Step 2 CS Exam Comprehensive Template To Handle Every Patient Encounter

Step 2 CS Exam day preparation

 

When I took USMLE step 2 CS, I made a master template like this and reviewed this every day. I used this for every patient so I never had to have issues with any patient. You can start from here and improve upon this template and ace your step 2 CS too. Good Luck.

Review USMLE.ORG page, watch the video in that page, you will know what are not needed to take with you to exam center

Book the date of exam as soon as you are planned

Practice the software

Items to take to the test center: White coat, Stethoscope

At the Exam Center:

Fill and sign the confidentiality form

Write your CIN on yellow laminated paper

Give finger prints and let them take a picture of you

Place unauthorized items in locker

Onsite orientation to get familiarity with exam room

Actual Exam: 8hrs

12 patient Encounters: a phone case may be there?

Each patient encounter is 25 minutes [15 minutes for patient and 10 minutes to write notes]

10 min Break after 3rd encounter. 30 min lunch break after 6th patient and 10 min break after 9th encounter

Wait for the Exam to start:

You are in front of the patient’s room

Overhead announcement: “SP please prepare. This encounter may now begin”

On the door is given info about patient inside the room. Slide the door of the box on the door. You will see 1. Opening scenario 2. Vital signs 3. Instructions as to what you should do

Write patient’s name [in capitals and large print] and chief complaint on top middle of your clip board and think of 2-3 differentials for a few seconds before entering standardized Patient room.

Knock and open the door

Smile, “Hello, Mr. Smith, I am Dr. YourLastName“, while shaking their hand. “I am going to be your doctor today. What brought you here today?”

Patient tells you the ‘Chief Complaint‘

Can you please tell me more about it?” Get the history, do not interrupt for one minute. At this time, see if you can see the time on wall clock in room and note down the time on your paper.

Write down the points patient tells you on a clip board they give you as you may forget otherwise.

History Of Present Illness: ask more about the chief complaint

Most common complaint could be Pain: Remember ‘LIQORAAA‘–>useful forever in your life

L = Location
I = Intensity [mild, moderate, severe, or scale 1-10]
Q = Quality [throbbing, burning, sharp, squeezing, pressure like, heavy, someone sitting on chest]
O = Onset

R = Radiation [to jaw, back, arm, neck]

A = Associated symptoms [shortness of breath, palpitation, dizziness, syncope]
A = Alleviating factors [what makes it better?]
A = Aggravating factors [what makes it worse?]

 

Past Medical/Surgical History:

Medications for those medical problems – “Are you taking any medications including over the counter? Allergies -“Do you have any allergies?”

 

I will ask you some personal history, I will keep it confidential. Is it OK with you?

FOSS history: Family, OBGYN, Social [SAD=Smoking, Alcohol, Drugs], Sexual history

Hospitalizations

Review of Systems Ask from ‘top to bottom’, headache, syncope, nausea, vomiting, chest pain, any heart problems [heart attack, stents, heart failure etc], any lung problems [asthma, COPD etc], fever, chills, cough, any liver problems [cirrhosis, gall bladder removed, hepatitis, etc], kidney problems [stones], urinary problems [blood, burning, frequency, dysuria, etc], bowel problems[-diarrhea, blood, black stools, ], swelling in legs, rash on legs [cellulitis]

“5 minute warning” after 10 minutes -announcement

While Washing your hands with very very little soap [saves time to wash off] and water-with every patient. “Is there anything you want to add to what we already discussed so far?” At this time while washing hands, check the time on the wall clock if you can manage and adjust the speed based on the time left.

Is it OK if I do a quick physical exam on you?

Vitals: Already given to you initially which you can use

Warm your hands [rub them with each other] before touching them and warn them to ‘excuse me if my hands or stethoscope are cold’

Physical Exam:

General Appearance: well kept, flat affect, pleasant, obese, male/female, comfortably sitting/lying on bed, appears to be in mild/moderate distress due to pain

HEENT: pupils-equal [“Please look straight, I will check your eyes”, put the light from a distance from lateral to medial], reacting to light, icterus, palor, lymph nodes, neck stiffness, look in the mouth [Please say ‘aaaah’]

 

Now I will check your heart and lungs” – put steth on skin not on clothes

HEART: S1 S2 regular

LUNGS: Clear, crackles, wheezing, reduced breath sounds

 

“Now, I will check your belly, Can you please fold your knees? I will cover you with bed sheet and lift your gown”

ABDOMEN: no scars, no distension, bowel sounds present, percuss if ascitis, no tenderness [be very gentle with deep palpation]

“Now I will check your legs “

EXTREMITIES: edema, pulses

CNS: AAO x3, CN 2-7, facial droop, motor, sensory

SKIN: rash

Musculoskeletal: Joint swelling, muscle tone

[Breasts, Genitalia including inguinal hernia exam, Rectal, Pelvic, corneal reflex-are not to be performed]

[If at any time during physical exam, you remember a question you forgot to ask, I would ask that question while doing physical exam]

Close with Impression and Plan.

Counseling: [SAD  DEW CRESS] Smoking, Alcohol, Drugs,     Diet,  Exercise, WeightLoss,  Compliance, Reassurance, Education, Seat belt, SafeSex

“Do you have any questions for me? or if they have anything more to tell that I missed”

“Thank you and you have a wonderful rest of the day,  I will be back when I get the test results.”

“This patient encounter is over and you must now leave the room” -announcement

Once you step out, you have 10 minutes for writing Patient Notes.

Relax, Calm down.

Try to write 3 differential diagnoses in order of possibility with ‘History findings’ and ‘Physical exam findings’ for each to support and also write ‘Diagnostic tests’ needed for further evaluation.

Don’t write a long story, just write the chief complaint, opening scenario, positive and negative findings

“You have two minutes to complete your patient notes”-announcement

Submit your notes before time is up. Sample Note 1,  Sample Note 2

“Please click submit on your computer screen or stop writing” – announcement

Move on to the next with a fresh start.

Some general points:

Patient in pain-Show empathy

Patient coughs-give water

Patient cries-Give napkin

Patient said his parents died-“sorry to hear that”

Patient is angry-be patient. Try to explain the medical condition. Reassure that you will everything you can do make him feel better. One patient may ask why are you late? “I am sorry, I was held up with a sick patient”

When in doubt, do as you do in real life patient scenario.

It is very helpful to have a phone partner to discuss every case on phone for this step 2 CS exam. It is also very helpful to practice at least 5 cases with a live person a few days prior to the actual exam. Read the above template repeatedly after tweaking it a little bit as per your taste while you are preparing for this exam. I don’t think you would need to attend any live lecture paying a lot of money.