)


Age, Sex and vitals


Diagnosis
Write down your mnemonics. Below is an example of what my scribble sheet looked like. I used to write down my differential diagnosis as well. It helped me in framing my questions and also helped me during counselling.

History

-Knock knock knock, Smile

-"Good morning Mr. Smith, I am Dr. Anybody and am here to see you as your physician."


-Firm hand shake. 


-At this point some recommend asking "Is the room comfortable Mr Smith?...Let me make you a little more comfortable..."and then drape the patient. This way you would have the stool (on which the drape would be sitting) to yourself. You can than ask, "Do you mind if I sit?" and then sit down.


-"So Mr. Smith, what brings you here today?" (Note: Some people fear that the patient will answer 'train' or 'bus' in response to this. In most cases they won't. If they do use it in your' favor by giving a small laugh and saying "…And what seems to be the problem today, Mr. Smith" I feel what brings you here today is the best way to phrase the first question to your patient. In most cases the chief complaint is written on the door. You may alternatively say "I have been told that you have been experiencing headaches, would you like to tell me more about that?")


-Express sympathy "I am sorry to hear that, Mr. Smith I shall try my best to help you get rid of the pain."


- Would you mind if I took some notes as we speak?


-Ask ODP(onset duration progress)


- Beat around the chief complaint. Ask more questions pertaining to the chief complaint. For e.g. ask LIQUORAAA for pain. Different symptoms will need different questions. For e.g. in a patient with cough you will need to ask timing of cough, productive/not, if sputum then amount/color/smell/positional variation, etc.


-Localize a system based on the CC and then ask other symptoms of that system. For e.g. If a patient comes with chest pain, ask about dyspnea, syncope, palpitations, pedal edema etc.


-Review of systems (ask about other systems, relevant questions only)


-It is a good idea to warn the patient that you will need to ask some personal questions before you ask sexual and social questions and take their permission. You can say for example "In order to reach an accurate diagnosis I need to ask you some questions pertaining to your personal life, are you comfortable with that?"


-Summarize the history for the patient (I think it is optional to do this)


-Do not tell the patient that you are done with questioning or history taking. Believe me you will be tempted to tell that. Instead say "Mr Smith I will now need to perform a quick physical exam. Is that okay with you?" "yea sure" "Please excuse me for a moment as I wash my hands Mr. Smith." Remember to dry your hands with paper towel and then warm them before touching the patient. You can ask their occupation and talk for a few seconds about their work or something not related to their illness (of course this may not be appropriate in an angry patient or in emergency cases.)

Exam
-Drape respectfully

-Rather than doing the exam by systems do all the exams you can do in one position at once. For example when you open their back examine upper and lower back at the same time. When auscultating, listen to heart and lungs in the same go. Show respect when undressing. Help the patient untie and tie the gown.


-Keep talking as you examine. Explain every step that you do.


PICCLEN [Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema, Neck vessels(JVD and Carotid bruit)]


-Systemic exam starting with the affected system first.

Conclusion

-"Mr Smith based on what you told me and the findings of my physical exam there a few possibilities that could be causing your 'headache'. The the most likely cause is either 1) or 2) we can not rule out 3) 4) and 5). In order to arrive at a more accurate diagnosis we will need to run few labs. I shall order a complete blood cell count, Blood electrolyte levels, and a CT scan of your brain. A CT scan is a method of imaging the brain in slices. It is like multiple X Rays that provide a view of the inside of your brain. We shall call you with the results of these tests in a couple of days. In the mean time I will write you a prescription for a pain medicine that should relieve the pain."


-"Do you have any questions about the plan Mr. Smith?" 


-Answer the questions if any and then counsel about all bad habits. Especially those that predispose to the presenting condition. "Also Mr Smith are you aware of ill effects of smoking?"…."Have you ever considered quitting?"…."If you wish we have an excellent smoking cessation program that we could enroll you in."


- " Have you understood everything we have discussed today Mr Smith ?"…." Is there any other concern that I can address today? "


- "Thank you very much Mr. Smith. It was pleasure meeting you." (say this depending on the case of course). "I shall talk to you soon once the results of you labs are available. Good bye Mr Smith."

8 comments:

  1. Thanks for posting this. I am going to use this to make my own "CS protocol sheet"

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  2. I think the crux of Step 2cs is in showing empathy. Empathy, empathy and more empathy.

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  4. Thank you very much. Do you recommend waiting outside the room for a few extra seconds?

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  5. I don't think waiting outside the room will hurt. However if you are done taking notes (which you should be in the time you have) and generating your differential then you should not wait.

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  6. Thanks. Very helpful

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Thank you for your time.