Introduction.The Clinical Skills is part of the USMLE Step 2.
It is composed of 12 Standararized Patient's Encounters. This exam is standarized. You will have 25 minutes per patient, from which 15 minutes are for Interview and Physical Exam and 10 minutes are for Writting your Clinical Notes.
Make it a routine when practicing. The day of the CS it will come natural.
DOORWAY INFORMATION
-You will started when you hear the instructions "you might begin". At this moment your 25 minutes start to run, and only at thismoment you can start writting on your scratch paper.-You will open the slide door that is covering the doorway information.
-We highly recomend you to write down all the Information to your scracth paper:
Patient's full name
Age
Chief Complaint
Vital signs
ROADMAP
We also consider important to write down at this time your road map. Which Includes:
Write 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
L Location
I Intensity
Q Quality
O Onset
R Radiation
A Aggravating Factors
A Alleviating Factors
A Associated Factors
P Past Medical History
A Allergies
M Medications
H H I T S Hospitalization, Injuries, Trauma and Surgery
U Urinary Problems
G Gastro Intestinal Problems
S Sleep
F Family History
O Ob / Gyn
S Social History
S Sexual History
(-) (+)
NOTE: It does not matter if you loose 1 minute making your road map, you wont be lost.
You will only write LIQORAAA PAMHUGSFOSS (+) (-), so you have to remember the meaning of these letters.
THE INTERVIEW
Knock the door.
Introduce your self to the patient. Say " Hi MR (Last Name) I am Dr (last name) I will be you rphysician today". You can shake hands with the SP (standarized patient) if you think is pertinent. Some SPs might be acting as if htey have a lot of pain, or with body languaje show they wont shake your hand. Then you can asked "what brings you here today? or what can I do for you today?" etc.
Drape the patient. This will give you an easy earned point. Do it inmediatly so you wont forget to do it and loss this easy point. Talk to the SP and explain what you are doing always.
Start the interview. Remember to use transitional phrases, avoiding to sound like you are interrogating. You have to sound more like if you are friendly chating with the SP. Maintain a good eye contact and good patient doctor relationship.
You can start doing questions to cover the points in LIQOR AAA and PAM HUGS FOSS, also cover pertinent positives and negatives of your diferentials.
Wash your hands after completing the questions. Take a dept breath, did you forgot to ask some questions? Check your differentials, did you have all pertinent positives and negatives? Use this time to think and check if you have all the info you need. You can continue asking the SP during this time.
THE PHYSICAL EXAMINATION
Start the Physical Exam. From the top to the bottom. You wont have to do a complete PE in each SP. You need to carefully consider what is really necesary. Remember you only have 15 minutes to Interview and do the PE. You wil choose from the following:
HEENT
-Head
-Eyes
-Ears
-Nose
-Throat
Heart
Lungs
Abdomen
Extremities
Neuro
Closure
Sumarize
Explain what you think
1.- Differentials
2.-Labs, test and work up
3.-Treatment
4.-Ask if the pt has understood and if he has questions to ask.
THE CLINICAL NOTE
Now you will have 10 more minutes to complete your note. You can 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, consice and complete. You need to write neat. If you have a terrible hand writing you can try the computer version.
The sapace for writting is very similar in both ways.
The Clinical Note consist of the following:
HISTORY
PHYSICAL EXAMINATION
DIFFERENTIAL DIAGNOSIS
DIAGNOSTIC WORKUP
About the Pictures
Thanks to Dr. Miguel Casillas, Dra. Nallely Flores, Dra. Selene Lozano, Dra. Nidia Payan, Dra. Marcela Perez and Dra. Susan Rojas for their permission to take this pictures while they were practicing for their CS. Photos taken by Dr. Gilberto Cota
