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  • The Most Vital Minute in the 15 min encounter
  • What is the most important minute of your 15 minutes patient encounter?

    Any guesses? In my opinion the most important minute is the time spent outside the door! Why? Here are the reasons………

    You are first exposed to a clue as to what case is on the other side of the door eg. abdominal pain. Remember you just know that the diagnosis has something to do with abdomen but you are still far from the list of DD's you have to come up with. Say you walk in and the patient points to the epigastric region,…..then your mind should go racing after Acute peptic ulcer disease, GERD, Duodenal ulcer, Acute pancreatitis, etc etc……..while if she sits with her hand on the Rt. Iliac fossa frowning, you probably would switch gears to think of Acute appendicitis, PID, torsion ovarian cyst, Endometriosis, Ileitis etc. Keep your options open ……..dont jump into conclusions until you get a thorough history!

    It is the time to organize your encounter - If you dont take the time now, you will not be able to coherently handle "the show" inside the room. Go over mentally or write down in your blue sheet, what are the possibilities you are thinking of, what systems you will be examining, how will you start the History of present illness, what DD's are you ruling out and recollect the name of the patient ……….before you put on that beautiful smile of yours and go on in…….KNOCK KNOCK…… is show time!

    Make a mental note of what systems you are going to examine for eg. if it is LOC (loss of consciousness) you know you must examine CNS and CVS. If you barge in through the door without spending those vital seconds letting your brain pause, think and proceed – you are likely to end up just doing CNS. What are the likely chances that you would be thinking of examing CVS also when your brain is rushing through the History of Present illness, or trying to get the difficult patient to talk or console a crying patient…or get that long CNS history and exam done………let alone thinking about the clock ticking !

    Make a list of DD's – Hey! it is just common sense to do that before you enter …… can always add more as you get more information from the patient. But without even having a couple of DD's in mind, how are you going to rule out or rule in the diagnosis for this patient while you take history of present illness.

    Dont forget your mnemonics - "How can I help you ? " ………Doc I have severe abdominal pain"…..uh…..uh…..hmmm………ahhhaaaaa…….Oh yes ………….When did it start ? …………Cut all the fumbling and mumbling ……..make the flow smooth by writing down your OPDFSC and PAMHUGS FOSS, WADES , FTLW, LIQORAAA…….The first few sentences can set the stage for the entire encounter. For the SP, it is a time (during the intial 10 sentences or so) to decide "Am I going to have a hard time understanding this doctor?" ……… SO, bottom line ………..Make a good impression in the initial greeting and if you have your mnemonics written…… are well on your way for a smooth encounter!
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  • Should I Sit or Stand during the encounter?
  • This is a common question I get asked by my students. Well, its really up to you……..if it is an emergency you want to be standing while taking history but otherwise, in my opinion, I think sitting during the encounter is a better option… Here are the reasons…… Please see if it makes sense to you personally …...

    1. It is a long exam….the fatigue factor and the tension/stress of the exam will take its toll on you (at least during the last stretch of the exam). When you sit down you are a little more relaxed (creates a rapport as patient feels more at ease that you are not rushing through), easy on your feet (not giving orthostatic hypotension a chance!) and also, you can sit more professionally : sitting tall, shoulders held back, maybe criss-cross your leg if you are comfortable that way.

    2. Sitting helps you to hold your clip pad better as you can rest it on your thighs. For those of you who can't read their own handwriting (most of the time)… to the clip pad and sitting posture can make a world of a difference!

    3. The drape is folded and kept on the seat. Now, you're not going to sit on it before you drape the patient, right?

    • I suggest that you sit about an arms-length away from the patient (of course asking his/her permission before you sit down).
    • Maintain direct eye contact at all times except briefly to scribble on your blue sheet. Remember that the Patient (SP) is more important than your clip board!
    • Last but not the least ………DON'T GET TOO COZY SITTING…….it shouldn't slow down your speed……..All you got is 15 minutes and the CLOCK is ticking whether you are sitting or standing !!!!
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  • Pocket Questions – what are they?
  • I know we are all expected to enter the room, greet the SP and carry out a smooth co- ordinated encounter. Wouldn't we all like to be fluent, coherent, well modulated, asking the next question without missing a beat (though our heart is skipping beats), smiling (though tensed) and pretend we have it all under control ………until it comes to that "POINT" ……….YES ……..POINT BLANK……..where you are just blank…….What do I ask next ? What case is this I am dealing with? Did I already ask this? Gosh …God help me…..……

    Now here's where you use what I call "the pocket" questions.

    • Do you have any fever?
    • Any headache?
    • Any rash?
    • Do you feel cold when others don't?
    • Has there been any changes in your weight recently?
    • How is your apetite?
    • Do you exercise ?
    All these questions can be asked for any case in the exam (any abdominal, chest, cns case). You wont sound inappropriate or obscure! So instead of stammering, stuttering..(uh……..ah……umm…) and getting further worked up……….Just HAVE THEM IN YOUR POCKET. They can come in handy!

    P.S. Hopefully you are again back on track with your line of questioning, ruling in or out the DD's. Cheer up!
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  • Doorway info – should I write it down?
  • Do I have to copy everything? Not all, but some essentials. Let's see what they are ……Say you glanced at the doorway information saying " A 60 year old male Sang Lee comes to ER with loss of consciousness. BP 150/80 mm Hg , PR – 80/min, RR 14/min T 99.8 F ".

    Remember to remember the patients name before your hand goes to knock on the door. So it is a good idea to write the name down to use it then and also during the encounter.

    Age and sex ?– of course …..if you are thinking of premature menopause in a case of amenorrhea half way through history and happen to check her age on your blue sheet and find it to be 66 years, you probably will revise your diagnosis to a "definitely" menopause.

    Also say in the above case of Sang Lee, say the man gives a positive history of attacks of dizziness ….your mind goes " was he hypertensive ….what did I read outside? ..150 over…..over…???…" -so if the vitals are written on the blue sheet, you just have to glance down at your clip board!

    Also, when you come out after the encounter, if u had already written them before you entered the room, you just have to transfer it to the patient notes while typing! Bottom line……..please write down name, age, sex, vitals, chief complaints on your blue sheet before entering. Helps??? ……..I think so….
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  • 10 kick starters CS robot!
  • Oh yes!…….you are a Robot at "certain times" of the patient encounter. Some things are to be done routinely for every case. For example the entry and introductory part (except for changing the last name of the patient), the PAMHUGS FOSS (the questions you ask are the same, the answers may be different from patient to patient). Therefore, from an examinee's perspective you have to be so fluent and proficient in these sections that it should flow as if it were your second nature. No awkwardness or fumbling in these sections of the patient encounter. So, let's find out how to go about the initial introductory sentences/procedures to impress the SP. Shall we?

    There are 10 things to be done in order …..and each of them gets graded!

    10 KICK STARTERS FOR THE CS ROBOT: You may want to remember it 2 at a time.
    BEFORE ANYTHING–TAKE A DEEP BREATH–dont undermine the value of its relaxing power!

    1. KNOCK KNOCK (Recall patient's last name before knocking) —-
    2) Enter SMILING
    3) Mz/Mr……… –
    4) I am Dr………… (first patient name then your name)physician at this hospital. Nice to meet you.
    5). Shake hands and
    6) Eye contact with patient (3,4,5 &6 are done together)
    7) When you hear the Chief complaints (after you have asked How can I help you)
    8) I am so sorry to hear that (empathy!)
    9) DRAPE (as you say "Can I make you more comfortable")
    10) SIT DOWN on the Stool ("Do you mind if I sit down and take some notes")

    All 10 come with practice – in reality in the exam you hardly remember to do these – it becomes natural while your mind is racing on the questions for history of present illness. Without even thinking, after knocking you should realize you are sitting – you know what I mean, right?

    P.S. Remember the patient is forming his first opinion about the new doctor who just entered in the room in these initial few seconds………we want him/her to be impressed, dont we? Practice , practice, practice…… till these 10 kickstarters are your very own !
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  • New Patient Note (2012)
  • In mid 2012, the pattern of the patient note writing for the USMLE Step 2 CS exam changed.
    History History
    Physical Examination Physical Examination
    5 Differential Diagnosis 3 Differential Diagnosis
    ( H&PE findings- 3 each )
    5 Diagnostic Workup 3 Diagnostic Workup
    Though the general theme and subheadings remain the same, the new format is challenging to the examinee because he/she has to pay attention to details in history and P/E. In the old system, you just had to enlist your possible diagnosis for the case with no explanation as to why you picked the DD. For example if it is a case of chest pain, you could just rattle away with Angina, MI, Costochondritis, Rib Fracture, Pleurisy but now you got to lay it down-Why you think it is MI? Why you think it is Rib fracture?

    Chest pain on exertion, associated sweating, location on the precordial region probably radiating to left arm would probably be the basis why you picked Angina/MI. I think the CIS component gets tested here as well because ‘listening effort’ will play a big role in getting to the basis of your diagnosis. If you are focused on just asking questions and not listening and recording the information mentally, you may find it difficult to list the reasons for your DD. The Data Gathering component is also important. What if you don’t ask for chest trauma during the encounter and list Rib Fracture as a DD in your patient notes for Chest Pain?

    Bottomline, it is challenging isn’t it? But that’s what we go to do in everyday practice as well. Right? Hence it is just a better system to evaluate you if you are good at what you call yourself to be – a doctor! That’s what your patient wants from you as a doctor as well – “to LISTEN “. So be a good one!

    P.S. In Target’s 7 Easy Steps 2 CS , STEP 4 has an interactive Differential Diagnosis module which will help you guide along the thinking process of pinning down the Diagnosis for various symtoms. Don’t miss to check it out!
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  • How best can you wash your hands?
  • I'm pretty sure about what you're thinking …….. "What? Who cares how good I wash my hands on the exam. I am already running out of time here…it is an awkward silence when my mind is racing as to what system I am going to examine …..the point is that I wash my hands. Right?" Correct…… I hear you ……..

    What's on my mind was more like " How best can you use your time and impress the patient while you wash your hands (sorry chewed up the "un-underlined" words in the title- is that even a word, I wonder ? Okay back to topic….)

    1. Excuse yourself while you go to wash your hands
    2. Don't turn your back completely to the patient. Stand diagonally, so you can still glance at them (eye contact) while you wash
    3. Keep a conversation going P.S. You don't want someone just watching your back, do you ? at least NOT the SP, huh?

    "So what do you do Mr/Mz George? Is your job stressful (you just asked the stress Q here and saved time too!) How about at home? Do you exercise ? That is a good stress reliever, as you probably know". (You threw in the exercise Q too ..and….. cut short on the history taking time …Bravo…..Go on now…to your PE.

    "Okay, shall I begin my physical examination now?………"
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