Your attire should make you look like a real doctor. Wear clothes similar to those you have seen doctors wear in a clinic in the US. Below are rough guidelines.
Bottoms:
Formal black/dark trousers or skirt.
Top:
Formal light colored shirt or top. May put on a sweater if it is winter time.
Hair:
Keep it all tied/gelled to the back. DO NOT play with/touch your hair during an encounter.
Jewelry:
KISS-Keep it simple stupid. I have heard conflicting things about wearing and not wearing rings. I don't think it matters!
Make up:
A light foundation and lipstick should do it. Careful when picking the color of your lipstick.
Shoes:
Black or dark brown formal shoes. No sandles, no open front shoes please.
Nails:
Cut short and clean. It's okay to paint them.
Perfume:
Take a shower and put on a mild deodorant.
Showing posts with label CS. Show all posts
Showing posts with label CS. Show all posts
Challenging Questions
There are 4 steps to answering a challenging question. Most people do the 2nd step but forget the rest.
1st- Express your understanding for the SP's concern
2nd-Answer the question
3rd-Counsel/Reassure
4th-Ask if they have more questions.
The basic idea to is to tell the SP that more diagnostic tests would be needed before one can be sure. Nevertheless read through the examples below .
Q "Can you give me some antibiotics to get better?"
A "I understand your concern Mr Smith. Antibiotics work only when there is a bacterial infection. While your symptoms could be due to it, there are many other conditions which
1st- Express your understanding for the SP's concern
2nd-Answer the question
3rd-Counsel/Reassure
4th-Ask if they have more questions.
The basic idea to is to tell the SP that more diagnostic tests would be needed before one can be sure. Nevertheless read through the examples below .
Q "Can you give me some antibiotics to get better?"
A "I understand your concern Mr Smith. Antibiotics work only when there is a bacterial infection. While your symptoms could be due to it, there are many other conditions which
can cause similar symptoms. I would surely prescribe you antibiotics if they are indicated. However for me to know if you need them, we need to run some tests first. If we find any evidence of bacterial infection, we will go ahead and take antibitics. Does that answer your question Mr Smith?"
Q "Do you think I will be able to use my leg again like before?
A "I understand your concern Mr. Smith. I am hoping that you will be able to use your leg like before, but to be sure, we need to confirm whether it's broken or dislocated and if there is any nerve or muscle damage. We will know once we run a few tests. Iwould then treat accordingly and try my best to preserve the function of your leg and make you comfortable."
Q "Do I have cancer, doctor?"
A "I understand your concern, Mr. Smith. We cannot exclude the possibility of cancer at this point. We need to perform additional tests. Once we have the results in, we will know for sure. Regardless of the results Mr. Smith, I want to assure you that we as a team would do the best we can to make you comfortable and address your concerns. Does that answer your question Mr Smith."
Q "Will I get better if I stop smoking?"
A "Mr Smith I totally understand your concern. I am glad that you are thinking about quitting smoking. Although we still have to find out exactly what's making you sick, stopping smoking should help your chronic cough. Overall it will also decrease the risk of cancer and heart disease. We have excellent smoking cessation counsellors that I can refer you to if you so wish." Does that answer your question?
Q "Doctor, am I going to die?
A "I understand your concern Mr Smith. Your condition may be serious, but until I get the test results back, we cannot be sure of the diagnosis. There are many disease that cause symptoms similar as yours. We will know the exact diagnosis only when we have the results. So please do not worry at this time. Now that you are here, we will do everything we can to help you".
Q "Do you think I will be able to use my leg again like before?
A "I understand your concern Mr. Smith. I am hoping that you will be able to use your leg like before, but to be sure, we need to confirm whether it's broken or dislocated and if there is any nerve or muscle damage. We will know once we run a few tests. Iwould then treat accordingly and try my best to preserve the function of your leg and make you comfortable."
Q "Do I have cancer, doctor?"
A "I understand your concern, Mr. Smith. We cannot exclude the possibility of cancer at this point. We need to perform additional tests. Once we have the results in, we will know for sure. Regardless of the results Mr. Smith, I want to assure you that we as a team would do the best we can to make you comfortable and address your concerns. Does that answer your question Mr Smith."
Q "Will I get better if I stop smoking?"
A "Mr Smith I totally understand your concern. I am glad that you are thinking about quitting smoking. Although we still have to find out exactly what's making you sick, stopping smoking should help your chronic cough. Overall it will also decrease the risk of cancer and heart disease. We have excellent smoking cessation counsellors that I can refer you to if you so wish." Does that answer your question?
Q "Doctor, am I going to die?
A "I understand your concern Mr Smith. Your condition may be serious, but until I get the test results back, we cannot be sure of the diagnosis. There are many disease that cause symptoms similar as yours. We will know the exact diagnosis only when we have the results. So please do not worry at this time. Now that you are here, we will do everything we can to help you".
Dos and Don'ts during the CS exam
DO
Explain what you are doing when you are examining the patient (Mr. Smith I am now going to feel for your thyroid gland...and that feels normal...)
Acknowledge everything that the SP tells you by OK or thank you or similar words or at least gestures. Use appropriate words/phrases. (For e.g. don't say OK when SP says "My sister died of lung cancer"!)
Ask permission before exam, before untying the gown
Congratulate, encourage whenever you get an opportunity
Speak slowly and clearly. Use can not in stead or can't and do not in stead of don't
Try to keep your eyes at the same level as the patient
Use open ended questions not leading questions
If you don't understand something ask the SP to repeat
Act confident and imagine as if you were seeing a real patient
DON'T
Do not interrupt when the SP is talking
Do not fill in words for the SP
Do not make the patient change too many positions
Do not forget to say "Did that answer your question ? Do you have another question
Do not put the pen in your mouth
Do not raise eye brows or frown
Do not repeat same questions again and again
Do not keep looking at the computer in the room!
Do not mumble. Be loud and clear
Explain what you are doing when you are examining the patient (Mr. Smith I am now going to feel for your thyroid gland...and that feels normal...)
Acknowledge everything that the SP tells you by OK or thank you or similar words or at least gestures. Use appropriate words/phrases. (For e.g. don't say OK when SP says "My sister died of lung cancer"!)
Ask permission before exam, before untying the gown
Congratulate, encourage whenever you get an opportunity
Speak slowly and clearly. Use can not in stead or can't and do not in stead of don't
Try to keep your eyes at the same level as the patient
Use open ended questions not leading questions
If you don't understand something ask the SP to repeat
Act confident and imagine as if you were seeing a real patient
DON'T
Do not interrupt when the SP is talking
Do not fill in words for the SP
Do not make the patient change too many positions
Do not forget to say "Did that answer your question ? Do you have another question
Do not put the pen in your mouth
Do not raise eye brows or frown
Do not repeat same questions again and again
Do not keep looking at the computer in the room!
Do not mumble. Be loud and clear
Lay man phrases for medical terms
Food regurgitation: Bringing up food.
Amaurosis fugax: Sudden loss of vision that is usually transient.
Palpate: Feel for.
Percuss: Tap.
ECG: Records the electric activity of your heart.
CT scan: Imaging the inside of your brain. It is like taking many X-rays and pooling them together.
MRI: Stands for magnetic resonance imaging. Basically takes pictures of the inside of your brain
Ultrasound: Looking at the inside of your belly (or the part in question) using a device on the surface of your body. The waves produced by the device are similar to sound waves and are totally harmless.
Appendicitis: Swelling and inflammation of the appendix.
Inflammation: Swelling due to irritation of the tissue due to a variety of reason.
Ovarian torsion: Twisting of the ovary on its stem.
Pneumonia: Infection of the lung.
Gastroenteritis: Infection of the stomach and the intestines.
Amaurosis fugax: Sudden loss of vision that is usually transient.
Palpate: Feel for.
Percuss: Tap.
ECG: Records the electric activity of your heart.
CT scan: Imaging the inside of your brain. It is like taking many X-rays and pooling them together.
MRI: Stands for magnetic resonance imaging. Basically takes pictures of the inside of your brain
Ultrasound: Looking at the inside of your belly (or the part in question) using a device on the surface of your body. The waves produced by the device are similar to sound waves and are totally harmless.
Appendicitis: Swelling and inflammation of the appendix.
Inflammation: Swelling due to irritation of the tissue due to a variety of reason.
Ovarian torsion: Twisting of the ovary on its stem.
Pneumonia: Infection of the lung.
Gastroenteritis: Infection of the stomach and the intestines.
Cholecystitis: Swelling and inflammation of the gall bladder.
Hepatitis: Swelling and inflammation of the liver.
USMLE Step 2 CS pass/fail rates
The data in the tables below may be outdated. Please click this link for newest tables:
Above data indicate that almost 1 in every 4 international graduates will fail the USMLE Step2 CS. Commonest reason for failing used to be ICE (Integrated Clinical Encounter) but more and more IMGs are now failing the CIS (Communication and Interpersonal Skills). Unlike the popular belief, English proficiency is an uncommon cause of failure (see the table below)
Patient Note
Importance of PNs in the USMLE Step 2CS is often underestimated. Many test takers score low on the data gathering because of a poor patient note. Here is a template that I suggest you use for every patient note. Make sure to include every heading. Even if you think it is not important in this particular case. I preferred writing down the Differential Diagnosis and Diagnostic Work Up part before writing the history and physical exam part but you can do either way that you feel comfortable.
History template
[Basic info] 30 yo female c/o [CC] pain in abdomen x 2 days.
[ODP and CC description] Pain is in the lower half of her abdomen, colicky, 7/10 without any radiation. Pain started at rest and gradually worsened to present state. Has taken 2 tabs of Tums today morning with partial relief. There is no specific aggrevating factor.
[Associated symptoms from the affected system] She has associated Nausea and Vomiting. She vomited 2 times today morning. Non bilious/non bloody. No diarrhea.
[Review of other systems] No cough. No pain elsewhere in the body, No trauma, No urinary complaints.
[ODP and CC description] Pain is in the lower half of her abdomen, colicky, 7/10 without any radiation. Pain started at rest and gradually worsened to present state. Has taken 2 tabs of Tums today morning with partial relief. There is no specific aggrevating factor.
[Associated symptoms from the affected system] She has associated Nausea and Vomiting. She vomited 2 times today morning. Non bilious/non bloody. No diarrhea.
[Review of other systems] No cough. No pain elsewhere in the body, No trauma, No urinary complaints.
[P]Past medical history is significant for asthma for which she takes [M] budesonide and albuterol. No previous surgeries. [A]Allergic to penicillin and sea food. [S]Is sexually active with her husband and uses condom for contraception. [O] Has one living child that was born vaginally at term 3 years ago. No pregnancy or delivery related complications. [H] That was her only hospitalization. [U] No urinary complaints. [G] LMP was 4 weeks back. Is normally regular every month and lasts 2-3 days. [S] Does not smoke or drink alcohol. Works as a teacher in primary school. [F]Family history significant for grandmother with ovarian cancer. No DM or HTN in family.
Physical exam template
[General] Appears to be in pain but in no acute distress.
[Vitals] Vitals HR: 80/min, RR 20/min, BP 120/80mmHg, Temp 37 C
[GPE] No pallor or icterus. Neck supple. HEENT normal with moist mucous membranes.
[Sytemic Exam]Abdomen: Non distended, Normal bowel sounds in all 4 quadrants. Tenderness on palpation of thr right illiac fossa. No rebound tenderness. No masses or organomegaly.
Chest: Symmetric movements, Normal vesicular breath sounds bilaterally.
Heart: S1S2 normal. No murmur.
Differential diagnosis
1) Acute appendicitis
2) Ectopic pregnancy
3) Ovarian torsion
4) Pelvic inflamatory disease
5)
[Remember to write the Differential in order or possibility]
Diagnostic Work Up
1) Pelvic exam
2) US abdomen and pelvis
3) CBC
4) Urine pregnancy test
5)
[Remember to write Pelvic and other such exams in your Diagnostic Work Up. Examples of commonly forgotten things include
Pelvic exam
Digital rectal exam
Orthostatic vitals
Minimental state exam
Pure tone audiometry]
What to take to the Step 2CS test center
The four things you need to take to the test center are as follows:
1) Stethoscope (If you forget they will provide one but it is generally recommended that you take your own)
2) White laboratory coat (If you forget they will provide one but it is generally recommended that you take your own. And of course make sure the pockets are empty!)
3) Scheduling permit
4) Photo ID [Acceptable forms of ID include the following forms of unexpired identification: passport, driver's license with photograph, national identity card, other form of unexpired government-issued identification, ECFMG-issued identification card. Your identification must contain both your signature and recent (no more than 10 years earlier) photograph. If it contains your photograph but not your signature, you can use another form of unexpired identification that contains your signature, such as a student/employee identification card or a credit card, to supplement your photo-bearing, governmentissued identification.]
A compilation of possible connecting phrases that one can use in USMLE Step 2 CS
Could it be that…?
Let me see if I understand…
That sounds frustrating.
I’m not sure if I understand, do you mean that…?
Do you feel a little…?
Correct me if I’m wrong, but…
Does it sound reasonable that…?
…is that what you mean?
… is that how you feel?
This is what I think I hear you saying…
Commonly asked cases in USMLE Step 2CS - Please add to the list
Headache
Backache
Pain in abdomen (usually a lady of child bearing age!)
Loss of consciousness
Neonatal Jaundice
Diarrhea in a child
Chest pain
Hemoptysis
Cough
Diabetes Follow up
Asthma Follow up
Deafness
Bleeding PR
Shoulder pain
Breathlessness
Vomiting
Depression
Abuse
Pre-employment exam
Menopause
Dysphagia
Urinary incontinence
Fever
Backache
Pain in abdomen (usually a lady of child bearing age!)
Loss of consciousness
Neonatal Jaundice
Diarrhea in a child
Chest pain
Hemoptysis
Cough
Diabetes Follow up
Asthma Follow up
Deafness
Bleeding PR
Shoulder pain
Breathlessness
Vomiting
Depression
Abuse
Pre-employment exam
Menopause
Dysphagia
Urinary incontinence
Fever
USMLE Step 2 CS Courses - To take or not to take
In last few years since the USMLE has made it a little more difficult to pass the USMLE Step 2 CS exam a number of real life courses have emerged. ("Performance levels required to pass the Step 2 CS examination have increased in two of the three Step 2 CS subcomponents. Those categories affected are Communication and Interpersonal Skills (CIS) and Spoken English Proficiency (SEP). There will be no change to minimum passing requirements for the Integrated Clinical Encounter (ICE) subcomponent of Step 2 CS.
If this increase in passing standards were applied to a recent group of test-takers, the passing rate for examinees from US schools would have decreased less than one percent and the passing rate for examinees from international medical schools would have decreased approximately eight percent. This new minimum passing score will affect students taking the Step 2 CS exam on or after July 15, 2007.")
Step 2CS is a very unpredictable exam. However my personal opinion is still against taking the live courses for most. There may be a select few who will benefit from these courses (those with really poor communication skills, no clinical exposure at all-not even internship and those who are not able to practise with a partner). These courses do guarantee passing and while some of them may return part of your money if you fail, that is not what counts!
I suggest practising with a live partner at least 40 full cases. Live courses are expensive and often not conducted in an ideal manner or by experts. If you decide to take one such course, talk to those who have taken it before. Do not rely on "testimonials" for obvious reasons.
If this increase in passing standards were applied to a recent group of test-takers, the passing rate for examinees from US schools would have decreased less than one percent and the passing rate for examinees from international medical schools would have decreased approximately eight percent. This new minimum passing score will affect students taking the Step 2 CS exam on or after July 15, 2007.")
Step 2CS is a very unpredictable exam. However my personal opinion is still against taking the live courses for most. There may be a select few who will benefit from these courses (those with really poor communication skills, no clinical exposure at all-not even internship and those who are not able to practise with a partner). These courses do guarantee passing and while some of them may return part of your money if you fail, that is not what counts!
I suggest practising with a live partner at least 40 full cases. Live courses are expensive and often not conducted in an ideal manner or by experts. If you decide to take one such course, talk to those who have taken it before. Do not rely on "testimonials" for obvious reasons.
USMLE Step 2 CS Score reporting time-table/schedule for 2011-2012 and 2012-2013
Step 2 CS 2011-2012 Result Reporting Schedule (See below for 2012-2013 schedule)
| Testing Period | Reporting Period | |
|---|---|---|
| For examinees who test | Reporting start date | Reporting close date |
Jan 1 through Jan 29
|
Mar 2
|
Mar 23
|
Jan 30 through Mar 26
|
Apr 27
|
May 25
|
Mar 27 through May 14
|
Jun 15
|
Jul 13
|
May 15 through July 16*
|
Aug 17
|
Sep 14
|
Jul 17 through Sep 10
|
Oct 12
|
Nov 9
|
Sep 11 through Nov 5
|
Dec 7
|
Jan 4, 2012
|
Nov 6 through Dec 31
|
Feb 2, 2012
|
Feb 22, 2012
|
2012-2013 Step 2 CS Result Reporting Schedule
Step 2 CS 2012 Reporting Schedule
|
||
Testing Period
|
Reporting Period
|
|
For examinees who test
|
Reporting start date
|
Reporting close date
|
Jan 1 through Jan 28
|
Feb 29
|
Mar 28
|
Jan 29 through Mar 24
|
Apr 25
|
May 23
|
Mar 25 through May 19
|
Jun 20
|
Jul 18
|
All test centers closed.
No testing May 20 through June 16 |
||
Jun 17 through Aug 25
|
Oct 3
|
Oct 31
|
Aug 26 through Nov 3
|
Dec 5
|
Jan 2, 2013
|
Nov 4 through Dec 31
|
Jan 30, 2013
|
Feb 20, 2013
|
For each testing period in the above schedules, Step 2 CS scores are released every Wednesday over a corresponding four- to five-week “Reporting Period.” It is expected that results for the vast majority of examinees who take the exam during the testing period will be reported on the first Wednesday of the Reporting Period. Over the past four years, results for 98%-99% of examinees who take the exam during the testing period were reported by the third Wednesday in a Reporting Period.
From: usmle.org
Acceptable abbreviations for the USMLE Step 2 CS
yo year-old
m male
f female
b black
w white
L left
R right
hx history
h/o history of
c/o complaining of
NL normal limits
WNL within normal limits
Ø without or no
+ positive
- negative
Abd abdomen
AIDS acquired immune deficiency syndrome
AP anteroposterior
BUN blood urea nitrogen
CABG coronary artery bypass grafting
CBC complete blood count
CCU cardiac care unit
cig cigarettes
CHF congestive heart failure
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CT computed tomography
CVA cerebrovascular accident
CVP central venous pressure
CXR chest x-ray
DM diabetes mellitus
DTR deep tendon reflexes
ECG electrocardiogram
ED emergency department
EMT emergency medical technician
ENT ears, nose, and throat
EOM extraocular muscles
ETOH alcohol
Ext extremities
FH family history
GI gastrointestinal
GU genitourinary
HEENT head, eyes, ears, nose, and throat
HIV human immunodeficiency virus
HTN hypertension
IM intramuscularly
IV intravenously
JVD jugular venous distention
KUB kidney, ureter, and bladder
LMP last menstrual period
LP lumbar puncture
MI myocardial infarction
MRI magnetic resonance imaging
MVA motor vehicle accident
Neuro neurologic
NIDDM non-insulin-dependent diabetes mellitus
NKA no known allergies
NKDA no known drug allergy
NSR normal sinus rhythm
PA posteroanterior
PERLA pupils equal, react to light and accommodation
po orally
PT prothrombin time
PTT partial prothrombin time
RBC red blood cells
SH social history
TIA transient ischemic attack
U/A urinalysis
URI upper respiratory tract infection
WBC white blood cells
Note : This is not intended to be a complete list of acceptable abbreviations, but rather represents the types of common abbreviations that may be used on the patient note. When in doubt - write it down! Also this list is available in every cubicle that you will sit in to write/type your patient notes.
From usmle.org
m male
f female
b black
w white
L left
R right
hx history
h/o history of
c/o complaining of
NL normal limits
WNL within normal limits
Ø without or no
+ positive
- negative
Abd abdomen
AIDS acquired immune deficiency syndrome
AP anteroposterior
BUN blood urea nitrogen
CABG coronary artery bypass grafting
CBC complete blood count
CCU cardiac care unit
cig cigarettes
CHF congestive heart failure
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CT computed tomography
CVA cerebrovascular accident
CVP central venous pressure
CXR chest x-ray
DM diabetes mellitus
DTR deep tendon reflexes
ECG electrocardiogram
ED emergency department
EMT emergency medical technician
ENT ears, nose, and throat
EOM extraocular muscles
ETOH alcohol
Ext extremities
FH family history
GI gastrointestinal
GU genitourinary
HEENT head, eyes, ears, nose, and throat
HIV human immunodeficiency virus
HTN hypertension
IM intramuscularly
IV intravenously
JVD jugular venous distention
KUB kidney, ureter, and bladder
LMP last menstrual period
LP lumbar puncture
MI myocardial infarction
MRI magnetic resonance imaging
MVA motor vehicle accident
Neuro neurologic
NIDDM non-insulin-dependent diabetes mellitus
NKA no known allergies
NKDA no known drug allergy
NSR normal sinus rhythm
PA posteroanterior
PERLA pupils equal, react to light and accommodation
po orally
PT prothrombin time
PTT partial prothrombin time
RBC red blood cells
SH social history
TIA transient ischemic attack
U/A urinalysis
URI upper respiratory tract infection
WBC white blood cells
Note : This is not intended to be a complete list of acceptable abbreviations, but rather represents the types of common abbreviations that may be used on the patient note. When in doubt - write it down! Also this list is available in every cubicle that you will sit in to write/type your patient notes.
From usmle.org
Physical Exam
Undressing and draping the patient for the exam.
Expose one part at a time. Use the drape effectively. Draping can be done as soon as you enter the room after introduction or be done just prior to the exam. Draping, in context of the CS simply means covering up the lower half of the patients body with a sheet (will be kept in the room for you) in order to cover the private area while examining the abdomen and/or lower extremities.
Order of exam:
Most patients would be in sitting position when you enter the room. In such case the usual order of exam should be as follows:
While in sitting position.
While in sitting position.
HEENT: Head Eyes Ear Nose Throat
PICCLEN: Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema, Neck vessels (JVD and Carotid bruit)
PICCLEN: Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema, Neck vessels (JVD and Carotid bruit)
Front of chest and entire (upper and lower) back while in sitting position. Auscultate front and back next. For auscultation do not ask the patient to remove the bra. You can have help him/her untie the gown (say I need to look at your back now. Let me help you untie your gown) and listen around the bra. The next step is going to be making the patient lie down. Before you do so think if you need to do anything else in the sitting position. (e.g. In a respiratory case you can percuss the front and back of the chest, in a neuro case you can do rinne, webers, finger nose test, cranial nerves etc in sitting position). We are taught examination system wise but we have to preform them in a way that is most comfortable to the patient (usually you can not complete exam of one system all at once).
Then make the patient lie down. (remember to pull the foot board)
Then make the patient lie down. (remember to pull the foot board)
Drape appropriately and then examine the abdomen. Remember to auscultate the abdomen too. You would almost never need to go below the waist area. I feel it is okay to skip inguinal nodes and hernial orifices without a problem for the sake of this exam. Before you make the patient sit up think if you need to do any other tests in a lying position (e.g. for backache case I would do SLR-Straight Leg Raise test. In a neuro case one can do ankle jerks and plantar reflexes while lying down.)
I usually at some point during my exam make a note of SSS - Skin Skull and Spine.
Hygiene: Always wash your hands before touching the patient (or use gloves). Some people recommend cleaning your stethoscope with alcohol wipes prior to auscultation. I am not sure if it matters.
Don't forget to document all the exams that you performed. People commonly forget to document "No abnormality on ophthalmoscopy" or "No carotid bruit"
In summary for all patients you must do - PICCLEN, Heart auscultation and Lung auscultation. In most patients you would feel and listen to the belly. Rest of the exam depends on the presenting symptoms. In most cases you would also need to do a quick Neuro exam (mainly ocular movements, power, knee jerks, vision{finger counting}and hearing{finger rubbing})
Before the exam: Tell the patient "Mr. Smith now I need to do a quick physical exam. Is that ok with you?"
During the exam: Tell the patient every step that you do. Look at the following conversation to get an idea. There is no wrong way of doing it. Each patient will be different.
"Lets start top to bottom Mr Smith. Can you show me your tongue...That looks normal. Let me look at your throat at the same time...can you open your mouth wide and say Ahhh as I shine this light inside...Throat looks normal. I am goind to shine this light in your eyes too ok MR. Smith?... Pupils look normal. Now I need to feel you neck...No enlarged lymphnodes, thyroid gland feels normal, neck veins look normal... Now I am going to listen to heart. I need you to untie your gown in order to do that...Let me help you with that. Ok...Your heart sounds normal. Let me listen to your neck vessels at the same time...No abnormal sounds here too. Now I am going to have a look at your back. Your lungs sound clear, spine looks normal, there is no lump or fullness. Good. Can you lie down Mr. Smith so that I can examine your belly. Feeling for your Liver... And now for your spleen. Liver and spleen are normal and belly feels soft. Listening for your bowel sounds now...They are normal. So far so good Mr. Smith...Can you.... .....
Specific parts of the exam that commonly trouble the CS taker:
Mini Mental State Examination:
The MMSE is a series of questions and tests, each of which scores points if answered correctly. If every answer is correct, a maximum score of 30 points is possible. People with Alzheimer's disease generally score 26 points or less.Remember the MMSE is not a test for Alzheimer's disease or any other cause of dementia. There are many other reasons why someone might score less than 26 points.
While it is not possible to do the entire test in the CS exam I feel doing the following tests is more than sufficient. You cannot score it but will only give you a rough idea. You can put "Mini Mental Scale Evaluation screen" in your plan in your patient note.
1) Orientation in Time: Ask "What month is it?"
2) Orientation in Place: Ask "What city are we in?"
3) Orientation in Person: Ask "Who am I?"
4) Memory: -"I'd like to test your memory. Please say these words: boat, egg and house"
-"Begin with 100 and count backwards by 7s" (Answer = 93, 86, 79, 72, 65)
-"Can you repeat the three words I told you earlier?"
4) "Name the following items" Point towards your pen.
5) Activity "Take a paper in your right hand, fold it in half, and put it on the table."
6) Activity Tell the patient to imitate drawing of two intersecting pentagons. "Can you make a figure similar to this one?"
I like to remember the MMSE as the test that tests "Time-Place-Person, Memory, Name and two activities" The activities being folding the paper and making the pentagons.
Rinne's and Weber's tests:
These should be done in all patients who complain of decreased hearing. These need not be done in all neuro patients.
Rinnes test : "Mr Smith, I am now going to test your hearing with these tuning forks. I will place the fork behind your ear and you should be able to hear the sound. I want you indicate to me when you stop hearing."
Repeat the same instructions for air conduction. Remember to use 512 fork. It is the shorter of the two. (Longer one is to test for vibration). And remember to test on both sides.Don't use the terms positive or negative Rinne's as they are confusing. Simply document AC>BC or BC>AC.
Webers "Mr Smith I am now going to place this fork on the middle of your forehead. Please indicate if you hear the sound equal in both ears and if not which side is louder"
Fundus and vision testing:
Fundus exam must be performed in patients with Hypertension, Diabetes, Headache, Visual Complaints and if time permits in all neuro cases. You have to at least pretend that you are using it correctly. You should see patient's left eye with your left and patient's right eye with your right. (In other words avoid kissing the patient on the lips!)
Detailed vision testing (with Snellen's Chart) is rarely indicated in Step 2 CS. In most cases documenting that the patient 'can count fingers at 6 feet' suffices. Six feet is about your own height! So keep your hands at about 6 feet and tell the patient to count your fingers. Commonest mistake made while doing this is testing for both eyes at the same time!!! You cannot do that. You must test each eye separately and the patient must be instructed to cover one eye with ipsilateral hand.
Taking vital signs:
Vital signs are already mentioned on the door. You do not need to measure them unless something different happens while you are in the room. (I haven't heard of an SP crashing during the exam!)
Step 2 CS Counseling
Asthma follow up:
"Mr. Smith asthma is a chronic disease that needs long term therapy. Most common cause of recurrence of asthma symptoms is interruption of controller medications. The inhaled medication (name it if the patient told you the name) is a steroid that suppresses swelling of your airways and prevents symptoms. You should take it every day without missing a single dose. I am happy to see that you are regular with your follow up checkups and I would like to see you again in about 3 months for a checkup. Do you have any questions regarding the treatment plan Mr. Smith?"
Alcohol addiction:
Most patients in the CS exam will either be occasional drinkers or chronic alcoholics. So it wont be so confusing as to who to counsel. But when you are confused go ahead and counsel. Some people counsel if a man has more than 3 drinks a day and if a woman has more than 2. If you feel unsafe you can say "Mr. Smith you are doing a great job by restricting your alcohol intake to____ drinks a day. However ... ..." and then say the following paragraph. If he is a clear cut alcoholic just counsel him as follows.
"As a concerned physician, Mr. Smith, I must inform you about the ill-effects of alcohol consumption. Besides altering judgment, excess consumption raises your risk of liver disease, heart disease and stroke. (In case of a woman of childbearing age also talk about ill effects on fetus.) If you ever decide to quit Mr Smith we have a team of professionals who would be eager to help you overcome your habit.
Depression:
Diabetes:
"Mr. Smith drugs are not the only things that will help control your blood sugars. Regular exercise and modified diet will play a big role in managing your diabetes. In addition diabetes makes you more prone to infection, especially infection of your feet. You must use footwear with soft soles and avoid wearing tight shoes. This maintains adequate blood flow to your feet and prevents infection. "
Enuresis:
"Mrs. Smith, bed wetting is extremely common at this age. Studies show that with each advancing year about 10% of kids with bed wetting will outgrow their symptoms. A number of behavioral modifications can help decrease bed wetting. These include not drinking liquids in the last couple hours prior to going to bed, waking the child up in the middle of the night to urinate, avoiding tea/coffee or caffeine containing soda with dinner and ensuring that 'Tommy' goes to the bathroom just before going to bed. If these modifications don't work we may consider bed wetting alarms or even medications in the future. Do you have any other questions that I can answer Mrs. Smith?"
Hypertension:
"Mr. Smith drugs are not the only things that will help control your high blood pressure. Regular exercise and modified diet will play a big role in managing your hypertension. Hypertension also puts you at high risk for heart disease and stroke. You must at once contact a doctor if you experience chest pain, weakness of any limbs, sudden severe headache or have visual problems."
Smoking cessation:
"Mr. Smith, in the end I would like to inform you about ill effects of smoking. Smoking increases the risk for chronic lung disease, heart disease and lung cancer. I understand that it is very difficult to let go old habits but our trained professionals can help. They have a number of ways to minimize the urge to smoke and reduce the withdrawal symptoms. Please feel free to contact us if you ever decide to quit."
Trichomonas positive:
"Ms. Smith the test we had sent to check for infection has returned positive for trichomonas. Trichomonas is a parasitic infection that is easy to treat by oral medications and I shall write you a prescription for the same. The medication is called Metronidazole and is an antibiotic. It has mild adverse reactions that you should be aware of. It can cause metallic taste in the mouth that will go away when you stop this medication. Also you should avoid alcohol while on this medication as you may develop flushing and headache. In addition you should abstain from sex until therapy is complete. In addition Ms Smith your sexual partner needs to take the same medication in order to prevent further transmission. Do you have any questions about the treatment Ms Smith?"
Domestic violence:
You should not get very personal but at the same time demonstrate empathy and show that you are ready to help. You can say something like:
"From what you said I understand that at times you feel unsafe at your own home. That sounds very frustrating Mrs Smith. I am glad that you came to seek attention. If you ever need someone to talk with do not hesitate to call our office. If ever you feel unsafe or are hurt you should seek attention from the police or appropriate authorities. And if you do not feel comfortable doing that you can always come to us for help and if you wish we could arrange for someone to go to the police with you. Does it sound reasonable to you?"
Febrile Seizure:
"Mrs. Smith, the description you provided makes me think Tommy has febrile seizures. It is a common and benign condition in children. While some of them may have a recurrence with fever most of them will not have a second episode. Almost all children will out grow the seizures by age of 5 or 6 years. Most of these seizures stop in 5-6 minutes and if Tommy has another episode lasting longer than that you must take him to the Emergency Room. Some doctors would recommend seizure medications for frequent febrile seizures but at this point I don't fell Tommy needs it. Do you have any questions about the plan Mrs. Smith?"
Safe Sex Counseling:
You should ask the following 5 questions about sex to all patients. Before asking these you should ask for permission saying "Mr. Smith I now need to ask you certain personal questions in order to arrive at a more accurate diagnosis. Is that ok with you?" (You should ask for Addictions and Sexual history once you have asked for permission to ask personal questions.)
1) Are you sexually active?
2) With men, women or both?
3) How many active partners do you have?
4) Have you had other partners in the past?
5) Do you use condoms? (In women you can in addition ask "What other form of contraception do you use?")
Based on the answers of above you should determine if the patient is at high risk of STDs.
If the patient is at high risk you can tell them "Mr. Smith as your concerned physician I should warn you that your sexual habits put you at a high risk of acquiring sexually transmitted diseases including Hepatitis, HIV and Gonorrhea. It is safest to have one constant partner and use condom everytime you have sex. Oral and anal sex also increases the chances of infection and a condom should be used at all times. If you wish we can test you for such infections. Also Mr Smith, don't be afraid to talk about safe sex with your partner. Your partner is probably just as concerned about risks as you. Talking about safe sex is an expression of caring for your partner and yourself."
Popular Mnemonics for Step 2CS
History: ODP PAMHUGSFOSS
O Onset
D Duration
P Progress
P Past occurance of same symptoms
A Allergies
M Medicines
H Hospitalization
U Urinary
G Gastrointestinal
S Sleep
F Family
O OB/GYN
S Sexual
S Social job/house/smoking/alcohol
The last S is very important. Do not forget to ask the occupation. One trick I learnt from an online blog was to ask about the occupation while washing my hands. Some people like to use the mnemonic SODA for detailed social history. ( Smoking, Occupation, Drugs and Alcohol)
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Pain: LIQORAAA
L Location
I Intensity ask to rate severity (1/10)
Q Quality
O Onset
R Radiation
A Associated
A Alleviating
A Aggravating
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Domestic abuse: SAFEGARD
S Safety
A Afraid of anyone?
F Family/friends?
E Emergency plan?
G Gun at home?
A Alcohol?
R Relationship with spouse.
D Drugs? Depression?
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Depression: SIGECAPS
S Sleep
I Interest
G Guilt
E Energy
M Mood
C Concentration
A Appetite
P Psychomotor
S Suicidal
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CAGE Questionairre.
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
The CAGE questionnaire scores >=2 has a sensitivity of 93% and a specificity of 76% for the identification of problem drinkers.
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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."
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