Tips and tricks for the USMLE Step 2 CS

Introduction

Studying for Step 2 CS can seem like a daunting task, but with enough practice you will develop a routine and the test will become less and less intimidating. In contrast to the other USMLE exams, the main challenges of CS are time management and writing the patient note. For that reason, make sure to time yourself and practice writing the patient note starting on day one.

When you practice patient encounters, make sure to go through the entire case and write the patient note, following the tips and guidelines offered here. Some patient encounters have a slightly different structure (see “Special scenarios” below), and you should make sure to be aware of these. However, you will likely encounter no more than one or two of these scenarios during the examination, meaning that the majority of your preparation should be focused on the scenario outlined below. By the time your test day comes around, you will be more than ready for the exam.

If, despite all your preparation, something goes wrong during the examination, relax – everyone makes mistakes. Do not fixate on mistakes that you might have made in previous encounters; focus instead on the case before you. Every case is a new opportunity.

And remember, everything that happens in the exam room happens for a reason: Be attentive! If you are unsure about something, ask the patient.

Good luck – we know you can do this!

Minute 0: At the doorway

  • Each examinee is positioned in front of the door to an examination room.
  • Have your clipboard and pen ready.
  • You will hear this announcement inside the examination room: “SPs, please prepare,” which lets you know that the encounter is about to begin.
  • Relax and take a deep breath!

Announcement: “Examinees, you may begin your first patient encounter.”

Do not look at the doorway information or write any information on your blue sheet before you hear this announcement!

Minute 1: Preparation and introduction

  • Slide open the panel to reveal the doorway information.
  • Before you enter the examination room, read the doorway information and the expected tasks carefully.
    • Quickly note and assess name, age, vitals, and chief complaint.
    • Write down mnemonics for the patient history.
    • Take a few seconds to note the most important differentials.
  • Knock on the door and enter (even if you do not hear a response from within the room).
    • Introduce yourself and confirm the patient's identity.
    • Smile!
    • Shake hands.
    • Speak up and enunciate clearly. Patients will appreciate your confidence in the exam room.
  • Drape the patient if needed.
  • Scan the room for any “unusual” items that may be relevant to the encounter (e.g., a tissue the patient is holding or a tablet that may be handed to you during the encounter).

If you need to drape the patient, you will see a folded drape in the room.

Minutes 2–6: The patient history

  • Begin taking the history of present illness, review of systems, and past medical history.
    • Begin with open-ended questions.
    • Listen actively and maintain eye contact.
    • Make sure the patient is comfortable and address any discomfort/aggressive attitudes.
    • Use professional and clear language. Avoid medical jargon.
  • Only ask relevant questions. You will not be able to take a complete history.
    • Follow your mnemonics to make sure you do not forget important questions, but skip any mnemonic questions that are less relevant for the present case.
    • Keep the most likely differential diagnoses in mind when you decide which questions to ask.
  • If you forget to ask a question, it is fine to ask it during the physical exam.
  • After every AMBOSS practice case, review the check boxes in the case and note the questions you forgot to ask. Review this list shortly before the exam.

Before you end the history, ask the patient if there is anything else they would like to tell you. Many patients will give away hints or important bits of information that you might otherwise miss.

Minutes 7–7.5: Transition to physical exam

  • Tell the patient that you would like to perform a physical examination and ask for permission to begin.
  • Wash your hands with soap and water.
    • OR use hand sanitizer
    • OR use gloves

The time while you wash your hands can be used to bond with the patient or ask questions about their social history (e.g., job, family).

Minutes 7.5–12: Physical examination

ALWAYS

  • Try to begin with the most pertinent system.
  • Perform a FOCUSED physical examination. You will not be able to perform a complete physical examination.
  • Ensure that the patient is comfortable.
    • If you recline the examination table, do not forget the leg rests.
  • Cover the patient respectfully using the drapes.
    • Ask the patient for permission to lower their gown.
    • Try to expose the patient only to the extent that is necessary.
  • Avoid being unnecessarily forceful when you examine the patient.
  • Talk to the patient and describe what you are doing/about to do.
  • Observe the patient carefully for any pathological findings that they might be mimicking.

NEVER

  • Examine through the patient's gown.
  • Examine sensitive areas or perform:
  • Repeat painful exam maneuvers
    • The patients simulate pain for a reason!

At minute 10, you will hear an announcement. At this point you should be about halfway done with the physical examination.

Announcement: “There are 5 minutes remaining in this patient encounter.”

Minutes 12–14.5: Counseling, challenging questions, and closure

  • Counsel the patient on relevant points regarding health promotion and/or disease prevention (e.g., counseling on smoking cessation).
  • Respond to the patient's (challenging) questions.
    • Show empathy.
    • Do not give false hope – be honest, but do not be abrasive or rude.
    • Address fears and concerns.
    • Ask if the patient has any further concerns.
    • Often patients are scared to openly address important concerns!
  • Closure
    • Communicate your findings from the history and physical exam (mention both positive and negative findings).
    • Explain which diagnostic steps you would like to take and why.
    • Avoid medical jargon!

Minutes 14.5–15: Wrap-up and goodbye

  • Say “Thank you.”
  • Say goodbye and leave the room.

Announcement: “This patient encounter is now over. You must now leave the room.”

Minutes 16-23: Patient note

  • If you finish the direct encounter in less than 15 minutes, you can leave the room and use the extra time for the patient note.

ALWAYS

  • Write up the most important information first.
  • Copy and paste the vital signs from the examinee instructions to save time.
  • Use correct medical terminology and abbreviations.
  • List only diagnoses that can be supported by the findings in your patient encounter.
    • List the diagnoses in order of likelihood!
    • List the positive and negative aspects of the patient history and physical examination findings that are pertinent to your diagnoses!
  • Be as specific as possible when you note examination findings or supporting arguments.
  • Copy and paste supporting arguments from the history and physical exam sections whenever you can in order to save time.
  • Stick to the strategy and time management that you have practiced.
  • Order the appropriate tests.
    • If needed: breast/pelvic/genital/rectal exams

NEVER

  • Make up history or exam findings because they would make your diagnoses more plausible.
  • Use medical abbreviations that are ambiguous or unclear.
  • Treat, refer, or admit the patient.
  • Counsel the patient. (Do this in the encounter, not the note!)

Announcement: “You have 2 minutes to complete your patient note.”

Minutes 24–25: Finishing up

  • Keep typing and do not panic.
  • Add the last few important findings, and make sure that every differential diagnosis has at least one or two supporting arguments.

Announcement: “Examinees, the patient note portion of this encounter is now over. Please stop writing and place pens on your desk. Give your written patient note and blue scrap paper to the proctor.”

  • HANDS OFF the keyboard!
  • The patient note is automatically submitted.
  • The blue sheet with your notes on it will be collected.
  • Follow the instructions of the proctors to move to the next room or take a break.

Special scenarios

Telephone encounters

  • You will not find a patient in the examination room. Instead, once you enter the room, you will see a telephone on the desk.
  • Do not dial any numbers.
  • Press the yellow button to start the call.
    • You can only press the button once.
    • Do not press any other buttons during the conversation – doing so might end the encounter!
  • Take the patient history as you would in any other case. (You may be talking to the caregiver of a minor or elderly person; see “Caregiver scenarios” below.)
  • Once you are ready to end the phone call, press the yellow button again.
    • This will end the conversation.
    • You will only be able to place a single phone call. If you end the call, you will not be able to call back!
  • There is no physical examination for this type of patient encounter.
  • Patient note: Leave the physical exam section blank.

The USMLE posts the same doorway information for telephone patient encounters as it does for normal patient encounters, so you may be surprised to enter the room and only find a telephone. For telephone cases, you can complete the focused history as you normally would, but you will not conduct a physical examination and can leave this section of the patient note blank. Remember that you should not dial any number yourself in telephone cases; just use the yellow speaker button to place and to end the call!

Caregiver scenarios

  • Instructions will be provided with the doorway information.
  • Once you enter the room, you will see the caregiver of a patient (a child or elderly patient), or in some cases a telephone on which you will speak to them (see “Telephone encounters” above).
  • Proceed with the task assigned in the doorway information (usually taking a patient history).
  • There is no physical examination for this type of patient encounter.
  • Patient note: Leave the physical exam section blank.

Skill demonstrations

  • Instructions will be provided in the doorway information.
  • Tasks include performing (sensitive) physical examinations on models or mannequins.
  • The instructions will tell you exactly how to proceed with the patient note.

Tablet encounters

  • The patient may present you a digital image on a tablet (e.g., imaging or photo) and ask you to interpret and explain it.
  • You can try out the tablet (along with all the other medical equipment) before starting the exam.
  • Take your time to review the image. Do not panic if you do not see the pathology!
  • Do not explain or mention any pathological findings that you do not see.

Communication scenarios

  • Instructions will be provided in the doorway information.
  • Tasks can range from counseling a patient on various health issues to discussing a difficult situation with a patient (e.g., breaking bad news).
  • The instructions will tell you exactly how to proceed with the patient note.
last updated 03/27/2018
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