Step 2 CS study guide

Step 2CS study guide
Home
Overview
Test Structure
Parts
Test Center Locations
On Test Day
Patient Encounter
Interviewing Process
Doorway Information
Patient Introduction
Chief Complaint
Medical History
Challenging Questions
Counseling
Physical Examination
Patient Note
History
Physical Exam
Differential Diagnosis
Diagnostic Studies
Wiki Mnemonics
Practice Cases
Layman Terms
Medical Abbreviations

Overview

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

Watch the official USMLE website video first to get an overall idea of this board examination. Please watch the USMLE official onsite orientation for STEP 2 CS Video [[1]].

Test Structure

USMLE Step 2 CS is designed to assess clinical skills through simulated patient interactions, in which the examinee interacts with standardized patients portrayed by actors. Each examinee faces 12 Standardized Patients (SPs) and has 15 minutes to complete history taking and clinical examination for each patient, and then 10 more minutes to write a patient note describing the findings, initial differential diagnosis list and a list of initial tests. Administration of the Step 2-CS began in 2004. Before 2004, a similar exam, the Clinical Skills Assessment (CSA) was used to assess the clinical skills of foreign medical graduates.

The clinical skills assessed during this examination are:

• Relevant medical history
• Communication skills
• Physical examination
• Documenting the findings on the patient note
• Determining diagnostic hypothesis
• Ordering initial diagnostic studies

Test Center Locations

The examination is offered in five cities across the United States:

1. Philadelphia (PA)
2. Chicago (IL)
3. Atlanta (GA)
4. Houston (TX)
5. Los Angeles (CA)

On Test Day

Remember to bring the following items to the test center on test day:

• 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
• Standard stethoscope (not-enhanced)

Items not permitted:

• Electronic devices such as: beepers, recorders, watches, cameras, cell phones and other devices
• Study materials: any type of notes, reading materials and study summaries
• Other medical equipment

Interviewing process

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

Doorway Information

Mr/Mrs Wiki, a __ year old ___ (male/female) comes to the clinic complaining of "Chief Complaint"

Vitals: BP HR RR Temp

1. Write down on given blue sheet of paper: name and last name, age, altered vitals, chief complaint
2. If possible write quickly 3 differential diagnosis for the chief complaint and useful mnemonics
3. Knock the door and enter the room

Introduction to Wiki-Patient

1. Hello Mrs/Mr WikiPatient (shake hand with the patient, not if the patient is in pain)
2. I am Dr. Romero the Dr. taking care of you today. I will ask you some questions and perform a brief physical exam on you.
3. Is the room OK for you? (Dim light or adjust temperature if possible)
4. Let me make you more comfortable (drape and/or dim light if applicable)
5. How would you like to be addressed? (Wiki-patient says he/she likes to be called Wiki)
6. What brought you in today? (Elicit chief complaint)
7. I am very sorry to hear that! I will do my best to help you!

Chief Complaint

• Use the following mnemonics:

LIQORAAA (for pain)

1. Location
2. Intensity
3. Quality
4. Onset
5. Radiation
6. Alleviating factors
7. Aggravating factors
8. Associated symptoms

OCDPFAAA (for non-pain)

1. Onset (time)
2. Constant
3. Duration
4. Progression
5. Frequency
6. Alleviating factors
7. Aggravating factors
8. Associated symptoms

• For pediatric patients use ON CALL IDIOT

1. Onset
2. Number
3. Cry
4. Associated symptoms
5. Listless
6. Liquid (urine)
7. Inmunization
8. Diet, dehydration, daycare
9. Infection/Ill contacts
10. ORS: Oral rehydration solution
11. Travel

Past History

• To continue the interview you can use the PAMHITRFOSS mnemonic:

1. Past Medical History (PMHx) / Previous episodes: i.e. Hypertension, Diabetes, MI
2. Allergies to medications (prescribed and OTC)
3. Medications prescribed and OTC (i.e. vitamins or acetaminophen)
4. Hospitalizations
5. Immunizations
6. Trauma
7. Surgical History (PSHx)
8. Family History (FHX)
9. Ob-Gyn History: FMP, LMP, Period every 30 days, lasts 5 days, tampons/pads, GPA (gestation, pregnancy, abortion)
10. Social History (SHx): Occupation, Support (SAFE), tobacco, (PPD: 1pack per day for X years, EtOH (CAGE 0/4), recreational drugs, Travel
11. Sexual: active, number of partners (men/women/both), condom use, STDs, HIV test

Counseling

• Immediately when the patient gives you the pertinent information

Challenging Questions

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Physical Exam

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Patient Note

• Remember to practice typing the patient note in less than 10 minutes
• Should you finish earlier, you can earn extra time towards typing the patient note
• You can practice typing the patient note on the official USMLE website [[2]].

History

• CC (chief complaint): 45 y/o F/M c/o "symptom"
• HPI (history of present illness):
• ROS: negative except as above
• PMHx: negative
• NKDA
• PSHx: none
• FHX: none
• OB-GYN Hx: FMP, LMP, periods come Q30 days and last 5 days, number tampons, G2 P1 A1
• SHx: occupation, support (SAFE), 1 PPD x 30 years, EtOH (CAGE 0/4), denies rec drugs or travel history
• SEXUAL: active with males/females/both. Uses condoms consistently. No STDs. HIV test.

Normal Physical Exam

• NAD.
• General: hydrated, afebrile, tired, flat affect, tired, speech, movement
• VS: WNL except: BP/R/HR/T
• HEENT

Head: AT, NC Eyes: EOMI, PERRLA, normal eye fundoscopy. No conjuctival pallor Nose: no nasal congestion Throat: no tonsillar erythema/exudates/enlargement, central uvula Mouth: moist mucous membranes, good dentition

• Neck: supple, no JVD, no carotid bruits, no cervical LAD, normal thyroid
• Chest/Lungs: NT, TVF WNL, CTA & P B/L, (-) wheezes/crackles/rhonchi/rubs
• Heart: PMI not displaced, RRR (normal S1/S2 w/o m/g/r)
• Abdomen: BS +, ND/NT, soft, neg Murphy/McBurney/Rovsing/psoas/obturator sign, neg CVA tenderness, no Hepatosplenomegaly (organomegaly)
• Extremities: no edema/clubbing/cyanosis/asterixis, peripheral pulses 2+ and symmetric, no bruises, preserved active and passive ROM on abduction/adduction/flexion/extension/external rotation, strength 5/5, DTR 2+ B/L, preserved sensation B/L
• Skin: preserved turgor
• Neuro

Mental Status: A & O x3, spells backward, recalls 3 objects CN II-XII 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 -.

• 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

Cardiovascular

• 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

Lungs

• CTA B: clear to auscultation bilaterally

Abdomen

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

Back

• Ø CVAT: no costovertebral angle tenderness

Neuro

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

Differential Diagnosis

Give 3 differential diagnosis with pertinent positives or negatives from the history and physical exam

Diagnostic Study/Studies

1. Differed physical examination: breast, rectal, pelvic, genital
2. CBC and electrolytes
3. Cultures
4. Imaging

• Do not include referrals, consults, and medical or surgical therapies

Wiki-Mnemonics

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Practice Cases

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Layman Terms

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Accepted Medical Abbreviations

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External Resources

http://www.usmle.org/step-2-cs/