Preparing for the USMLE Step 2 CS – Part I

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For the past few months, I’ve written articles that deal with all the different Steps except for Step 2 CS. So this will cover preparations for Step 2 CS.

Like most IMGs, I felt really anxious preparing for the Step 2 Clinical Skills. This was primarily due to the novelty of the examination method. (simulated patients, etc.) Although, we had a type of clinical skill exam in training, we had actual patients which we examined rather than a simulated patient and what was graded was more on did we get the diagnosis and treatment right, rather than how we did the interview or physical examination. In other words, on the results rather than the process.

Meanwhile for AMGs they feel the whole exercise is a waste of time and money, since simulated patients are part of their normal curriculum. Which of course makes this exam to them just another exam they’ve done countless times before.

It is important to realize that in Step 2 CS, unlike all the other steps, the process is more important than the result. How you do the interview, your physical examination and a good differential is more important than nailing the diagnosis. In fact you will encounter cases where there is no clear diagnosis.

In my own exam, of the 12 cases I encountered, 4 had clear-cut diagnosis, another 4 had less clear cut but highly probable diagnosis, while 4 others have no real diagnosis and could be any of the differentials. You could imagine how disconcerting it was to encounter the latter as my first case. I ran into overtime and it was only after the 4th case when I encountered another case with no possible specific diagnosis, did I realize my first case did not have one either.

In forums, you find people asking whether using USMLE World is better of First Aid. For me (I used both) either one will do as well. What is not needed is the really expensive Step 2 CS course of Kaplan. USMLE World has more cases than First Aid but what is more important is to practice the cases in real live format. The process must be second nature to you as in the actual examination, with the pressure to perform well in limited time, you have no leeway to make too many mistakes or to call a time out to rethink your approach.

So how do you practice for the clinical encounter. Well, the clinical encounter can be divided into 2 major parts. The clinical part and the social part. The clinical part can be further divided into 2, which is the medical interview and the physical examination. The social part has to do with bedside manners like greeting the patient, introducing yourself, washing your hands, etc. The social part must be intertwined with the clinical part and done while doing the clinical part. We will first discuss the clinical part, then list down all the things you need to do in the social part and when we should do each of them in the clinical part of the encounter.

The 2 most important thing to remember during the medical interview are LIQORAAA and PAMHUGSFOSS. Although some of you may know about this already from the different forums and prep courses, I would like to emphasize its importance. You not only have to know them, but you must be able to do them in your sleep. When I forgot what to do or somehow went astray during the clinical encounter, LIQORAAA and PAMHUGSFOSS keeps me focus on what I need to ask even if all the patient answers is I don’t know or normal. So what does this two acronym mean.

First, LIQORAAA is done when discussing the History of Present Illness. The chief complaint is already given on the door before you enter the room (although you still have to ask, “How can I help you today?” ” Or “What seems to be the problem”)

L = Location of symptom (e.g. stomach, head,etc.)
I = Intensity of symptom (e.g. mild, moderat, severe, or scale 1-10)
Q = Quality of symptom (if pain, pulsating, throbbin, burning, sharp, etc.)
O = Onset of symptom (when it started, continuous or intermittent, etc.)
R = Radiation of symptom ( to other parts of the body – jaw, leg, etc.)
A = Associated symptoms (shortness of breath, palpitation, fainting spells, etc.)
A = Alleviating factors ( rubbing makes it better, burping relieves pain,  etc.)
A = Aggravating factors (walking makes it worse or starts the pain, etc.)

Use PAMHUGSFOSS to finish the rest of the interview.

P = Past Medical History
A = Allergies
M = Medications
H = Hospitalizations – previous illness, surgeries
U = Urinary complaints (polyuria, dysuria, etc.)
G = Gastrointestinal complaints (change in diet, bowel movements)
S = Sleep habits – any changes, insomnia, early morning awakenings, etc.
F = Family history of any illnes, esp. similar to chief complaint
O = Ob/Gyne history (females only) like LMP, parity, abortions, etc.
S =  Sexual History (preferences, activity, STD, etc.)
S = Social History – occupation, tobacco, alcohol, etc.

It is best to practice this multiple times, coming up with actual questions for each part until asking them becomes second nature to you. For example, for medications you can ask “Are you currently taking any medications or drugs?” For allergies, you can ask “Have you ever had an allergic reaction to any food or medication before?” It is important to choose words that are easy for you to pronounce and sounds natural for you when you enunciate them.

You can also skip some of the letters as needed. For example, no need to ask Ob-gyne history if patient is male. Also, you should be flexible enough depending on the case. For example, if the chief complaint is diarrhea, obviously intensity would be more of amount of diarrhea and frequency rather than the level of pain. Plus an associated symptom like abdominal pain, may deserve its own LIQORAAA.

We will deal with physical examination, social aspect of the examination and the very important patient notes next time.

note: Part II on physical examination and Part III on bedside manners now available.



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