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mrknowitall

2+ Year Member
Aug 27, 2015
24
67
Status
Medical Student
I know I cannot talk about specific cases so I will try to write this guide without giving away the specific details of my exam.

Hey everyone, when I was studying for step 2 cs I found out that it was very hard to find concise information that would help me study quick. I studied for this exam for a total of 3 to 4 days within 1 week and practiced about 4 cases on a friend. I will be writing my exact study material I used and some helpful hints, as well as the mistakes I made and what I could have done better so hopefully it helps you all. I studied only through FA for step 2 cs, but the mnemonics I looked up online and narrowed them down to my list (there are just too many out there to know)

I may be missing some mnemonics so add to the list as you wish, but I feel that these cover everything important (other than anxiety)

I memorized all of these mnemonics on the 3 hour plane ride to LA and it took me like 30 minutes to get through them (obviously I wrote them and went through them couple times before so it wasn't brand new information)

I took my exam in LA, I made a bunch of mistakes and these are the biggest mistakes I made that I remember:
1) forgot to mention patients name on the FIRST patient because I was too worried about asking all the other questions
2) did 2 physical exams without wearing gloves/washing hands (BIG MISTAKE)
3) did not summarize 2 patients in their own words
4) this was not a big mistake, or a mistake as far as I know, but I completely misdiagnosed a patient, (the patient knew it was wrong diagnosis), but i was being very friendly towards the patient so he kept on insisting that whatever diagnosis I have is not right. I kept on insisting it is right and the results will tell us (patient got so annoyed by my insistence and let it go). After I went outside and looked over the vital signs again I found out I was wrong about my DDx and it was a completely different thing, so I put it in my patient notes as my number 1 diagnosis.

These are the things I thought I did well:
1) counselled every patient on one thing or another (alcohol, smoking, depression, anxiety)
2) was extremely friendly towards patients and kept asking them about their mood/energy/daily activities
3) turned off lights to a patient who seemed to have photophobia, and immediately they opened their eyes. I did this right when i entered the room and didn't even ask the patients name but because I saw that they were uncomfortable, i switched the lights off.
4) I was extremely tired by the time i got to my last patient and that patient was the hardest, plus I did not prepare for that condition specifically. I started counselling the patient and kept encouraging them to be strong, and the patient helped me out by giving me some answers to the questions I should have asked but didn't think about them. I felt like the patient like my friendly nature and that I was running out of questions to ask 5 mins into the encounter and they helped me out. So again, be nice to patients, they are not allowed to give you answers unless you ask direct question about it, but they help you if you're nice to them and hint at what you should be asking about.
5) I followed my script word by word (Script is posted below)
 

mrknowitall

2+ Year Member
Aug 27, 2015
24
67
Status
Medical Student
Menumonics:

Pain:

LIQORAAAP

Location

Intensity

Quality

Onset

Radiating

Aggravating factors

Alleviating factors

Associated Symptoms

Precipatating event

– Previous episodes

– Progression


No pain:

DOC PA FAA

Duration

Onset

Constant/Intermittent

Precipatating event

– Previous episodes

– Progression

Associated Symptoms

Frequency

Aggravating factors

Alleviating factors


Peds:

BINDERS

Birth history

Immunization/Illness

Neonatal Hx

Development/Day care

Eating/Excercise/Weight

Rash

Sleep


FEVERS CUD (for peds fever)

Fever

Ear pulling

Vomiting

Ear discharge

Eye discharge

Rash

Sore throat

Cough

Urination

Diarrhea

Neonate

DCT SFDC

Delivery

Complications

Term

Substance use during pregnancy

First bowel movement

Diapers/day

Color of urine/stool


OB/GYN

LMP RTV CS PAP

Last menstrual period

Menarche

Period (after how many days)

Regularity

Tampons/Pads per day

Vaginal discharge, itching, dryness

Cramps/Contraception

Spotting (intermenstrual, post coital)

Pregnancy (Hx and complications)

Abortion/miscarriage

PAP smear


HAVOC

Hot flashes

Atrophy of vagina

Vaginal dryness

Osteoporosis

Coronary artery disease


ACCOD (discharge)

Amount

Consistent

Color

Odor

Duration


DEMENTIA

ADL (activities of daily living)

DEATH

Dressing

Eating

Ambulation (way around the house)

Toilet

Housing




IADL (instrumental activities of daily living)

SHAFT

Shopping

House keeping

Accounting

Food

Transport


ABUSE (domestic/elderly)

SAFEGARDS

Safe at home?

Alcohol

Friends/family know about it?

Emergency plan

Guns

Any escape plan

Relationship with abuser

Depression/drugs

Suicidal ideation


SYNCOPE – think cardio problem/neuro problem/seizures

PDS DBLP

Palpitations (think HYPERTHYROIDISM, SAME WITH ANXIETY IMPORTANT, whenever you see

Palpitation!!)

Dizziness

Shaking

Duration

Bit tongue

Loss of urine

Post Symptoms (weakness/numbness/speech/confusion)


SMOKING

5 A’s

Ask about tobacco use

Advice quitting

Assess will to quit

Assist to quit

Arrange follow up


Goes something like this:

1. “Do you smoke”

2. “I would like to advice you to quit smoking because it causes lung cancer and heart disease”

3. “Have you ever thought of quitting”

4. “We have medications that can help you quit, and I will be here every step of the way”

5. “Lets make an appointment for 2 weeks from now and we will start then”

6. Move on to the next part of the encounter




ALCOHOL

CAGE

Cut down (felt the need to)

Annoyed by criticism

Guilty

Eye opener


DEPRESSION

SIG E CAPS

Sleeping changes

Interest (lost in regular activities)

Guilty

Energy (low)

Concentrations problems

Appetite (increased or decreased)

Psychomotor (agitated)

Suicide (homicide)


FOR ALL PATIENTS

PAM HITS FOSS

Past medical history

Allergies

Medications

Hospitalizations

Ill contacts

Trauma

Surgical hx

Family hx

Ob/gyn

Sexual hx

Social hx


SOCIAL HX

TIA SHOE

Tobacco

Illicit drugs

Alcohol

Sexual hx (repeat if needed)

House (who do you live with?)

Occupation

Eating(Diet)/Exercise









ROS (everyone has their own, I use the head to toe method + extras) (tip: start with extras and don’t stop just because patient is saying no to all and getting annoyed. YOU MUST ASK ALL, my patients got annoyed but later I found out that they are having sleep problems and I didn’t ask when I should have during ROS)


EXTRAS:

CONSTITUTIONAL: Fever/Chills/Night sweats

SLEEP

WEIGHT

DIZZINESS

CONCENTRATION

ENERGY


HEENT : headaches, Ear pain/discharge/hearing loss, Eye pain/discharge, runny nose, sore throat

CVS : chest pain, shortness of breath, edema, palpitations

RS : wheezing, coughing, shortness of breath

GI : nausea, vomiting, diarrhea, constipation

GU : urination (frequency, weak stream), discharge, pain

MOVEMENT : joint pain, muscle pain

DERM : skin rash, itching

ENDO : excessive thirst

CNS : pain, numbness, tingling















How to write patient note: (Physical exam findings part)

What I did was practice writing ALL normal findings as fast as I can. After that I would JUST change the specific system that had abnormal findings. I have my normal finding template below. Try typing it within 2 minutes, type it again and again until you are super fast at it. Then let’s say you have a patient who has abdominal tenderness, so instead of writing “nontender” in abdomen, write “tender” and you will never run out of 10 mins of patient notes time.


Add whatever else you need to to this normal template if you think it is incomplete, but use my method of typing your normal template as fast as possible, then just change the abnormal findings. I always finished my patient notes in 5 to 6 minutes then just reviewed. Gives you more time to think of your DDX and tests.


NORMAL PHSYICAL EXAM FINDINGS TEMPLATE


VS: WNL

HEENT: PERRLA, EOMI without diploplia or lid lag

Neck: no JVD, no bruits, no thyromegaly, no cervical LAD

Chest: no tenderness, clear symmetric breath sounds bilaterally.

Heart: RRR, normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nondistended, nontender, + BS, no heptosplenomegaly

Extremeties: No edema, peripheral pulses 2+ and symmetric

Neuro: Mental status: allert and oriented x3, good concentration. Cranial nervs: 2-12 grossly intact. Motor: strength 5/5 throughout. DTRs: 2+ intact, symmetric




Script for talking to patient (I scored very high in communications and interpersonal skills)

COUNSEL COUNSEL COUNSEL (alcohol/smoking/anxiety/depression counsel on everything)

1. Knock

2. Shake hands and say “Hello Mr. Smith, my name is Dr. So, How can I help you today?”

a. After chief complaint say “I am so sorry to hear that” (1 point for PEARLS)

b. “Can I make you more comfortable” ---> DRAPE PATIENT NOW

c. “Do you mind if I sit down and take some notes” ---> SIT NOW

3. “Ok Mr. Smith, I am going to ask you some questions and we will try to find the cause of your concern together” (1 point for PEARLS)

NO NOTES, NO INTERRUPTIONS UNTIL THIS POINT, YOU MUST LISTEN TO PATIENT AND KEEP EYE CONTACT UNTIL STEP 3

4. “Tell me more about your Chief complaint” YOU CAN TAKE NOTES NOW

5. HPI/ROS/PAMHITSFOSS – ANY OTHER MNEUMONICS HERE

6. “I am sorry this happened to you, let me summarize your concerns as I understand them”

SUMMARIZE IN PATIENTS WORDS (IMPORTANT!!)

7. Summarize in patient’s words only info relevant to C.C

8. “Do you have any other concerns?” ---> ASK WHILE WASHING HANDS (I put on gloves much faster)

THIS IS WHERE THEY ASK CHALLENGE QUESTION, know them from FA

9. “Ok Mr. Smith, Can I perform a physical exam on you?”

10. “I am going to untie your gown and exam your lungs”

EXPLAIN EACH EXAMINATION AS YOU DO IT

11. Palpate, percuss, auscultate lungs (Check costovertibral-angle tenderness (CVA) at this time if relevant). “thank you for letting me examine your lungs.”

12. “Now I am going to examine your heart”

13. Auscultate heart. “Thank you”

14. “Please lay down so I can examine … (whatever else needs examining)”

15. Other exams. “Thank you” (THANK YOU AFTER EVERY EXAM)

16. “Let me help you sit back up and tie the gown”

17. “Thank you Mr. Smith for letting me examine you, Let me give you my impression”

18. IMPRESSION: 3 DDX for C.C and work up for each (THIS IS A MUST)

19. “Do you have any other questions or concerns for me?”

20. “I will see you after I get the test results”

21. “Thank you Mr. Smith, goodbye” ---> SHAKE HANDS AND LEAVE


Quick PE tips for all cases


1. Look up for me

2. Look down for me

3. Open your mouth and say “ah” please

4. Can you swallow for me

5. Neck exam for nodes

6. Examine hands

7. Skin

8. Examine legs

9. Listen to lungs, palpate

10. Listen heart

Next any specific system exam specific to their C.C (Abdominal, extremities, neuro)


My sheet looked like this before going in (just the bold parts)


(Name) ---> DO NOT FORGET THIS I FORGOT ON MY FIRST PATIENT!!


CC

HPI DDx: write one or two
(write whichever menumonic you think applies here) before going in








ROS
PE findings
(mostly empty – no time)​



TESTS
P

A


M


H

I

T

S


F

O

S

S

T

I

A

S

H

O

E
 
Last edited:
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mrknowitall

2+ Year Member
Aug 27, 2015
24
67
Status
Medical Student
This is for step 2 cs, i didn't use the ck book although I had already passed ck
 
Aug 12, 2017
49
10
This might seem like an irrelevant question but what is your typing speed? Do you type without looking at the keyboard? I'm struggling with finishing patient note in under 10 minutes because of my slow typing speed.. It would be awesome if I could also finish notes in 5-6 minutes!
 
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