CS Notes(Pre Edition Med Res)

Preparation Notes for

USMLE Step 2 CS TO BE EDITED!

By XAK & MTA

1) Knock! Knock! (Knock and enter…don’t wait for the SP to say come in!) 2) Good Morning Mr. XYZ, I am Dr. ABC, it’s 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 won’t mind if I make my notes while talking to you. 6) (So let’s 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 you’re 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, how will you grade your pain? 14) Q = Quality: Can you please describe your pain? Is it sharp…burning…cutting…throbbing…? 15) R = Radiation: Does your pain go to any other part of your body? 16) A = Aggravating Factors: Is there anything that makes your pain worse? 17) A = Alleviating Factors: Is there anything that relieves your pain? 18) A = Associated SX: Is there anything associated with your pain? Ask separately about: (Make your own mnemonic for them!) IT WILL ALSO COVER YOUR ROS i) Fever: ii) Headache: iii) Stress: iv) Sleep: v) Travel: vi) Trauma: vii) Tick bite: viii) Wight loss: ix) Appetite: x) Temperature Intolerance: Ask…Do u feel abnormally cold when others don’t or do you feel abnormally hot when others don’t? (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

In case of BACK PAIN don’t forget to ask:   

20) Now ask about the past history. Mnemonic PAM HUGS FOSS

Have you ever passed urine without your knowledge? Have you ever passed stool without your knowledge? You may ask about impotence as well

TRANSITION SENTENCE “Mr./Miss XYZ, now I would like ask you a few questions about your past 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?

DON’T 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 you’re given Penicillin? or What happens when u r stung by a bee?

(c) SAY: OK, I’m making a note of it and I’ll 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? (b) If yes, ask: WHAT/WHICH? (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 haven’t asked earlier!) (a) Do you have any problem with urination? vi) G = GI Hx (if you haven’t asked earlier!) (a) Do you have any problem with your bowel movements? vii) S = Sleep Hx (if you haven’t asked earlier!) (a) How is your sleep?

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? (b) Are your parents alive? (c) If yes, SAY: “Its nice to hear that!” (d) How’s the health of your parents? (e) If parents have died or have something, SAY: “I am really very sorry to hear that!”

TRANSITION SENTENCE “Mr./Miss XYZ, now I would like ask you a few questions about your past 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? Are your cycles regular? 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. Don’t worry everything will be kept confidential; is it OK with you?” x) S = Sexual Hx (a) Are you sexually active? (b) If no, ask: WHY? (c) If yes, ask: WITH WHOM? (One partner/Husband =Don’t 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 questions about your social history; is it OK with 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 

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It is always better to first ask about their history and then counsel at this point about all of them. It will save you a lot of fuss in the end. & you will never forget to counsel about them!

“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 quit it; I am always here to help you out.” (b) Alcohol:  Do you drink alcohol? If yes…always ask about those 4 alcohol dependence questions! (CAGE questions!)  For how long you have been drinking?  Ask about frequency!  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?  Is your job stressful?

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 you’re washing your hands. In my experience, it’s 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 you’re done washing your hands and have told the SP you’re 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 (a) Start with hands. Say…  Can you please show me your hands like this? (Show the SP your palms facing upward)...  I am looking at your hands for any sweating or abnormality… [touch pts hand with your finger to check for sweating]  Can you please turn your hands for me…  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 SP’s pulse for 5 seconds!] (b) Say…Now I am going to examine your eyes…  Can you please look down for me…I am looking for any yellowness in your eyes!  Can you please look up for me…now I am looking for any pallor in your eyes! …and they seem normal to me.  Get the OPHTHALMOSCOPE, its light will turn on automatically. Don’t 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) Say…Now I would like to examine the inside of your mouth (oral cavity), for this I need to shine light in your mouth…  Can you please open your mouth for me…  …stick your tongue out… ← 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 it’s a CNS case!

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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. Don’t 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. Say…Now 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!

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Say…Now 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] Say…Now I am going to listen for any abnormal sounds in your neck. [Place the bell (not necessarily in CS if you’re 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 SP’s 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 SP’s abdomen. #2 Help the SP lie down [while placing your hand behind SP’s head] and slide the foot rest out from the foot-end of the bed saying…I 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) Say…Can you me exactly where you’re having pain? [Always ask this question for every case of pain, before starting your examination!] (e) INSPECTION: Say…Now I am looking at your belly for any abnormality, abnormal swelling, striae, scars or visible pulsations. (f) AUSCULTATION: Say…Now 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: Say…Now 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 PALPATION…Just form a very superficial “S” on the abdomen. DEEP PALPATION…Do not poke your fingers. Be very gentle in deep palpation as well.] Always keep looking at the SP’s face. Immediately stop if you see any discomfort on the SP’s face or the SP complains of pain.

(h) PERCUSSION: Say…Now I am going to tap your belly to look for any extra air or fluid in it! [Percuss only at 2-3 points!] (i) Say…Thank you, now let me help you sit up! 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) Say…Now 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. Don’t let it fall down!] (b) INSPECTION: Say…Now 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 ask if it hurts. For vocal fremitus…You 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: Say…Now 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: 

Say…Now 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.

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…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, say…Can you please lift up your left breast for me? …before palpating for apex beat and auscultating the mitral area!

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

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Always palpate for the apex beat; even if it’s not a CVS case! [My own personal exception to the rule was…ASSESS THE TIME REMAINING…if you think you can manage, go for it, otherwise leave it!]

(b) AUSCULTATION: Say…Now 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! 

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CN II & III: Do it only if you there is something in history or chief complaint; do it before checking the oral cavity and don’t forget to turn the light off! Say…Now 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: Say…Can you please follow my finger without moving your head. [Form the “H” with your finger and then move your finger close to SP’s nose to check for accommodation!]. Then comment…your 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? ii. Can you please blow your cheeks out for me? iii. Can you please close your eyes and don’t let me open them. [Place your thumbs on SP’s 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: Say…Now I will touch your face like this [touch the SP’s 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 at forehead, cheeks and jaw simultaneously with your index fingers!]  Keep on asking…Can you feel this…every time you touch the face of SP.  Then ask when you’re done and the SP has opened his/her eyes…Were they equal on both sides? 

CN XI: Say…Can you please shrug your shoulders for me? [Place both hands on SP’s shoulders!]

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CN VIII: Only check this nerve if you get a case of hearing loss or SP gives you something in the history. WEBER’S TEST: Say…Now 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. RINNE’S TEST: Place the base of tuning fork behind the ear on the mastoid prominence and say…I 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: Say…Now I would like to touch you like this [touch SP’s 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 asking…Can you feel this…every time you touch the SP.  Then ask when you’re done and the SP has opened his/her eyes…Were they equal on both sides?

(c) MOTOR SYSTEM: Say…Now I am going to check the power of your muscles.  

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Hold my fingers and don’t 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] Say…Can you move your arms in for me? Can you move your arms out for me? [Place your hands on outer arms!] [Now place your hands on the inner surface of arms] Say…Now can you move your arms in for me? Can you move your feet up for me? [Place your hands on top of SP’s feet!] [Place your hand on soles now!] Say…Now 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!] Say…Now can you move your legs in?

 Case of “BACK PAIN”: Say...Now I would like to evaluate for your pain in the back…do let me know if it hurts; I will stop right away. i. INSPECTION: Say…Now I have to look at your back for any abnormality [Now open the lower knot and look at the back] Say…everything seems fine [Unless they have put some paint there! Do watch out for such kind of things!] ii. Say…Can you exactly show me where the pain is? [SP will point out!] iii. PALPATION: Say…Now 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 Say…Let 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 in your backbone by lifting your leg. Keep your right leg straight while I 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 SP’s heels and keeping the leg straight, lift the SP’s 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. Say…Thank you for your patience, now let me help you sit up!  Close the foot rest.  Help the SP sit up. (d) GAIT: Say…Now I would like to check your gait. 

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

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Say…Can you please walk a few steps for me, turn around and get back. Don’t worry; I won’t 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 summarized…not how elaborately you summarized. …Based on your history and physical findings, I am considering a number of possibilities here like…your D/D here…but 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, we’ll 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 you…Have a good day…Bye 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]

CHIEF COMPLAINT RELATED QUESTIONS 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 Difficulty in adjusting to 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), say…Mr./Miss XYZ, it seems that you’re a bit distressed; is there anything that I can do to make you feel more comfortable. [If it’s your uncooperative patient, you can also add…Let 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 say…Mr./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 It’s your turn and I am ready to help you out!  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 isn’t holding one.  If a napkin does get involved, don’t forget to take it in the end tell the SP that you need it to get phlegm examined.  HEADACHE CASE:  Always switch off the light after taking SP’s permission.  Never forget to ask about the location of pain in case of headache.  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. 

GOOD LUCK FOR YOUR EXAM & REMEMBER US IN YOUR PRAYERS!