Step 2CS All You Need to Know

# Overview
The clinical skill component of Step 2, tests the fundamental clinical skills essential to safe and effective patient care under supervision.
Watch the official USMLE website video first to get an overall idea of this board examination. You can get practice materials. Please watch the USMLE official onsite orientation for STEP 2 CS Video ].

# Test Structure
USMLE Step 2 CS is designed to assess clinical skills through simulated patient interactions, in which the examinee interacts with standardized patients portrayed by actors. Each examinee faces 12 Standardized Patients (SPs) and has 15 minutes to complete history taking and clinical examination for each patient, and then 10 more minutes to write a patient note describing the findings, initial differential diagnosis list and a list of initial tests. Administration of the Step 2-CS began in 2004.
The clinical skills assessed during this examination are:
- Relevant medical history
- Communication skills
- Physical examination
- Documenting the findings on the patient note.
- Determining diagnostic hypothesis
- Ordering initial diagnostic studies

# Test Center Locations
The examination is offered in five cities across the United States:
- Philadelphia (PA)
- Chicago (IL)
- Atlanta (GA)
- Houston (TX)
- Los Angeles (CA)
Before 2004, a similar exam, the Clinical Skills Assessment (CSA) was used to assess the clinical skills of foreign medical graduates.

# On Test Day
Remember to bring the following items to the test center on test day:
- Scheduling permit
- Confirmation notice
- Unexpired government issued form of identification (with picture and signature) such as current driver's license or passport
- Comfortable professional clothing
- Clean white lab coat
- Standard stethoscope (un-enhanced)
Items not permitted:
- Electronic devices such as:  beepers, recorders, watches,  cameras, cell phones, and other communication devices
- Study materials:  any type of notes, reading materials and study summaries
- Other medical equipment besides your Standard Stethoscope

# Interviewing process
- Avoid using medical terms when interviewing. Use Layman terms instead.

## Doorway Information
Mr/Mrs Wiki comes to the clinic complaining of "chief complaint".
Age  BP  HR  RR  Temp
- Comes due to symptom (back pain/ sore throat)
- Write down on given paper Name/Last-name, Age, Altered vitals, chief complaint
- If possible write quickly 3 differential diagnosis for the chief complaint
- Knock the door and enter the room

## Introduction to Wiki-Patient
- Hello Mrs/Mr Wiki-patient (Shake hands with the patient)
- I am Dr. Romero I will be your doctor today, I will ask you some questions and perform a brief physical exam on you. Is that OK with you?
- Is the room OK for you? (Dim light or adjust temperature if possible)
- Let me make you more comfortable
- How would you like to be addressed? (Wiki-patient says he/she likes to be called Wiki)
- How may I help you today? (Wiki-patient describes chief complaint)
- I am sorry to hear that. I will do my best to help you.

## Chief Complaint
- When the chief complaint is pain use the LIQORAAA mnemonic
- When the chief complaint is not pain use the OCPDFAAA mnemonic
LIQORAAA (for pain)
- Location
- Intensity
- Quality
- Onset
- Radiation
- Alleviating factors
- Aggravating factors
- Associated symptoms
OCDPFAAA (for non-pain chief complaint)
- Onset
- Constant
- Duration
- Progression
- Frequency
- Alleviating factors
- Aggravating factors
- Associated symptoms
- When you encounter a pediatric patient use the mnemonic ON CALL IDIOT to guide your interview
- Onset
- Number
- Cry
- Associated symptoms
- Listless
- Liquid (urine)
- Inmunization
- Diet, dehydration, daycare
- Infection/Ill contacts
- ORS: Oral rehydration solution
- Travel

## Past History
- To continue the interview you can use the PAMHITRFOSS mnemonic:
- Past Medical History (PMHx) / Previous episodes:  Hypertension, Diabetes, MI.
- Allergies to medications (prescribed and OTC). NKDA (not known medical allergies)
- Medications prescribed and OTC) and vitamins.
- Hospitalizations
- Immunizations
- Trauma
- Surgical History (PSHx)
- Review of Systems (ROS)
- Family History (FHX): only pertinent
- Obstetrics-Gynecological History: FMP, LMP, Period every 30 days, lasts 5 days, tampons/pads, GPA (gestation, pregnancy, abortion)
- Social History (SHx):  Occupation. Support (SAFE).
- Sexual: active with "number of partners" (men/women/both). Uses condoms every time. No previous STDs. HIV test. smoking (PPD: 1pack per day for 30 years, EtOH (CAGE 0/4), Illicit drugs, Travel history.

# Counseling
- Immediately when the patient gives you the pertinent information
- During closure

# Challenging Questions
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# Physical Exam
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# Patient Note
- Remember to practice typing the patient note in less than 10 minutes, which will be the time given during the exam.
- You can get extra time if you finish  the patient encounter before the 15 minutes given for this section.
- Practice typing the patient note on the official USMLE website ].

## History
Use the mnemonics: LIQORAAA (for pain), OCDPFAAA (for non-pain chief complaint), PAMHITSFOSS for the rest of the medical history.
ROS: negative except as above
PMHx: previous symptoms like this or major medical condition Hipertension, Diabetes, MI. HOSP.
NKDA, Medics: prescribed and OTC
PSHx: TRAUMA, SURGERY
FHX: none (only pertinent)
OB-GYN Hx FMP, LMP, Period every 30 days, lasts 5 days, tampons/pads, GPA (gestation, pregnancy, aborption)
SHx:  Occupation. . Occupation. Support (SAFE). SEXUAL: active with. multiple Men/wome/both. Condoms every time. No STDs. HIV test. smoking (PPD: 1pack per day for 30 years, EtOH (CAGE 0/4), Illicit drugs, Travel history.

## Physical Exam
- Remember to report unable to examine due to pain
- NAD (hydrated, afebrile, tired, flat affect, tired, speech, movement)
- VS: WNL except: BP RR HR Temp.
- HEENT (head, eyes, ears, nose, throat)
Head: AT, NC (atraumatic, normocephalic)
Eyes: EOMI, PERRLA, normal eye funds. No conjuctival pallor
Nose: no nasal congestion.
Throat: No tonsillar erythema, exudates or enlargement.
Mouth: moist mucous membranes, good dentition
- Neck: Supple, no JVD, no carotid bruits, no cervical LAD, normal thyroid. (CAT ORGAN: Carotid, Abdomen, Thyroid)
- Chest/Lung: no tenderness, clear to percussion bilaterally, tactile fremitus normal, clear breath sounds bilaterally. (No wheezes, crackles, rhonchi, rubs)
- Heart: PMI not displaced, RRR, normal S1/S2 WNL, no M, G, R.
- Abdomen: ND, BS +, Soft, NT. (NO Murphy, McBurney, Rovsing, CVA tenderness, psoas/obturator sign "just one"). No Hepatosplenomegaly/ organomegaly.
- Extremities: No edema +2 +3, clubbing, cyanosis, hairless, asterixis, skin changes. Peripheral pulses (don't write it radial, brachial, dorsal is pedis, posterior tibilalis) 2+ and symmetric. No bruises. ROM (limited passive/active "abduction/adduction/flexion/extension/external rotation" MRS (motor, reflexes, sensation)
- Neuro
Mental Status: A & O x3, spells backward, recalls 3 objects.
CN 2-12 WNL/grossly intact. Rinne WNL, AC> BC?. Weber not lateralized.
Motor: strength 5/5 in all limbs except
DTRs: 2/4 except (normal) absent ankle jerks. Babinksy - Left or right.
Sensation: intact to pinprick and soft touch (sharp and dull). Vibration and position normal
Gait: normal
Cerebellar: finger to nose normal (dysmetria, diadococinesia) Romberg -.
- Skin: preserved turgor.
- Mental Status Exam
Pt speaks slowly
No hostile behavior toward interviewer
Blunt affect with poor aye contact
Inattentive to interviewer
3/3 registration, 3/3 recall at 3 times
Distant memories are impaired
Oriented to person, date and place
Completed 3 step command
Right handed
1/5 on serial 7s
Poor judgement

# Brief Version of Physical Exam Note
HEENT
- NC/AT: normocephalic / atraumatic
-  LAD: no lymphadenopathy
Cardiovascular
-  M/G/R: no murmurs, gallops, rubs
- 2+ PT/DP B: 2+ posterior-tibial and dorsalis pedis pulses bilaterally
-  JVD: no jugular venous distension
-  LE edema: no lower extremity edema
Lungs
- CTA B: clear to auscultation bilaterally
Abdomen
- NT/ND: non-tender, non-distended
-  HSM: no hepatosplenomegaly
- + BS: bowel sounds present
Back
-  CVAT: no costovertebral angle tenderness
Neuro
- EOMI / PERRL: extraocular mvmnts intact / pupils equal, round, reactive to light.

## Differential Diagnosis
Give 3 to 5 differential diagnosis with pertinent positives or negatives from the history and physical exam

## Diagnostic Studies
- Specific physical examination (rectal, pelvic, breast, genital) if applicable
- CBC and electrolytes
- Cultures
- Imaging
- Do not include referrals, consults, and medical or surgical therapies.

# Wiki Mnemonics
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# Practice Cases
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# Layman Terms
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# Medical Abbreviations
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