USMLE

Step 2 Clinical Skills

Introduction

The Clinical Skills is part of the USMLE Step 2. This exam is standardized in several ways: the time allowed to interview and complete your patient physical exam, the time allowed to write your note, and the patient is also standardized. The exam is composed of 12 Standardized Patient's (SP) encounters. You will have 25 minutes per patient, from which 15 minutes are for Interview and Physical Exam and 10 minutes are for writing your Clinical Notes. The trick for this exam is to learn a routine, and when practicing always use it; then the day of the CS it will come natural. That is the roadmap, your routine for the CS.

Doorway Information

You will start when you hear the instructions: "You may begin." At that moment, your 2 minutes will start to run, and only at this moment you can open the slide door and start writing on your scratch paper. You will open the slide door that is covering the doorway information.

We highly recommend you to write down all the Information to your scratch paper:

  • Patient's full name
  • Age
  • Chief complaint
  • Vital signs

Road Map

We also consider important to write down your road map at this time. Your road map includes:

  • Writing 5 differentials on the upper right corner of your scratch paper next to your doorway info.
  • If at any time you get lost return and ask questions for pertinent negatives and positives regarding your differentials.

Then write down,

  • Location
  • Intensity
  • Quality
  • Onset
  • Radiation
  • Aggravating Factors
  • Alleviating Factors
  • Associated Factors
  • Past Medical History
  • Allergies
  • Medications
  • HITS - Hospitalization, Injuries, Trauma, and Surgery
  • Urinary Problems
  • Gastro Intestinal Problems
  • Sleep
  • Family History
  • Ob/gyn
  • Social History
  • Sexual History
  • (-)(+)

Note: It does not matter if you spend 1 minute making your road map, you won't be lost. You will only write LIQORAAA PAMHUGSFOSS (-)(+), so you have to remember the meaning of these letters.

The Interview

Knock on the door. Introduce yourself to the patient. Say "Hi Mr. (patient’s last name), I am Dr. (your last name). I will be your physician today". You can shake hands with the SP (standardized patient) if you think is pertinent. Some SPs might be acting as if they have a lot of pain, or with body language show they don’t want to shake your hand. Then you can ask, "What brings you here today?" or "What can I do for you today?"

Drape the patient. Do it immediately so you won’t forget to do it and lose an easy point. Always remember to talk to the SP and explain anything that you do.

Start the interview. Remember to use transitional phrases and avoid sounding like you are interrogating them. You have to sound like you are having a friendly chat with the SP. Maintain good eye contact and good patient-doctor relationship.

Start asking questions to cover the points in LIQOR AAA and PAM HUGS FOSS. Also, cover pertinent positives and negatives of your differentials.

Wash your hands after completing the questions. Take a deep breath. Did you forget to ask some questions? Check your differentials. Do you have all pertinent positives and negatives? Use this time to think and check if you have all the information you need. You can continue asking the SP questions during this time.

The Physical Examination

Start the Physical Exam (PE). Always go from the top to the bottom. You won’t have to do a complete PE for each SP. You need to carefully consider what is really necessary.

Remember you only have 15 minutes to Interview and do the PE. You will choose from the following:

  • Head
  • Eyes
  • Ears
  • Nose
  • Throat
  • Heart
  • Lungs
  • Abdomen
  • Extremities
  • Neurological Examination
  • The Closure

Summarize. Try to briefly summarize what you learned from the patient. This will help you to make sure you did understand what troubled the patient today. Then explain what you think, including:

  • Differentials
  • Labs, test and work up
  • Treatment
  • Ask if the patient has understood an dif s/he has any questions

The Clinical Note

Now you will have 10 more minutes to complete your note. You can either write it down or complete it on the computer. You need to decide how you are going to do this while you are studying and practicing. Try both ways and decide which one fits you better.

Your note has to be clear, concise and complete. You need to write neatly. If you have a terrible hand writing you can try the computer version. The space for writing is very similar in both ways.

The clinical note consists of the following:

  • History
  • Describe what the patient told you in an organized, chronological manner including:
    • CC: Chief Complaint
    • HPI: History of Present Illness
    • PMH: Past Medical History (PAM HUGS FOSS)
  • Physical Examination
    • Gen: General AO x3 (Alert and oriented times 3), NAD (not acute distress). Include Vital Signs here (all of them).
    • HEENT: NC/ AT (normocephalic/ atraumatic), PERRLA (pupils equal, round, reactive to light and accommodation), EOMI (extra ocular movements intact), TM (tympanic membrane) clear BL (bilaterally), MMM (moisture mucus membranes), OP (oropharinx) clear, neck supple, no LAD (lymphadenopathy).
    • Heart: RRR (regular rate and rhythm), No MRG (murmurs, rubs or gallops). Nl S1-S2 (normal S1- S2), PMI (point of maximum impulse) non displaced. (-) JVD (negative jugular venous distention), (-) pedal edema.
    • Lungs: CTAB (clear to auscultation bilaterally).
    • Abdomen: + BS (positive bowel sounds), NT/ ND (non tender/ no distended), soft, no pain, no HSM (hepato spleno megalies)
    • Ext: Extremities. No c/c/e (clubbing, cyanosis or edema), pulses equal bilaterally.
    • Neuro: CN II-XII (cranial’s nerves 2-12) Intact, motor strength 5/5 all muscle groups, DTR (deep tendon reflexes) 2 + intact symmetric, sensation intact to sharp and dull, Romberg negative, finger to nose intact, plantar reflexes normal, Kernig negative, Brudzinski negative.

Differential Diagnosis

Just write down your most likely 5 differential diagnosis in this specific patient.

Diagnostic Workup

Write 5 ancillary and laboratory procedures that can help you to get the right diagnosis in this patient. You can order a rectal or pelvic exam here, as you won’t be able to perform it on your SP.

  • Subjective
  • Objective
  • Analysis
  • Plan

Extra Tip

Think for one second. What does the SP want? What does the real patient like about a physician? Look into their eyes. They have the opportunity to evaluate you before you have a license. Maintain eye contact, show respect always, show empathy, be proactive and help your patient in every way possible during your interview. Avoid being judgmental. Provide solutions to your patient, provide counseling. Always ask if they have any questions (they will, and that is an extra point). How would you like to be treated as patient?

Updated October 2010