7/9/2017 CLINICAL SKILLS CS PROTOCOL

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CLINICAL SKILLS CS PROTOCOL

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USMLE STEP 2 CS PROTOCOL

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How to pass the USMLE Step 2 CS without attempts?

This page will help you ace the exam first time. You will need two things to the exam:
Primary Study source which is usually the First Aid CS and the CS protocol printed
down here. Follow the CS protocol on each case present in the FA. The key to
success is: practice and practice.
CS Blog List

CS PROTOCOL FREE USMLE STEP 2 CS VIDEOS

HOW TO COUNSEL

USMLE STEP 2 CS EXAM

You are standing at the door, befor entering the room:

-Read the case scenario posted on the door. IMG Home Page
-Write down the patient's last name, the chief complain, abnormal Vitals, 2DD and
SIQORSPDF AAA PAM HUGS FOS SODA
Interview and Match Section

1) Knock 3 times wait 3 seconds and open (sometimes you will not hear the patient NRMP SOAP
giving a response, it is ok).
2) Mrs. Anderson? ( Call pt by last name as you open the door and enter) RESIDENCY INTERVIEW TIPS
3) Introduce yourself: Good morning./afternoon Mrs. Anderson. My name is Doctor
Thank You Letters
Roman (last). Nice to meet you (with a smile and firm handshake). I am your
attending physician today and I am here to take care of you .(eye contact)
4) (Look around the room) Is everything in the room as comfortable as possible for IMG Blog List
you? yes. Mrs. Anderson I am going to ask you few questions and then do a brief
physical examination. Is that Okay for you? Yes. HOW TO SURVIVE RESIDENCY
5) Ok let me first cover your legs by the drape so you will feel more comfortable?
(apply the drape over the legs) Is that ok? Yes thank you.
6) May I sit down? Do you mind if I take notes while we talk? Application Section

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7) How can I help you today? /what made you come in to the hospital today (Open ECFMG Certificate
ended questions at least 4-5)
SP: I have been experiencing chest pain doc ERAS Token
Doc: Oh I am really sorry to hear that. I can understand what you are going through.
MSPE Dean's Letter for IMG
Ill do my best to make you feel better. (Show empathy and reassure in the
beginning, middle and at the end) (in some case like depression use this phrase: Mr. PERSONAL STATEMENT TIPS
xyz, would you be willing to share with me what happened at that time?)
PTAL - California Letter
8) Doc: Can you tell me more about your complaint, Mrs. XYZ?? (open ended
question) Samples Letter of Recommendation
9) SP: Well its a crushing type of pain and has been going for 3 months LOR
Doc: (each time you got to paraphrase throughout the encounter as follows)
Crushing type of chest pain for 3 months (while you paraphrase you need not look
at the sp. you can write down notes when you do that) or repeat the last phrase he USMLE NOTES
said
Do you have any other symptoms? FREE USMLE STEP 2 CS VIDEOS

USMLE RECOMMENDED BOOKS AND

NBs: Don't look at your watch, safely look at the watch on the wall behind the patient. MATERIALS
Dont look shocked, surprised or raise eyebrows.
Dont interrupt the patient. USMLE SCORE CORRELATION
If the patient tears up, keep silence for few seconds, offer him
USMLE STEP 2 CK
a napkin/tissue (available near the place where you will
wash your hands later), then say this must have been USMLE STEP 2 CS EXAM
difficult time for you let me take care of you.
USMLE STEP 3

Mnemonic: SIQORSPDF AAA PAM HUGS FOS SODA

USCE & Research
10) Onset/ Setting Duration Intermittent or constant /Frequency/ /Progression (5
components) Malpractice Insurance for IMGs for
When did it start? 3 months ago (this must have been a difficult USCE
time for you)
Is the pain present all the time? How long does it last? 20 minutes Research Opportunities for IMGs
How often does it come? About 3 times a week USCE OBSERVERSHIPS for IMGs
What were you doing when it started? Are you aware of anything that might have
brought this on?
Does it become worse? yes (Club all 5 points together and paraphrase as follows: so IMG Friendly Residency Lists
it comes and goes about 3 times a week , last for 20 minutes each time and its
getting worse ) yes doc anesthesiologyimg.blogspot.com/
11) Quality: Can you describe your pain? (I dont know) is it sharp? Burning?
Combined MED-PEDS IMG FRIENDLY
Pressure like? Is it dull? (One question at a time) its pressure like (paraphrase for
RESIDENCY PROGRMAS
each response through out the encounter as I have explained above
12) Radiation: Does the pain move anywhere? Yes it moves to my left arm (To your EMERGENCY MEDICINE IMG
left arm) yes thats right doc FRIENDLY RESIDENCY PROGRMAS
13) Site: Can you show me exactly where do you feel the pain?
FAMILY MEDICINE IMG FRIENDLY
14) Intensity: How would you grade your pain on a scale from 1-10, 10 being the
RESIDENCY PROGRAMS
worst? 7/10 (show empathy. It must be pretty bad)
15) Aggravating factors: What makes your symptoms worse? Walking the dog INTERNAL MEDICINE IMG FRIENDLY
16) Alleviating factors: What makes your symptoms better? Resting. (Paraphrase RESIDENCY PROGRAMS
now: so walking the dog and climbing stairs makes it worse and resting makes it
NEUROLOGY IMG FRIENDLY
better yes thats right doc
RESIDENCY PROGRAMS LISTS
17) Associated symptoms: Open ended question: Do you have any other
symptoms other than chest pain? No doc. OB/GYN IMG FRIENDLY RESIDENCY
Now ask specifically- Do you have any SOB? How about cough, how about fever? PROGRAMS LISTS
Any stomach pain? Any N and V? Change in bowel, any leg swelling ect
PATHOLOGY IMG FRIENDLY
18) How this pain has affected your day to day life? Well I really cannot do my daily
RESIDENCY PROGRAMS LISTS
routine activities like walking to the mall walking the dog and I am really frustrated. (I
understand. It must have been hard for you ) PEDIATRICS IMG FRIENDLY
19) I finished asking about your recent complain, Do you have anything else to add? RESIDENCY PROGRAMS LISTS
20) Transition : Now I need to ask questions about your health in general
PSYCHIATRY IMG FRIENDLY
21) Past medical history: (PMH)
RESIDENCY PROGRAMS LISTS
Have you had similar symptoms before? Not before 3 months
Do you have any medical problems? (Yes I have had STDs), how about high blood RADIOLOGY IMG FRIENDLY
pressure, how about asthma? How about high cholesterol? (each separately!!) and RESIDENCY PROGRAMS LISTS
ask for duration and paraphrase as follows :HTN for 3 year, Stds 3 months ago yes
SURGERY IMG FRIENDLY RESIDENCY
doc
PROGRAMS LIST
22) Allergies: Do you have allergies of any kind? No
23) Medicines: Do you take any any medications? Are you taking any over the
counter medications? Can you show me the prescription? Paraphrase
24) Hospitalization(PSH):
Have you been hospitalized before? Have you had any surgeries before? Have you
had any accidents or injuries in the past? Paraphrase
25) Urinary habits: Do you have any problem with urination? Do you have any
problems controlling your bladder? Paraphrase
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26) GIT habits: Do you have any problems with your bowels? (Follow up question
and paraphrase)
27) Sleep /Appetite/Weight loss: Have there been any changes in your sleeping
pattern (If yes) How many hours do you sleep.( Empathize: it must be pretty hard for
you to sleep when you are in pain )
How is your appetite? I have lost appetite
Have you noticed any changes in your weight (open ended Q) yes I am losing weight
doc. Can you please tell me about your diet?
How much have you lost? About 15 pounds. Over what period of time? In 6 months.
(paraphrase: So you have lost 15pounds in 6 months. Yes thats right.
Transition: Ok Mr. Brown, now I would like to ask few questions regarding
your family's health. Is that ok with you?

28) Family history: What are the medical illnesses present in your family?
Does anyone in your family have similar problems?"
Do you have anybody at home to take care of you and to provide support? no
So you must be feeling very lonely at home? Yes doc
29) Transition: Mrs. smith now I would like to ask u about your menses
30) Obstetric and GYN history:
At what age was your first period? When was your LMP? Are your periods regular?
How often do you get your menstrual period? How long does it last? Do you have
cramps? Do you have any bleeding between cycles?
Have you ever been pregnant? How many times? Have you had a Pap smear
before?
31) Transition: alright I need to ask you some personal questions, the answers will
be kept confidential
32) Sexual history: Are you currently sexually active?
Who is your sexual partner? are they men, women or both?
Do you use condoms consistently?
Have you ever had any sexually transmitted ds?(this will be revealed in PMH so dont
ask again), Have you ever been tested for HIV?
33) Counsel briefly for high risk sexual behavior and prevention of STD
Mrs Anderson since you said you dont always use condoms I am very much
concerned that you might be putting yourself at risk of STDs.
So I would advise you to use condoms consistently to prevent STDs and unwanted
pregnancy. Period. dont explain too much. You can postpone counsel part to the end
of the exam.
34) Transition : Now let me ask some questions about your social life and personal
habits
35) Smoking :
Do you smoke?
How many packs a day?
How long have you been smoking? Paraphrase
36) Occupation:
Do you work? What type of work do you do? How are things at work/home,
Mrs. XYZ?
37) Drugs:
Do you take any recreational drugs?
Which one? How often?
38) Alcohol :
Do you drink alcohol? What do you drink?
How much do you drink per week/day? Paraphrase
Ask CAGE questions is you suspected a problem with alcohol:
1. Have you ever felt the need to cut down on your drinking?
2. Have you ever felt annoyed when someone mentions your drinking or
Suggests that you cut down?
3. Have you ever felt guilty about your drinking or something that you did while
under the influence?
4. Have you ever had a drink first thing in the morning to keep your eyes open?

39) Transition: IS THERE ANYTHING ELSE THAT I NEED TO KNOW ABOUT?

40) Mrs Anderson thank you very much for answering my questions, now I need to
examine you so I will just wash my hands, is it ok, ok excuse me.
DON'T TURN YOUR BACK TO THE PATIENT DURING WASHING YOUR HANDS.
Give him your side and ask him a question as: Is every thing ok in the room?
41) May I proceed now with physical examination?
Points to remember during physical
a) Be polite explain what you are going to do and say thank you each time you elicit a
sign ( for eg: I need to check your neck so if you could swallow for me please? Thank
you.
b) Now I need to look in your throat to see if there is any redness or swelling
c) Stick out your tongue please.
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d) PICKLE: Pallor, Icterus, Cyanosis, Koilonychia, Lymphadenopathy and Edema
e) Now I am going to listen to your chest. May I untie your gown?
f) When you make the patient lie down ask him Are you comfortable?
g) always support the SP's shoulder when made him lay down for the abdomen
exam.
h) When you do that please pull the extension out
i) Dont touch the patient b4 giving instruction
j) When you elicit pain. Say I am sorry
k) Always maintain eye contact when you elicit pain and when you explain what you
are going to do
l) Now I am going to check your memory Tell me your name. Where are we right
now? What is todays date?
m) Now I am going to check your nerves. Just follow my finger and keep your head
still Move finger to make H checked 3, 4 & 6
n) Can you clinch your teeth like this? (Show how to clinch teeth) checked 5th
motor
o) Can you raise your eyebrow? Can you show your teeth? Checked 7th
p) Can you open your mouth, stick out your tongue and say Ah? checked 9, 10, 12
q) Now I am going to check power of your muscles
r) Squeeze my fingers, pull me in checked motor in upper extremity
s) Kick out (put your hand at ankle of patient and asked to kick out) checked
motor for lower extremity
t) Now I am going to check sensation of your body Take cotton and tooth prick in
your hand and show patient which is dull and which is sharp then
ask patient to close their eyes and check on face (5th sensory), check on tip of
finger on hand (if peripheral is ok then proximal is ok too so only check at finger tips.
If no sensation at finger tips then move upwards.) And same way check on toes.
u) Now I am going to check reflexes of your body Check Brachial and Patellar
v) Now I would like you to walk here. I wont let you fall [Be prepare. Patient should
not be fall]
w) Thyroid: Do you have problems adjusting to temperatures?"Has your voice
changed recently?" Are you losing any hair?

Mini-Mental State Exam MMSE

Before you begin the MMSE, use a statement like this, Mr. Watson, I will now ask you
simple questions to test your memory and thinking, shall we begin ?
1. In which state we are?
2. Who is the president of the United States?
3. Can you tell me what day it is today?
4. What was the name of the high school you attended?
Mention three objects slowly and clearly - ask the patient to repeat once you are
done. (e.g. Pen, Watch, Ball)
1. Ask patient to say "NURSE" backwards
2. Ask patient to count back from 7
Ask the patient to repeat again those 3 words u told him before (Do not forget these
yourself in the heat of the exam, practice with three standard words ready)

42) After you are done with examination Summarize using 4 important points as
follows: All right, Mr. xyz, thank you so much for your kind cooperation. Now, I'd like
to sit down and talk over what I think so far. First, let me summarize." (transition).
You told me that __ and __. Also, you said that __ and __, Is that right? According to
the information I got from you and the examination, I am considering a couple of
possibilities. It may be __ (your probable diagnosis) or possibly __(differential
diagnosis). It looks like you might have a problem involving the blood vessels in your
heart and there might be inadequate oxygen supply to your heart. But there could be
other conditions causing your pain. So In order to pinpoint the exact cause I need to
run some blood test and Order an X ray of your chest and measure the electrical
activity of your heart. Once we get the test results we can talk about what is going on
with you and about the best possible way to manage your problem. Does this sound
OK?

Posted by Medical Blogger at 10:24 AM

Labels: USMLE STEP 2 CS PROTOCOL IMG FRIENDLY RESIDENCY PROGRAMS LISTS

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