Preparing for the USMLE Step 2 CS – Part II

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We now come to Part II of our discussion on “Preparing for the USMLE Step 2 CS”.  In Part I, we discussed how to prepare for the medical interview part of the clinical encounter. We will now tackle the physical examination part of the clinical encounter,

To answer the first question on a lot of people’s mind. No, you should not do the physical examination while conducting the medical interview. Not only is it rude, you miss the opportunity of building rapport with your “simulated patient”. A question your “patient” is asked is if they would want you to be their physician and depending on the source could be an additional 1 or 2 points for you.

Next, you need to be able to write down the information in the medical history on paper or risk forgetting it. However, it is unsanitary if you have washed your hand or wear your gloves to examine the patient and hold the paper and pen at the same time. Third, you don’t have time to do a complete physical examination and a good clinical history can point you to what areas to concentrate your examination on. Last, unless you are really good at multitasking, doing both at the same time can distract you and lead you to do things less than perfect. Remember, you are being judged on the process, and not the result. By doing them separately, you are better able to concentrate on doing each of them correctly.

That is not to say that you cannot ask questions you forgot to ask in the medical interview during the physical examination part. If you realized you forgot to ask something, by all means as them as you do the PE. If it’s short and not too many, you could just try to remember it and write it down later. Just don’t make it your standard operating procedure.

There are a couple of issues we have to tackle when you do the PE part. If the patient has a particular complaint focused on a particular system, then you should do a thorough examination on those part. However, you should not forget to the following in all your patient regardless of the chief complaint or other complaints that you were able to gather from the interview.

Always listen to the lungs. You don’t have to do a full PE of the lung unless the patient had any respiratory related complaints. Just listen to the six areas at the back and at least the two area in front below the breast. (The middle lobe of the right lung can only be heard in the front of the chest while the posterior lobe at the back.) Then always listen to the 4 auscultatory areas of the heart corresponding to the 4 valves. You should always make sure you do a complete PE on those parts that corresponds to your patient’s chief complaint and other complaints. For example if your patient complains of abdominal pain, you should auscultate, inspect, percuss and palpate all four quadrants of the abdomen.

What if you have a patient with vague, generalized systemic complaint, like fever, myalgia, etc. Or coming in for pre-employment or annual physical examination? How should you conduct your PE. If the patient has no localized complaint, these are the minimum examination you should do. First examine the conjuctivae, sclera for icterus then pupillary reaction to light. Examine the mouth for erythema, (say aaah) then just rub your fingers near their ear and ask if they can hear the sound. Palpate the lymph nodes on the submandibular, anterior and posterior triangle area including the posterior auricular area. Listen to the lungs and heart as mentioned above. Do percussion and palpation of the abdomen. You may cursorily inspect the extremities. That’s it.

Here are some tips for specific parts of the examination that you should take note of.

Ask the patients to look at a spot far behind your shoulder when you are testing the pupillary light reflex and not to look at the light. Make sure you dim the lights.

Tell the patient to stick out his tongue and say aaah aloud when examining his throat not when examining the oral cavity.

When palpating the lymph nodes, stay on the patients back and use both hands to palpate both sides simultaneously. Start on the submandibular area, palpating down the anterior triangle up to the clavicle, then the posterior triangle until the posterior auricular nodes.

When using the stethoscope, make sure it’s warm. Use your hands. You can place the bell of the stethoscope in your pocket to keep it warm. Your patient will appreciate it. Also, always make sure the bell or diaphragm is touching bare skin and not pieces of clothing because that will cause you extra points.

When examining the abdomen, remember that unlike all the other parts of the body, you should start with inspection, then auscultation, then percussion and lastly palpation. The reason is that any manipulation of the abdomen can alter the bowel sounds, so you should do the auscultation first. Another thing to note while doing the abdominal examination, is to ask tha patient to pull up his knees and rest his feet on the bed. This is to relax the abdominal muscles for palpation. You lost points if you forgot to ask the patient to do this.

Two more points, when eliciting Murphy’s sign, place the tips of your fingers just below the costal margin on the right. Just place them gently. Do not dig them in. When specifally percussing and palpating for the spleen, ask the patient to roll onto his right side and palpate the left side of the abdomen, not just the front left.

Additional general tips.

Try to come up with a sequence that minimizes the effort of the patient like sitting up, lying down and removing their gown. Group examinations together so the patient only sit up, lie down and remove parts of their gowns only once.

Make sure the patient is covered at all times. Practice draping techniques until it becomes second nature to you. You could lose points doing this poorly.

When you palpate the patient, palpate gently even if you need to do deep palpation. In fact just touch them while telling them loudly that you are palpating their liver, etc. They will appreciate it. This simulated patients have to endure from 12 to 24 clumsy examiners everyday. 5 days a week. 😕 You could imagine how you feel if that were you. So be gentle,

Always make sure the light is dimmed when you do any eye examination that requires response to light.

If you see something marked on the skin of the patient do not ignore it. Usually, their make-up department does a good job of simulating bruises, although not always. For example, patient had linea negra on her abdomen, However, I wasn’t sure if there was any attempt to simulate a CS scar. So I asked the patient if she had undergone CS while pointing to her abdomen. She looked at me askance and said it was normal. I shrugged my shoulder and proceeded. 🙂 As I said, they may try to simulate certain signs and symptoms and may not be that accurate. For example, a supposedly inflammed knee looks like a painted knee. 😛

Now this covers our discussion on physical examination. We will discuss next the social aspects of the clinical encounter, then on to the patient notes.

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