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.
The USMLE Step 2 CS Exam Protocol is by far the most complete educational material that will guide you on how to pass the CS exam from the first time. Whether you are appearing for the exam in Atlanta-Georgia, Chicago-Illinois, Houston-Texas, Los Angeles-California or Philadelphia-Pennsylvania it will be the same level of exam and passing rates. Don't be misguided by what people post in forums about difficulty of the exam in some centers and how they are not friendly with IMGs, all centers are same, they are made for one purpose, help you to reach residency in a very professional unbiased fashion.
Managing your time:
It is very important to plan for this test before ahead and practice the protocol in a timely manner each time you finish reviewing a case from the book. This way you will be ready at any point to take the test even if you were not finished studying with all the cases in the FA.
The time-line to work along is:
Doorway= 1 minute
History= 7-8 minutes
Physical= 3-5 minutes
Closure= 2-3 minutes
Pt. Note= 10 minutes
CS PROTOCOL
You are standing at the door, befor entering the room:
-Read the case scenario posted on the door.
-Write down the patient's last name, the chief complain, abnormal Vitals, 2DD andSIQORSPDF AAA PAM HUGS FOS SODA
1) Knock 3 times wait 3 seconds and open (sometimes you will not hear the patient giving a response, it is ok).
2) Mrs. Anderson? ( Call pt by last name as you open the door and enter)
3) Introduce yourself: Good morning./afternoon Mrs. Anderson. My name is Doctor 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 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.
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?”
7) How can I help you today? /what made you come in to the hospital today (Open ended questions at least 4-5)
SP: I have been experiencing chest pain doc
Doc: Oh I am really sorry to hear that. I can understand what you are going through. I’ll 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. xyz, would you be willing to share with me what happened at that time?)
8) Doc: “Can you tell me more about your complaint, Mrs. XYZ?”? (open ended question)
9) SP: Well it’s a crushing type of pain and has been going for 3 months
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 said
Do you have any other symptoms?
NBs: Don't look at your watch, safely look at the watch on the wall behind the patient.
Don’t look shocked, surprised or raise eyebrows.
Don’t interrupt the patient.
If the patient tears up, keep silence for few seconds, offer him
a napkin/tissue (available near the place where you will
wash your hands later), then say ” this must have been
difficult time for you” let me take care of you”.
Mnemonic: SIQORSPDF AAA PAM HUGS FOS SODA
10) Onset/ Setting Duration Intermittent or constant /Frequency/ /Progression (5 components)
When did it start? 3 months ago (this must have been a difficult
time for you)
Is the pain present all the time? How long does it last? 20 minutes
How often does it come? About 3 times a week
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 it comes and goes about 3 times a week , last for 20 minutes each time and its getting worse ) yes doc
11) Quality: Can you describe your pain? (I don’t know) is it sharp? Burning? Pressure like? Is it dull? (One question at a time) its pressure like (paraphrase for 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 left arm”) yes that’s right doc
13) Site: Can you show me exactly where do you feel the pain?
14) Intensity: How would you grade your pain on a scale from 1-10, 10 being the worst? 7/10 (show empathy. “It must be pretty bad”)
15) Aggravating factors: What makes your symptoms worse? Walking the dog
16) Alleviating factors: What makes your symptoms better? Resting. (Paraphrase now: “so walking the dog and climbing stairs makes it worse and resting makes it better” yes that’s right doc
17) Associated symptoms: Open ended question: Do you have any other symptoms other than chest pain? No doc.
Now ask specifically- Do you have any SOB? How about cough, how about fever? Any stomach pain? Any N and V? Change in bowel, any leg swelling ect…
18) How this pain has affected your day to day life? Well I really cannot do my daily routine activities like walking to the mall walking the dog and I am really frustrated. (I understand. It must have been hard for you )
19) “I finished asking about your recent complain, Do you have anything else to add?”
20) Transition : Now I need to ask questions about your health in general
21) Past medical history: (PMH)
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 pressure, how about asthma? How about high cholesterol? (each separately!!) and ask for duration and paraphrase as follows :”HTN for 3 year, Stds 3 months ago” yes doc
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
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 that’s 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 don’t 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 don’t 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. don’t 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.
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) Don’t 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 today’s 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 won’t 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?
