USMLE step 2 CS

Speak clearly and slowly Practice in front of mirror,
smile all the time,
Summerize history,
Explain PE while doing that,
Empathy

Open the box, 30 secend: write name, CC, abnormal VS, your plan for Hx, PE, DDx, W/u, consult, Write: A A WAT SUB PAM PM PS F O S S

Knock
Smile
Patient`s name?
Hello Mr./Mis. xxxx (SMILE)!
I’m Dr.XXXX. I’m the physician on duty today. Nice to meet you!

Look into the eyes! Is everything fine in this room?(Yes)
May I sit down?

Mr./Ms. …… What brought you here today?
Mr./Ms. …… What made you come here today?
Mr./Ms. …… How can I Help you ?

Empathy:
I can see you have been under a lot of stress/ I can see you are in pain/ Oh my goodness/ I understand that
Oh! I’m really sorry /to know about your problem/ to hear that, it must be very difficult.
Is there anything I can do to help you feel more comfortable. How does it affect your daily life?
I shall try my best to help you in this regard.

Facilitate: aha, yes, go on…, I see.., OK..,

First I like to ask you a few questions about your problem and I hope you wont mind if I write down a few notes while we talk. Now tell me more about your…… (problem), whats going on?

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History Taking

HPI ( History of Present Illness): O P P C ( L I Q R - A B C O ) A A A WAT SUB PAM

Onset:
When did it start first?
Was the onset sudden or gradual?
How long have you been feeling this way? ( I feel a bit down)

Precipitating factor:
What were you doing when it started?
Do you remember anything which could be responsible for it?

Progression:
How did it progress? Did it get better or did it become worse?

Constant v/s intermittent:
Is it constant or does it come and go?

(If intermittent:
Frequency:
How often does it happen?
How many episodes/times per day do you have it?

Duration:
How long does it last each time?)

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+ L I Q R (If Pain)

Location:
Would you please show me the exact location of your pain ?

Intensity:
On a scale of 1 to 10, how severe is your pain? (with 10 being the most severe pain of your life)

Quality:
How will you describe your pain? burning, Cramping, dull or sharp, pressure like, pulsating, Piercing?

Radiation:
Does the pain travel anywhere else?
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+A B C O (If Vomiting, diarrhea, constipation, cough, vaginal discharge)

Amount:
Can you estimate the amount of xxxxx( blood, phlegm, discharge, vomitus)? a teaspoon, a table spoon, or a cupful?
How many times per day did you have diarrhea? Was it watery, fatty or bloody?

Blood:
Have you noticed any blood in it?

Color:
What color was vomitus/discharge/stool?

Odor:
How did it smell –any specific odor?
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A A A ( for all cases)

A Alleviating factors: Does anything make it better?

A Aggravating factors: Does anything make it worse?

A Associated problem:Do you have any other associated problem like
Nausea,Fever,headache,Neck stiffness,Limb weakness,Numbness or tingling, ….

W Weight: Have you had any significant change in your weight recently?
A Apetite: Have you had any change in your appetite?
T Travel: Did you have any recent travel

S Sleep pattern (waking up/going to sleep...) How is your sleep?
U Urinary changes ( esp. if diabetic, elderly...): Do you have any urinary problem?
B GastrointestinalDo you have any problem with bowel movements?
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P Previous episode: Have you ever had similar problem before? Was it diagnosed? Was it treated?
Have you ever felt like this before?
A Allergies: Do you have any allergies? To any drug, food, pet, dust,fumes or smoke?
M Medicines: Do you take any medications?
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PMH (past medical history) Search for: P HUGS FOSS
Ok Mr./ Ms. ….., now I would like to ask you a few questions regarding your past medical health. May I continue?

P Past medical problem: Have you ever had any other medical problems? (High Blood pressure, Diabetes, Stroke, heart attack, thyroid problem, etc )
H Hospitalization: Have you ever been hospitalized for any illness?
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F Family history (similar chief complaints/serious illness)
Mr./Ms…… I need to ask you a few questions about your family so that I can get a clearer picture of your health. Is it okay with you to ask about them? (Yes) Thanks!

Has anyone in your family had….( any serious illness (high BP, diabetes, heart disease, stroke or cancers)
/ similar medical problem/ psychiatric problem/ mood problem?)
Are your parents alive? How they died?

O OB/GYN history (LMP, abortions, para...)
When did you have your first menstrual period?
When did you have your last menstrual period?
Were your periods normal/Regular?
Any vaginal discharge, any spotting, pregnancies, any problems in pregnancies, any abortion?
Any contraceptive?

S Social Hx (job/smoking/alcohol/recreational drugs/house)
Now, I’d like to ask about your social habits! Is that okay with you? (Yes)

-What kind of work do you do?
-Do you smoke? How long have you been smoking? How many packs per day?
-Do you drink alcohol? how many drinks per day? How many days per week?
Have you ever thought to cut down on your drinking?
Have you ever felt annoyed by criticism of your drinking habit?
Have you ever felt guilty about your drinking habit?
Have you ever taken a drink first in the morning to open your eyes?

-Do you take illicit drugs? How do you take it? How frequently do you take it?
- Exercise
- Diet
-Are you married? How many kids do you have?
-Who lives with you at home? How are they doing? Would you please explain for me your living condition?

S Sexual Hx (active/partners, preferences/STDs)
Now I need to know about your sexual habits. Please don’t be embarresed, whatever you say will be kept confidential. Is that ok?

-Are you sexually active? Do you have any problem in your sexual activities?
-Can you tell me about your partner or partners, how many partners do you have?/ How many partners did you have during the last year? Are your partners male or female or both?
-Do you use condom/ do your sexual partnes use condoms? Have you ever had any STDs? Have you ever been checked for HIV?

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Ok Mr./ Ms……. According what you said/ So as you said “………….”
Is there anything else you’d like to tell me ?

Physical Examination

Okay-Now I’d like to perform a quick Physical examination, May I do that? (Yes)Thanks.
Just let me wash my hands!
Drape the pt.: Let me make you slightly more comfortable.

at first I’d examine your eyes.Can you look up for me?

Patient sitting: HEENT, Back and Lung, Heart, Shoulder , elbow ,wrist and hand, Brachial and radial pulses, Fingers, Neurologic exam

Examine HEENT:
-Oral cavity, and LNs, sinuses.
- Thyroid
- Trachea
- Eye
- Ear

Now I need to examine your chest and lung, May I?
Let me open your gown
(Examine posterior chest: Routinely
- lung Auscultation,
- CVA tendernes or
- spinous tenderness simultaneously.

May I Bring your gown down to expose your chest to listen to your heart and lung.
(Auscultate anterior chest and heart at 4 points. Examine PMI)
( you can examine heart in lying position too.)
- bilateral Brachial and Radial pulses
Let me tie the gown.

Examine shoulder, elbow, wrist and hand in inspection, palpation, ROM, and strength.

Now examine Fingers for cyanosis/Koilonychias and clubbing.

If you need neurologic exam, move for Neurological examination in sitting position.

Now let the patient lay down and proceed for:
-JVP, Carotid bruit,
- abdominal examination if required in case(Inspection, Auscultation, palpation, Percusion, and if necessary: shifting dullness, obturator sign, psoas sign, rovsing sign, McBurney`s sign, Murphy`s sign, and Aortic palpation)
- bilateral femoral pulses, Popliteal pulses, Posterior tibialis, and Dorsalis pedis pulses
- Check SLR if suspect to sciatica
- Palpation, ROM, and strength of Hip, Knee, and Ankle
- Now examine legs for edema

Always pull the footrest out while patient is lying down.
Also pull the footstep out when patient is stepping down.
Help the patient while getting on or off the bed, sitting up or lying down in the couch.

Continue in standing position if you need to examine:
- gait
- Spine: inspection, palpation, ROM ( Cervical and Lumbar)
- Hip extension
- Inspection of hip, knee, and ankle

Conclude:

According what you said and your physical exam, It appears that you are probably having xxxx.
However, there are some other possibilities like xxxxx and ………, to rule out these possibilities and in order to ensure an acurate diagnosis we need to run :
-a routine blood test, and a blood test to check the function of your thyroid /your liver / kidney,…
-some imaging studies of your head/ abdomen/ wrist,….
-a urine test,
-and also I need to perform a pelvic/ rectal/ genital/ breast exam today.

Mr./Ms. …. , when the results are available I'll Explain to you the details of your diagnosis and we will talk about your options for treatment. Does it sound OK?”

Regardless of the final diagnosis, however I want you to be assured that I will be available for any help and support you need.
If it is a psychiatric case, like depression, grief, anxiety, or dementia, ask this question:
Miss xyz, Are you willing to talk to a counselor or go to a support group?

I strongly suggest that….

I Will remain in constant contact with you and your family to provide help and support.

If you need any more help from me, just let me know. I'll be glad to help you.

Mr./Ms. …. , do you have any concerns or questions you'd like to ask before I go?

Did I answer your question?

Thanks for your cooperation,It was nice meeting you. (Shake hand), have a good day.

USMLE step 2 CS

Friday, December 18, 2009

Clinical cases

Neurologic Exam Videos and Descriptions

DTR

Musculoskeletal exams

Abdominal exam

Respiratory and Cardiovascular exam

JVP

HEENT physical exam

Physical Exam Study Guides

Wednesday, December 16, 2009

Patient Encounter

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