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# Preparation Notes for

USMLE Step 2 CS
TO BE EDITED!

## By XAK & MTA

1) Knock! Knock! (Knock and enterdont wait for the SP to say come in!)
2) Good Morning Mr. XYZ, I am Dr. ABC, its nice to meet you! (Now shake hand!)
3) I am your physician here today. I am going to ask you a few questions about your health and perform a brief
physical examination; is that OK with you?
4) Before that, let me drape you first so that you feel more comfortable. (Now put the drape on the patient!)
5) (While draping, say) I hope you wont mind if I make my notes while talking to you.
6) (So lets get started ;) How can I help you today?
7) Patient will start telling you about the C/C, SAY: Can you please tell me more about your
condition/complaint?
8) O = Onset: When did it start?/How did it start? (Sudden or Gradual)
9) F = Frequency: Is it continuous or does it comes and goes?
a) If Continuous: Has it been the same or progressively worsening with time? (Covers #10 P = Progression)
b) If Comes & Goes/Intermittent: How many episodes do you have in a day? How long does each episode
last? When was the last episode?
10) D = Duration: For how long youre having this problem?
11) P = Progression: Has it been the same or progressively worsening with time?
12) L = Location: Can you show me where exactly are you having this pain?
13) I = Intensity: On a scale of 1-10 where 1 being the minimum and 10 being the maximum intensity of pain,
14) Q = Quality: Can you please describe your pain? Is it sharpburningcuttingthrobbing?
16) A = Aggravating Factors: Is there anything that makes your pain worse?
17) A = Alleviating Factors: Is there anything that relieves your pain?
mnemonic for them!) IT WILL ALSO COVER YOUR ROS
i) Fever:
iii) Stress:
iv) Sleep:
v) Travel:
vi) Trauma:
vii) Tick bite:
viii) Wight loss:
ix) Appetite:
x) Temperature Intolerance: AskDo u feel abnormally cold when others dont or do you feel
abnormally hot when others dont? (Sometimes this might be the only positive finding in a patient
with thyroid disease.)

## 19) For a joint pain case, ask CITRUS

i)
ii)
iii)
iv)
v)
vi)

C = Chest Pain/Cough/Conjunctivitis
I = Insect Bite
T = Travel/Trauma
R = Rash
U = Ulcers in mouth/Urinary Discharge
S = Stiffness/Sore Throat

PAM HUGS FOSS

## Have you ever passed urine

Have you ever passed stool
impotence as well

TRANSITION SENTENCE
medical history; is it OK with you?
i)

P = PMH
(a) Have you ever had any similar problem/complaint in the past?
(b) Are you currently suffering from any diagnosed medical illness?
(c) Any chronic conditions like Diabetes, High blood pressure? If yes, ask
How long have you been diagnosed with this condition?
or
When were you diagnosed with this condition?
Are you currently taking any medication for your complaint (Diabetes, high blood
pressure)?
Is your blood pressure/blood sugar level under control?
Do you check it regularly?
When did you last visit your doctor / last checked with your physician?
Have you been compliant with your medication?
Have you noticed any side effects of your medication?

## DONT FORGET TO COUNSEL SIMULTANEOUSLY!!!

(It will save your counseling points if you forget these points or run out of time in the end!)
ii) A = Allergies
(a) Are you allergic to anything or any medication?
(b) If yes e.g. Penicillin, ask:
What happens when youre given Penicillin?
or
What happens when u r stung by a bee?

(c) SAY: OK, Im making a note of it and Ill make sure you will never be given Penicillin in future.
Or advice the patient to avoid going to places where he/she could have an increase risk of a
bee sting.
iii) M = Medication Hx
(a) Have you taken any medication for your current complaint?
(c) Are you taking any medication apart from this?
iv) H = Hospitalization Hx
(a) Have you ever been hospitalized in the past for anything?
(b) If yes, ask: WHEN? and FOR WHAT?
(c) Did everything go fine at that time?
v) U = Urinary Hx (if you havent asked earlier!)
(a) Do you have any problem with urination?
vi) G = GI Hx (if you havent asked earlier!)
(a) Do you have any problem with your bowel movements?
vii) S = Sleep Hx (if you havent asked earlier!)

TRANSITION SENTENCE
Mr./Miss XYZ, now I would like ask you a few questions about your
family history; is it OK with you?
viii) F = Family Hx
(a) Does anyone else in the family have a similar complaint?
(c) If yes, SAY: Its nice to hear that!
(d) Hows the health of your parents?
(e) If parents have died or have something, SAY: I am really very sorry to hear that!

TRANSITION SENTENCE
gynecological history; is it OK with you?
ix) O = Gyn/Ob Hx
(a) When did you have your first period?

(b)
(c)
(d)
(e)

## When was your last menstrual period?

Have you ever been pregnant?
How many children do you have?

TRANSITION SENTENCE
Mr./Miss XYZ, now I would like ask you a few questions about your
sexual history. Dont worry everything will be kept confidential; is it OK
with you?
x) S = Sexual Hx
(a) Are you sexually active?
(c) If yes, ask: WITH WHOM? (One partner/Husband =Dont ask any further questions!)
(d) Do you have any other partner?
(e) Do you use any contraceptive measures?
(f) If no, COUNSEL FOR USING CONTRACEPTIVE MEASURES
You must use condoms as these not only prevent from unwanted
pregnancies but also from many sexually transmitted diseases as
well.
(g) Have you ever been tested or diagnosed for any sexually transmitted disease?
(h) Have you ever been tested for AIDS?
(i) If no, COUNSEL & ASK FOR CONSENT TO GET HIM/HER TESTED FOR HIV!

TRANSITION SENTENCE
Mr./Miss XYZ, now I would like ask you a few
you?
xi) S = Social Hx ( SODA )
(a) Smoking:
Do you smoke?
For how long you have been smoking?
How many cigarettes do you smoke in a day?
if yes then counsel like this

## SMOKING, ALCOHOL & ILLICIT

DRUG USE COUNSELLING

## It is always better to first

then counsel at this point
It will save you a lot of fuss
in the end.
& you will never forget to

## being your concerned physician I advise u that u must quit smoking

as smoking may cause many diseases such as heart ,lung and

## stomach diseases and many cancers in the body as well.if u want to

(b) Alcohol:
Do you drink alcohol? If yesalways ask about those 4 alcohol dependence
questions! (CAGE questions!)
For how long you have been drinking?
Counseling as well just like given for smoking.
(c) Illicit Drugs:
Do you use any sort of recreational drugs?
If yes, ask: SINCE WHEN? & FREQUENCY?
(d) Occupation:
What do you do for a living?

EXAMINATION
TRANSITION SENTENCE
Thank you for answering me these questions. Now I would like to
examine you; for this I need to wash my hands first and then come back
to you. Excuse me for a minute!

There is a debate that you should be doing some light conversation with the SP while youre
washing your hands. In my experience, its better to keep quite during that since a challenging
question might come during this time. You can even ask the SP Is there anything you would like
ask at this point? but do it only when your hands are wet!

21) Now I am going to examine you. During examination, I need to touch you several times. I will try to be very
gentle. Do let me know if you feel any pain or discomfort, I will stop right away.
22) Judge according to case and time left in the encounter (which you will guess from the last five minute
announcement!) from where you have to start.
Our rule of thumb has been; if youre done washing your hands and have told the SP youre going
to start the examination, you should have ample time in the end for counseling and proper
closure!
23) Here is a brief review of all examination steps. Do not consider it as final and read the examination
from USMLE World. During the real patient encounter, you normally do not have that much time

to do every step of systems examinations. Always do the chief complaint related exams first and
never forget to do the General Physical Exam or HEEENT (it will just take 20-30 seconds!).
i) HEENT
facing upward)...
I am looking at your hands for any sweating or abnormality [touch pts
hand with your finger to check for sweating]
I am looking for any color changes in your nails
I am looking for your pulse and comparing with the other side as well and it
seems normal to me [Feel for the SPs pulse for 5 seconds!]
(b) SayNow I am going to examine your eyes
Can you please look down for meI am looking for any yellowness in your
eyes!
Can you please look up for menow I am looking for any pallor in your eyes!
and they seem normal to me.
Get the OPHTHALMOSCOPE, its light will turn on automatically.
Dont forget to switch off the room light before doing
fundoscopy. There is no need to switch off light just for oral
examination!
(c) FUNDOSCOPY: Do it when you get a history of Diabetes Mellitus, Hypertension or a
case of stroke [CVA] OR any eye problem!
(d) SayNow I would like to examine the inside of your mouth (oral cavity), for this I
need to shine light in your mouth
checking CN XII
and say a big AAH
checking CN IX & X
While saying this, shine light into his mouth
Proceed to CNS exam from this point if its a CNS case!

## If you get a CNS or GIT case,

never forget to listen to heart &
lung sounds.
Always do it at the end when you
have completed the rest of the
relevant examination.
Dont forget to assess if you have
enough time for closure, since it
carries more marks!

## (e) AUSCULTATION OF NECK (for Carotid Bruits): Do it when

you get a history of Diabetes Mellitus, Hypertension or a case of stroke [CVA] or any
case of Dizziness.
SayNow I am going to listen for any abnormal sounds in your neck. [Put the
stethoscope on each side of the neck for 1-2 seconds!]

(f) THYROID EXAM: The scenarios in which it should be done are any case of fatigue,
depression, forgetfulness and a clear case of thyroid.
Do this step only in a
case of thyroid
related history!

SayNow I would like to look for any abnormal swelling in your neck; can
you please swallow for me (or drink a sip from the glass of water).
[Meanwhile, place your hand and palpate the area of thyroid and do
comment in the end that it looks normal to me]
SayNow I am going to listen for any abnormal sounds in your neck. [Place
the bell (not necessarily in CS if youre running out of time)of your
stethoscope on either side of front of neck]

ii) GIT
(a) Now I would like to examine your belly; for this I need to expose your belly and
drape you properly.
(b) Two very important things to remember here, while the SP is sitting:
#1 Go behind the SP open the lower knot of the SPs gown [better to open
the upper as well]. If you let the SP lie down without opening the lower knot,
you will not be able to pull up the gown to expose SPs abdomen.
#2 Help the SP lie down [while placing your hand behind SPs head] and
slide the foot rest out from the foot-end of the bed sayingI am going to
pull the foot rest to make you more comfortable.
(c) Pull the drape up to the abdomen well above the umbilicus and slide the front of the
gown beneath it to expose the abdomen. Then push the drape back till the iliac crest.

Always auscultate
the abdomen first
before touching the
belly!

(d) SayCan you me exactly where youre having pain? [Always ask this question for
every case of pain, before starting your examination!]
(e) INSPECTION: SayNow I am looking at your belly for any abnormality, abnormal
swelling, striae, scars or visible pulsations.
(f) AUSCULTATION: SayNow I am going to listen to your bowel sounds and other
abnormal sounds in your belly. [Place the stethoscope at just 2 points right and left
of the umbilicus for 2-3 seconds!]
(g) PALPATION: SayNow I am going to touch your belly, first lightly and then a bit
deeper. Do let me know if it hurts or you feel uncomfortable, I will stop right away.
[LIGHT PALPATIONJust form a very superficial S on the abdomen. DEEP
PALPATIONDo not poke your fingers. Be very gentle in deep palpation as well.]
Always keep looking at the SPs face. Immediately stop if you see any discomfort
on the SPs face or the SP complains of pain.

(h) PERCUSSION: SayNow I am going to tap your belly to look for any extra air or fluid
in it! [Percuss only at 2-3 points!]
i.
ii.
iii.
iv.

## Close the foot rest.

Help the SP sit up.
Tie the lower knot.
Proceed to chest exam!

THE EXAMINATION OF THE CHEST (RESPIRATORY & CVS) SHOULD BE DONE AT THE SAME
TIME! THE SP WILL HAVE A CHECK LIST; YOU CAN PROCEED WITH ANY ORDER YOU MAY LIKE.

## iii) RESPIRATORY SYSTEM

(a) SayNow I have to examine your chest. For this, I have [need] to untie your
gown is it OK with you? [Untie the top knot only and expose the chest of the SP,
both in males as well as females. Dont let it fall down!]
(b) INSPECTION: SayNow I am looking at your chest for any abnormality, scars or
visible pulsations.
(c) PALPATION: In my opinion, only do these steps if you get a respiratory system case!

You can make an S and feel the chest from back with the palm of your hand and
For vocal fremitusYou can feel with the ulnar side of your hand at any point on
the chest you want; it should include two points on left and 2 on right side up
and down, where ever you like.

(d) PERCUSSION: SayNow I am going to tap on your back with my finger to look for
any abnormal air or fluid in it. I will try to be very gentle [Percuss 3 places on each
side on the back!]
(e) AUSCULTATION:

SayNow I am going to listen to your lung sounds, can you please take
some nice deep breaths for me? NEVER ASK ANY SP COMPLAINING OF
CHEST PAIN (whatever the scale is!) OR DIFFICULTY IN BREATHING TO
TAKE DEEP BREATHS; and tell him that you are not asking him to take
deep breaths because of his/her chest pain or difficulty in breathing.

Now can you please say 99 for me, whenever I say yes [by placing the base
of stethoscope on his back].

## iv) CARDIOVASCULAR SYSTEM

(a) PALPATION:

In case of a female
SP, sayCan you
left breast for me?
before palpating
for apex beat and
auscultating the
mitral area!

For Apex Beat, SayNow I have to feel for your heart beat. (, can you please
lift up your left breast for me... in case of a female SP!)

Always palpate for the apex beat; even if its not a CVS case! [My own
personal exception to the rule wasASSESS THE TIME REMAININGif you
think you can manage, go for it, otherwise leave it!]

(b) AUSCULTATION: SayNow I am going to listen to your heart sounds, can you please
hold your breath for me? [Auscultate at pulmonary, aortic, tricuspid and mitral
areas for 1-2 seconds each!] DO NOT ASK THE SP TO HOLD HIS/HER BREATH IN
CASE OF CHEST PAIN.
At the end, do comment that your heart sounds seem fine to me!

## v) CENTRAL NERVOUS SYSTEM

(a) CRANIAL NERVES: Refer to the HEEENT section of the examination for CN IX, X & XII!

## CN II & III: Do it only if you there is something in history or chief complaint;

do it before checking the oral cavity and dont forget to turn the light off!
SayNow I am going to check the function of the nerves coming from the
brain (DO ALL THE CRANIAL NERVES EXAM AT THIS POINT THEN!) [Throw
light in the eyes from behind!]
CN III, IV & VI: SayCan you please follow my finger without moving your
nose to check for accommodation!]. Then commentyour eye movements
look normal to me or you have some difficulty in maintaining your eye
movements if there is a problem in real.
CN VII: Say
i. Can you please frown for me?
iii. Can you please close your eyes and dont let me open them. [Place
your thumbs on SPs eyes and very gently try to open his/her eyes!]
iv. Can u please smile/whistle for me?
v. I am rubbing my fingers in front of your ears; let me know if you
hear the sound equally on both sides or if there is difference. [Rub
your fingers and thumb simultaneously in front of both ears of the
SP]
CN V: SayNow I will touch your face like this [touch the SPs forearm gently
with your finger], you have to close your eyes and tell me if you can feel it

and if its equal on both sides; Is it OK? [Now touch the face of SP very gently
Keep on askingCan you feel thisevery time you touch the
face of SP.
Then ask when youre done and the SP has opened his/her
eyesWere they equal on both sides?

CN XI: SayCan you please shrug your shoulders for me? [Place both hands
on SPs shoulders!]

CN VIII: Only check this nerve if you get a case of hearing loss or SP gives you
something in the history.
WEBERS TEST: SayNow I would like to check the function of your ears. For
this I would use this tuning fork. I would first strike it with a rubber pad like
this and then I will place the base of this vibrating fork on the top of your
head. Do let me know if you hear equally on both sides or in which ear you
hear the most.
RINNES TEST: Place the base of tuning fork behind the ear on the mastoid
prominence and sayI will place the base of this tuning fork at back of your
ears; please let me know when you stop hearing. [When the SP stops
hearing, place the tuning fork in front of his ears and ask if he/she can still
hear the vibration].
In exam, you will not have time to explain in detail about the result of
this test.

(b) SENSORY SYSTEM: SayNow I would like to touch you like this [touch SPs forehead
with the tip of your finger]; kindly close your eyes and say Yes whenever you feel
my finger.
Now touch the following points simultaneously on both sides:

Hands
Forearms
Arms
Thighs
Shins
Feet
Keep on askingCan you feel thisevery time you touch the SP.
Then ask when youre done and the SP has opened his/her
eyesWere they equal on both sides?

(c) MOTOR SYSTEM: SayNow I am going to check the power of your muscles.

Hold my fingers and dont let it go. OR Can u please squeeze my fingers?
Now place your arms like this [Show the SP to place his/her arms flexed by the side
of chest] Can you move your arms out for me? [Place your hands on the dorsal side
of the forearms!]
[Now place your hands on the ventral surface of both forearms] SayCan you move
Can you move your arms out for me? [Place your hands on outer arms!]
[Now place your hands on the inner surface of arms] SayNow can you move your
arms in for me?
Can you move your feet up for me? [Place your hands on top of SPs feet!]
[Place your hand on soles now!] SayNow can you move them down for me?
Can you kick your legs out for me? [Place your hands on the shins!]
[Place your hands on the calves now!] SayNow can you move your legs in?

Case of BACK PAIN: Say...Now I would like to evaluate for your pain in the
backdo let me know if it hurts; I will stop right away.
i.
INSPECTION: SayNow I have to look at your back for any abnormality
[Now open the lower knot and look at the back] Sayeverything seems
fine [Unless they have put some paint there! Do watch out for such kind
of things!]
ii.
SayCan you exactly show me where the pain is? [SP will point out!]
iii.
PALPATION: SayNow I am going to touch your back, let me know if you
feel any pain. [Now palpate on the spine at 3-4 points!]
iv.
Now SayLet me help you lie down. [Open the foot rest and help the SP
lie down!]
v.
Ask the SP to abduct and then adduct his/her legs to check the power in
the same way.
vi.
STRAIGHT LEG RAISING TEST: Now I would like to check for any problem
lift up your left leg. Please let me know whenever you start feeling pain
at your back, I will stop right away.[Place one hand above the pt knee
and your other hand underneath SPs heels and keeping the leg straight,
lift the SPs leg to the point when he/she feels pain]
vii.
Now repeat for the other leg as well. [Even if SLR is positive in the first
leg!]
viii.
Close the foot rest.
Help the SP sit up.
(d) GAIT: SayNow I would like to check your gait.

Take the steps out and help the SP get off the bed.

SayCan you please walk a few steps for me, turn around and get back.
Dont worry; I wont let you fall down.
Now help the SP get on the bed again!

CLOSURE
24) Thank you for your patience and co-operation. Now let me summarize what you have told me so far
Summarize all the history and one or two significant finding in one or two lines maximum. The SP
has to check a box that you summarizednot how elaborately you summarized.
Based on your history and physical findings, I am considering a number of possibilities here
likeyour D/D herebut I am not sure right now; For this, I need to carry out some test first like CBP,
X-ray of spine and even an MRI (e.g. if required in the case). When the results of these tests will be
available, well meet again and discuss your management and treatment options. Then I will be in a
better position to comment on your diagnosis.
Meanwhile, you should take care of [All the advice needed for the case and also advise about
diet and regular exercise!]
25) Do you have any concerns before I leave?
26) Thank youHave a good dayBye for now!

CHALLENGING QUESTIONS
You will find a lot of material related to challenging questions in USMLE World / First Aid
(which ever you prefer!)and Neeraj Notes.

NEERAJ NOTES: Pay special attention to all the 6 cases in Neeraj notes (especially picky eater,
which comes in 5 to 6 different ways; but the questions asked should be the same which is
mentioned in the Neeraj notes]

STOOL QUESTIONS

Amount
Color
Consistency
Smell

## THYROID SPECIFIC QUESTIONS

Sleep
Stress
Appetite
Weight loss
Hair changes
Sweating
Skin changes
Voice changes
Swelling over feet
Swelling around neck
temperatures

USEFUL TIPS:
Never forget to counsel about colonoscopy in a SP whose age is more than 50.
If you enter the room and the SP is immediate distress (e.g. Coughing, acting to vomit
with a kidney tray in hand or in pain), sayMr./Miss XYZ, it seems that youre a bit
distressed; is there anything that I can do to make you feel more comfortable. [If its
your uncooperative patient, you can also addLet me assure you that I am here to help
you out and to solve your problems.]
If you enter in a room and patient starts yelling at you then you must sayMr./Miss XYZ,
I know you must be waiting for me for a long time; I really apologize for that and I really
appreciate your patience, actually I was with another patient and now Its your turn and
If the SP is coughing, offer water!
Never give water in case of abdominal pain.
In case of cough, offer a napkin if the SP isnt holding one.
If a napkin does get involved, dont forget to take it in the end tell the SP that you need
it to get phlegm examined.
Always switch off the light after taking SPs permission.
Never forget to rule out sinusitis. Ask the following questions:
i. Do you have any pain in your face?
ii. Do you have pain anywhere else?
iii. Do you have fever
iv. Dry or productive cough
v. Sore throat
vi. Headache at which particular time of the day
vii. Eye discharge, redness of eyes
viii. Runny nose
ix. Discharge from ears
x. Change in the quality of voice
xi. Postnasal dribbling [ I am not sure how can you describe this]
Never forget SLR in a case of back pain.
Never forget to mention rectal exam in all abdominal cases.
Never forget to mention pelvic exam in all females in abdominal or pelvic [Gyn/Ob]
cases.
Try to summarize all the details of history once again in the end in a telephonic case or
in a case where exam is not required (when a SP is sitting in the room wearing regular
clothes, not a gown).
Try to call the pt with his or her name. Try not to pronounce it incorrectly; ask him if you
are pronouncing his/her name in a wrong way in the beginning of your case.

In an abdominal exam, always make proper posture of the pt if he is lying to one [right
or left] side of the bed before starting your exam.

&