Gold Standard for the USMLE Step 2 CS - GOLD STANDARD FOR THE
FOR THE IMGs
USMLE STEP 2 CS
A GUIDE THAT CONTAINS ALL THAT YOU NEED TO PASS THE CS
GENERAL HISTORY TAKING AND PHYSICAL EXAMINATION THAT
CAN BE APPLIED TO ALMOST ALL CASES SPARING LONG HOURS
OF STUDYING EACH CASE ALONE.
HOW TO PERFORM A COMPLETE AND RAPID CLOSURE AND
USEFULL STUDY TIPS FROM STUDENTS WHO PASSED THE EXAM.
USEFULL EXAM EXPERIENCE FROM EXAM PASSERS.
USEFULL STRATEGIES FOR CHALLENGING PATIENTS WHATEVER
THE CHALLENGING QUESTIONS ARE.
WHAT TO SAY AND WHAT NOT TO SAY DURING THE ENCOUNTER.
REVIEW REPORTS ABOUT THE AVAILABLE CS BOOKS AND
CD INCLUDED CONTAINING PHYSICAL EXAMINATION VIDEOS.
The USMLE STEP 2 CS is a source of anxiety and concerns among all IMG’s and
that what inspired me to write this book. Being a USMLE step 1 and 2 passer with
scores of 99 , I felt while studying the CS that I could make It a lot easier for a lot of
fellow IMG’s who are not used to taking history and doing physical examination both
in English and by the American school of practice.
Through the help of a lot of fellow residents, attendings and friends I present to you
this book that will make a process that may be painful and difficult feel a lot better
This GOLD STANDARD includes:
A GUIDE THAT CONTAINS ALL THAT YOU NEED TO PASS THE CS EXAM.
GENERAL HISTORY TAKINGAND PHYSICAL EXAMINATION THAT CAN
BE APPLIED TO ALMOST ALL CASES SPARINGLONGHOURS OF
STUDYINGEACH CASE ALONE.
EVEN IF YOU DONT KNOW THE CASE FOLLOW THESE STEPS AND YOU
USEFULL STUDY TIPS FROM STUDENTS WHO PASSED THE EXAM.
USEFULL EXAM EXPERIENCE FROM EXAM PASSERS.
USEFULL STRATEGIES FOR CHALLENGINGPATIENTS WHATEVER THE
WHAT TO SAY AND WHAT NOT TO SAY DURINGTHE ENCOUNTER.
HOW TO PERFORM A COMPLETE AND RAPID CLOSURE.
USEFUL WEBSITES AND BOOKS FOR THE EXAM.
Aly H. Abayazeed
The exam …………………………………………………………………………….4
Study tips ………………………………………………………………………….….5
Of important presentations…………………………………………..….……………34
Closure and counseling………………………………………………………………44
The exam is in the form of 11 or 12 cases in which you are requested to take history
and do physical exam on each case in 15 minutes period and then to write the patient
notes including the history , physical exam , differential and workup in 10 minutes.
You are allowed only to have a white coat, a stethoscope and what you will eat during
the breaks into the exam area.
The day starts at 8am for morning session and 3pm for the afternoon session so it is
better to be at the exam center at 7:30 and 2:30 respectively.
The day start by an introduction about the exam and demonstration of the tools that is
used in the exam rooms during the encounter, please feel free to use all the
equipments during the demonstration so you can feel comfortable while using them
during the encounters.
At 9am and 3pm the sessions begins with every doctor standing in front of an
examination room with the patients notes written on the door, you are not allowed to
see the patient notes until you hear the announcement that you can start the encounter
then you knock and enter the room.
The encounter last for 15 minutes during which you have to take a focused history
and do a focused physical exam, then after leaving the room you will be given 10
minutes to write the patient notes (history , physical , differential and workup)
Of the 11 or 12 cases only 10 cases will be marked and the marks will be determined
by 3 components: Integrated clinical encounter (ICE) which contains data gathering
and patient notes, Communication/interpersonal skills (CIS), Spoken English
The score that you receive for the CS will be either “PASS” or “FAIL”.
1- Practicing the cases is the most important single strategy to pass the exam. The
time constraints during the encounter and writing of patient notes makes
practice so important so you do not have to think about every question and
examination technique and note to write, all will become a routine that you
will feel more confident during the encounter and spare your mind for better
communication with the SP the area that most IMG’s have the biggest
2- Studying of the mental check list of each case that you practice is very
important so not to miss a question in the history taking or a special
examination for one of the differential diagnosis.
3- Study groups where you can be the doctor and the SP in different cases will
put you very close to the real exam and will uncover all your weakness points
so you can work on before the real thing.
4- Dividing the history into 2 main sections: the HPI (history of present illness)
and the PAM-HS-FOSS. Discussed later in details in the how to take a history.
5- Examination is divided into case related system focused exam, heart and lung
auscultation and related general exam. Discussed later in details in how to
make the physical exam.
6- Closure and counseling needs good practice for what to say and how to say it,
through several study groups that I have been to, I found this to be a challenge
to IMG’s and this will be greatly improved after you read the section on how
to do closure and counseling.
7- Patient notes writing are better written from down-up. Discussed later in
details in how to write patient notes.
The more you practice the better you will gradually be.
English is one third of the exam so practice the language well.
Communication skills and how you approach the SP is another one
third and practicing patient approach and responding to challenging
questions will secure you the points on the exam and in the real
thing as well.
SAMPLE of how you should divide your history and physical exam paper
Mental check list
HPI + ROS
Positives in physical
Points to council the patient on at the end of the
MR ADAM Mental check list:
50 yo 1-
Vs WNL 2-
HPI + ROS
L I Q O R A A P A
P A M H S F O S S
Positives in physical exam points to council patient on
Is divided into 3 main parts:
1- HPI (history of present illness) + ROS (review of systems) + History to think
3- PSYCHIATRIC HISTORY.
1- Analysis of the CC which is divided into:
-PAIN LIQOR-F-AAPA stands for (location, intensity, quality, onset
course duration, radiation, frequency, alleviating factors, aggravating factors, ppt
event and associated symptoms)
-ANY OTHER CC OCD-F-AAPA stands for (onset, course, duration,
frequency, aggravating, alleviating, ppt event and associated symptoms).
HISTORY TO ASK IN SPECIFIC CASES:
1- ANY FLUIDS (sputum, blood, discharge, vomiting) amount (teaspoon,
tablespoon or cup full), color, odor, if not blood whether it contains blood or not,
vomiting (projectile or not?), bleeding per rectum (bright red or mixed with
2- MUSCLOSKELETAL swelling, redness, morning stiffness, pain in other
joints, bone fractures, numbness, tingling and weakness.
3- ENURESIS nights/week, episodes/night, amount/episode and particular
time during the night + stresses, environmental changes, sleep apnea (snoring,
night awakening), interventions and drugs tried.
4- CONFUSION OR FORGETFULLNESS problems with the DEATH-
SHAFT stands for (dressing, eating, ambulating, toileting, hygiene, shopping,
housekeeping, accounting, food preparation, transportation).
5- EAR SYMPTOMS hearing loss, vertigo(sensation of room spinning or
feeling of imbalance), tinnitus, discharge, pain.
6- CHRONIC DISEASE FOLLOW UP(DIABETES & HTN) OCD + ROS +
controlled or not, last measurement, medications ( current, previous eg.insulin in
diabetes, compliance, doses, sideffects), side effects of disease (retinopathy,
stroke, nephropathy, intermittent claudication, angina, MI)
7- INSOMNIA 4D-N-4S (Daily sleep habit, Duration of sleep, Difficulty
falling asleep, Difficulty staying asleep, Night mares, Snoring, Sleepiness during
the day, Smoking or alcohol or coffee before sleep, Seeing TV in bed)
8- SEIZURES ABCD, Aura (signs that the attack will happen),
Bowel/bladder control, Bite tongue, Consciousness lost, Confusion after
regaining consciousness, Describe it.
.Hot flushes, vaginal dryness/itching (Menopause/premature ovarian failure)
.Nipple discharge, visual changes, headaches (Hyperprolactinemia)
10- DOMETSTIC VIOLENCE are you Safe at home? is there Threat to your
personal safety at home or any where else? does Any one threatens or hurts you
or your children? can you tell me about these Bruises?, any family Members
know about the abuse?, do you have an Emergency plan? Child abuse at home?
Other injuries? Weapons at home? Regular abuse? Drinking problems for the
11- PEDIATRIC CASES ask about the following histories
BIRTH HISTORY: full term, regular antenatal care, pregnancy u/s,
complications during pregnancy, normal or cs delivery, first bowel
DEVELOPMENTAL HISTORY: “ is his weight, height, language
DIETARY HISTORY: breast feeding, fortified formula, solid foods,
IMMUNIZATION HISTORY: “is he up to date on his immunizations?”
“When was his last checkup?
12- FATIGUE Progression during the day, Performance/job affected or not
13- HEADACHE LIQOR-F-AAPA, Aura(signs that the attack will occur?),
visual changes/tearing/runny nose during the attack, relation to menstruation,
wake you up from sleep?.
14- ERECTILE DYSFUNCTION severity on 1-10 scale (1 for flaccid, 6 for
adequate for penetration), libido, nocturnal or early morning erections, marital
problems, depression, anxiety, buttock or leg pain when walking or resting.
15- WEIGHT GAIN hypothyroid symptoms, depression, PCOS (hirsutism,
irregular cycles), Pseudo tumor cerebri (headache, visual changes)
16- DYSPARUNIA LIQOR-F-AAPA, CD-PPP, libido, marital problems,
depression, anxiety, h/o STDs, premature ovarian failure(hot flushes, vaginal
17- BACK PAIN urinary of fecal incontinence, TB symptoms (fever, night
sweats, wt loss)
18- DIARRHEA OCD-F-AAPA, Relation to oral intake, Regular bowel
Pediatric: number of wet diapers and vigorous cry (to assess
dehydration), recent URI, day care center.
19- HEARING LOSS Ear symptoms, exposure to loud noises, insertion of
foreign bodies, neurological problems (weakness, numbness, tingling),
severity(mild, moderate, severe)
20- DIFFICULTY SWALLOWING OCD-F-AAPA, exact Location, Liquids or
solids or both (if both which first?)
21- FREQUANT FALLS Movement problem (initiating, stopping), Injuries,
Living conditions (support at home)
22- VOMITING Amount, Color, Odor, Blood, Content, Projectile or not?
23- JAUNDICE OCD-F-AAPA, color of stool and urine, itching/pruritis, blood
transfusion, bleeding tendency, sore throat.
24- BLEEDING PER RECTUM OCD-F-AAPA, 3C-MBA, bright red or mixed
25- BLURRED VISION OCD-F-AAPA, neuro, Discharge, DM symptoms
(excessive thirst, urination, wt loss and/or eating), Halos around the lights(cataract,
glaucoma), Loss of vision completely before.
26- POLYURIA OCD-F-AAPA, BUN-FSH-2P, Thirst, Water intake, Volume of
27- RASH OCD-F-AAPA, initial location and progression, initially flat or raised
and if changed, Pruritis, Pain over the rash, Pain in joints, Animal contact, Insect
28- SMOKING COUNSELLING
1- Habit: when? Why? How much? Stress? Concerned about your health? Like it?
2- Problems: ROS
3- Counseling: see later in details.
29- ALCOHOL COUNCELING
1- Habit: When? Why? How much? Stress? Concerned about your health? CAGE?
3-Counseling: see later in details.
30- DIZZINESS OCD-F-AAPA, what you Mean (room spinning around you or
you spinning inside)?, Tendency to fall and to which side, relation to Posture.
31- KNEE TRAUMA Noise at time of injury (popping sound for ACL injury),
uNstability of the joint, uNlocking and locking of the knee (meniscal injury).
32- SICKLE CELL ANEMIA AND PAIN attack crisis (diarrhea, dehydration,
infection, environment causing shortness of breath)
33- SORE THROAT OCD-F-AAPA, URT symptoms, Joint pain, Vaginal
34- BURNING URINATION IN YOUNG FEMALE OCD-F-AAPA, CD-PPP
(for vulvovaginitis, PID).
35- DRUG REFILL OR FOLLOW UP HTN DM HIV
1- disease: OCD
2- Medications: what? Doses? Compliance? Side effects? Other drugs in the past?
3- Monitoring: regular follow ups? How often? Last measurement?
4- Complications: HTN, DM ROS
HIV ROS, oral white patches, motor/sensory
problems, depression, informed sexual partner or not.
37- FIRST PRENATAL VISIT CD-PPP, how did you know? Blood transfusion?
Previous birth problems? Recent immunization?
38- CHILDWITH FEVER OCD-F-AAPA, how high? Last measured?
Chills/sweating? Medications? ROS, birth/developmental/dietary/immunization
2-Schematic drawing for associated symptoms to ask specific to the system of the CC:
RESPIRATORY AND CARDIAC
History to think about
These are important points in different cases that are commonly missed, you will
not necessarily ask all of them in every case but you should think about them and
ask what is relevant to the case.
3-Testing for TB or Exposure to TB.
4-Testing for HIV (as in high sexual risk practice e.g. Multiple sexual partners or
homosexual or sore throat cases).
5-Sick contacts (ie, sick contacts at day care center).
6-Screening tests (as in terminal cancer case).
8-Vaccines ( as in over 50 patients and pediatric cases)
P Past history similar problems.
Past history of medical problems.
M Medications (prescription and over the counter).
H Hospitalizations and past surgical history.
S Sleep problems.
F Family history (similar problems, parents alive, medical problems)
O OB/GYN ( this is asked in case of a female and the CC is not related to
OBGYN, so, only ask about LMP and whether cycles are regular or not)
S Social history (diet,appetite,weight / smoking,alcohol,illicit drugs /
S Sexual history (sexually active? Who is your partner? If not his wife ask do
you use any method of contraception? If condoms, ask used regularly or not?)
Is divided into: 1- HPI = TT-DSM-FAWR + ROS
Think what do you think your problem is related to?
Thyroid cold or heat intolerance, voice change, tremors, hair fall,
D Duration of symptoms.
Delusions and hallucinations (do you see or hear things that others
S Support (do you have someone to talk to when depressed?)
Suicide (considered ending your life? Plan? Guns or pills at home?)
Sense of guilt.
M Mood (what has been your mood lately?)
Memory (do you have problems remembering things?)
MMSE (discussed in details in neurological exam)
F Feeling lonely (have you been feeling lonely lately?)
A Anxiety (have you been feeling anxious lately?)
WR Realize (do you realize you have a problem?)
Willing (are you willing to get help?)
Mnemonic for the depression symptoms:
SIG-ME-CAPS (all covered within the general scheme)
Sleep, Interests, Guilt, Mood, Energy, Concentration, Appetite, Psychomotor
agitation or slowing, Suicidal ideation.
The examination room is equipped with all the instruments that you are suspected to
use during the physical exam, and these are:
1. Ophthalmoscope. 4. Cotton tips, tooth picks.
2. Otoscope. 5. Tongue depressors
3. BP cuff and monitor. 6. Tuning fork, hummer.
The physical exam is divided into:
1. General exam.
2. Systems examination.
3. Miscellaneous examinations.
These examinations are not necessarily done routinely in every case, but you should
think about them and do what is relevant to the case.
Head Tender sinuses.
Eye Conjunctive for pallor.
Nose For nasal discharge.
Throat Pharyngeal injection and tonsillitis.
Ear Ear discharge.
Thyroid + reflexes + hand tremors.
Carotid bruit auscultation.
Extremities Pulsations (radial and dorsalis pedis)
Chest examination: (patient sitting or lying down)
1. Inspection: Distress Depth,rhythm,rate Deformity.
2. Palpation: Trachea Tenderness TVF Thumb-expansion
4. Auscultation: if TVF +ve do bronchophony and whispering
pectoriloquy (ask the patient to say 99 loud and while
whispering while you are auscultating)
Cardiovascular examination: (sitting lying down sitting again)
A. Sitting: PULSE Carotid + bruit
Pedal + edema
B. Lying down:
1- Inspection, palpation: Pulsation of jugular vein at 30 degree.
Pulsations (aortic, pulmonary, sternal)
PMI (LIQ location, inch, quality)
2- Auscultation: 4 areas (aortic, pulmonary, mitral and tricuspid)
C. Sitting: Auscultate the 4 areas.
Abdominal examination: (lying down)
1. Inspection: Swelling Scar Pulsations Peristalsis.
2. Auscultation: Bowl Bruit
3. Percussion: 4 quadrants.
Liver (MCL up down and down up)
Spleen (last intercostal space AAL deep breath
percuss again dull=splenic enlargement)
4. Palpation: Superficial (watch the SP face)
5. Special exam: Tenderness Rebound (pain on releasing
hand), done if tenderness on palpation.
CVA (pain on CVA
Signs Psoas sign (extension of Rt hip
in left lateral position causes pain in appendicitis)
Obturator sign (flexion of Rt hip
with internal rotation cause pain in appendicitis)
Rovsing’s sign (deep pressure in
LLQ causes pain in RLQ in appendicitis)
Murphy’s sign (on deep palpation of
the RUQ with inspiration pain occur and patient stop breathing)
N.B: Tell the SP that you will need to do inguinal/rectal exam if male and
pelvic/rectal exam for female as these are forbidden during the exam.
1- Mental status : can be done at end of the history, beginning of physical or end of
Orientation tell me your full name? where are we? What day it is?
Memory SHORT I will say 3 words and I want you to repeat
them(pen, pencil, car) immediately and after 5 minutes so
please remember them.
LONG who was the previous president of the
Abstraction could you please say the word “WORLD” backward.
Judgment please take my pen with you right hand put it in your left
hand and give it back to me.
2- Cranial nerves:
Optic cover each eye and count fingers.
Eye movements (3,4,6)
Trigeminal palpate the masseter while the SP clinching his teeth.
Facial close your eyes please and don’t let me open them.
can you smile please.
Vestibulocochlear rub your fingers near the patient ears to see if he
Vagus and glossopharyngeal please open your mouth and say”AH”
Accessory please shrug your shoulders (against hand resistance)
Hypoglossal please stick out your tongue and move it form side to
a. Muscle tone: “I would like to examine your muscle tone, please relax your
muscles, ok?” Flex and extend the wrist and elbow, knee
b. Muscle strength: “I would like to examine your muscle power, ok?” “pull in
and push out maneuvers”
4- Sensory: “I would like to check sensory perception in different areas of your body,
a. Light touch(cotton), Pain(tooth pick):
“This is dull and this is sharp, please close your eyes and tell me whether
its dull or sharp when I touch you?”
b. Vibration, position:
Done if abnormalities in light touch and pain.
Tuning fork placed on/change in position of DIP of index finger and big
c. Special tests for meningitis:
Neck stiffness flexion of patient’s neck causes pain.
5- Reflexes: “I would like to check your jerks, please relax your muscles?”
UL Triceps, Biceps(tape on your finger), Brachioradialis.
LL Knee, Ankle + Babinski
6- Cerebellar function: “I would like to check your balance and movement, ok?”
a. Gait: GET UP AND GO TEST “please get up and walk toward the
wall and back”
b. Romberg’s test: “please stand with your feet together and arms
extended, close your eyes I wont let you fall”
c. Finger to nose test: “please extend your arm then touch your nose, now
do it while your eyes are closed”
Grading of muscle power: Grading of reflexes:
5/5 normal 0 absent
4/5 less than normal 1 hyporeflexia
3/5 not against resistance 2 normal
2/5 not against gravity 3 hyperreflexia
1/5 flicker 4 hyperreflexia + clonus
A- EYE EXAMINATION:
1. Conjunctiva : “please look upwards” while you are pulling the lower
2. Count fingers: “please put your Rt hand on your Rt eye and count my
2. Movement of extra ocular muscles : “please follow my finger to
examine your eye movement”. Lt thumb on the chin
to fix the head and the Rt index moves in the 3
cardinal positions on the Rt and vice versa.
3. Fields examination : (remove your glasses) done in 2 ways:
“please close your Rt/Lt eye and tell me how many
fingers do you see/when you see my finger”
Counting fingers ask the patient to close one eye and
you close the opposite one and then use both hands to make
counting fingers in both temporal and nasal fields, upper and
Moving finger as above but instead of counting fingers
move your index fingers from outward inwards in both fields
and both quadrants.
4. Fundus examination : (remove your glasses) “I will now dim the light
to examine your retina please look straight ahead”
use the Rt hand and Rt eye to examine the patient’s Rt eye and
B- MUSCULOSKELETAL EXAMINATION:
1- Inspect and compare (don’t forget the back of the areal you examine)
Appearance Atrophy Deformity Swelling Redness
2- Palpate and compare
Temperature Motion range Pulsations
Tenderness Motor, sensory, reflexes
1- UPPER EXTREMITY PAIN
Neck range of motion.
Adson’s test (palpate radial pulse while the patient extend his neck to
the opposite side for thoracic outlet syndrome)
Tinel test (Tap median N. on wrist for carpal tunnel syndrome)
Phalen test (Flex wrist for carpal tunnel syndrome)
2- BACK PAIN
Spinal and Para spinal tenderness (lumber strain)
Straight leg raising test (lumbar disk prolapse, L4-decreased knee
jerk, L5-decreased big toe dorsifexion, S1-decreased ankle
Eye examination for uveitis (ankylosing spondylitis)
3- DVT homan’s sign (dorsifexion of foot produces cuff pain), in cases
of chest pain, dysnea and LL pain.
4- EYE EXAMINATION in cases where uveitis may occur ( back pain,
rash, wrist pain, knee pain)
5- KNEE TRAUMA examine for: Drawer, McMurray’s, Effusion.
6- IN ANY JOINT PAIN examine the joints of the hands.
B- EAR EXAMINATION:
1. Inspect and palpate + mastoid “please tell me if you feel pain”
2. Hearing :
Whisper “please cover your Lt/Rt ear” whisper in the other ear with
pen/light and ask the SP to repeat.
Rene test (normally AC>BC, positive)
Weber test (normally no lateralization, negative)
3. Otoscope exam: rest your hand on the mastoid process.
C- NOSE EXAMINATION:
1. Inspection: “Please tilt your head backward” use the otoscope as a light
pen to examine the nose.
2. Sinuses examination: “I will press on your face, please tell me if you feel
Frontal Ethmoid Maxillary
D- THROAT EXAMINATION:
“Please open your mouth and say AH” use a tongue depressor.
“Please stick out your tongue” inspect upper and under surface.
N.B: ENT are always examined together.
E- NECK EXAMINATION:
1. Inspection: Swelling Scars Symmetry
2. Palpation: Tenderness
Thyroid anterior approach: press on one lobe with
your fingers while you examine the other
from inside out toward the sternomastoid
with the thumb.
Posterior approach: examine both lobes
together in a rolling movement while the SP
4. Lymph nodes:
Posterior occipital post auricular anterior
auricular submandibular submental
superficial and deep cervical supraclavicular
N.B: forbidden examination (not done but tell the SP you will need to do them if
indicated) female breast, pelvic, rectal, genital, corneal reflex and inguinal
F- EXAMINATION IN SPECIAL SITUATIONS:
If PE in DD (SOB and/or Cough) calf tenderness.
Difficulty swallowing give the patient water and ask him to
Motor vehicle accident (MVA) HEENT, chest, heart, abdomen,
neurological (mental status/cr N./motor/sensory), skin for lacerations.
Hearing loss examine: ENT, Fundoscopic exam (papilledema),
neurologic (cr n., motor, sensory, reflexes, Cerebellar)
Insomnia: Throat, Neck for thyroid+reflexes, listen to the heart, palpate
HTN drug refill must record BP in both arms.
Any case with malignancy in DD examine for enlarged LNS.
Constipation Motor, Sensory, Reflexes in the LL.
DM drug refill FOOT EXAMINATION.
If the case is not a neurological case and you have neurological diseases in
DD examine Motor, Sensory and Reflexes, if your timing is tight at
least examine for Reflexes.
sample of the exam paper
Patient notes are written from the bottom to the top starting with the differential
diagnosis diagnostic work up physical exam history.
Maximum of 5 DD and 5 diagnostic work up.
Differential diagnosis Diagnostic workup:
WRITING THE PATIENT NOTES
General format of the HPI:
… Yo F/M c/o …., LIQOR-F-AAPA or OCD-F-AAPA, patient
recalls/associated with ………, patient denies/not associated with…….
Points to be covered in the history are:
HPI, ROS, PMH, PSH, ALLERGY, MEDICATION, FH,
History to be added in pediatric cases:
BIRTH H, DEVELOPMENTAL H, IMMUNIZATION H,
History documentation in PSYCHIATRIC CASES: A-DSM-PTCI
Affect mood congruent.
D Delusions and hallucinations
Speech scant or excessive, goal oriented or not.
P Past traumatic event.
I Insight (does the patient realize he has a problem).
Normal in physical examination:
VS (vital signs): WNL
HEENT (head,eye,ear,nose,throat) :
Normocephalic, atraumatic, no bruises (in trauma or domestic violence)
Nose, mouth and pharynx WNL (in case of URI)
PERRLA(pupils equal round reactive to light and accommodation),
EOMI(extra ocular movement intact), no Fundoscopic abnormalities, no
No cerumen, TMs normal, + rene, - weber, no tenderness (for ear exam).
Rash: multiple circumscribed erythematous lesions, no pigmentation, scales
or jaundice noticed.
Supple, no lymphadenopathy (head and neck infections or metastatic cancer).
No JVD, no carotid bruit (in cardiovascular examination)
Apical impulse not displaced, RRR (rhythm,rate,regular), normal S1 and S2,
no murmurs, rubs or gallops.
No tenderness, clear breath sounds bilaterally, no rales, wheezes or ronchi,
trachea central, tactile fremitus normal.
Soft, non distended, non tender, +bowel sounds, no organomegaly.
( S/ND/NT/+BS/no organomegaly)
Mental status: alert, orientedx3, spells backward, recall 3 objects.
Cranial nerves: 2 to 12 intact
Motor: 5/5 upper and lower extremities.
Sensory: intact to touch and pinprick.
DTRs: 2+ symmetric in upper and lower extremities, - babinski.
Cerebellar: - Romberg, gait normal.
No clubbing, cyanosis or edema.
Pulses 2+ and symmetric.
G…P..., LMP…, regular/irregular, painful or not, bleeding or not (postcoital
and/or intermenstrual), discharge or not, no history of abnormal pap smear.
No warmth or erythema, no tenderness, normal range of motion,
1- Forbidden examinations.
2- CBC with differential.
3- Blood tests.
4- Radiological tests.
5- Special tests.
6- complications of the disease (ie obesity glucose, cholesterol, TGs),
7- Age related screening test.
Electrolytes are a common investigation to order.
Similar tests could be written in the same line.
DIAGNOSTIC WORKUP IN SPECIAL CASES:
Diabetic patient blood glucose, Hb A1C and urinalysis for
Drug abuser serum and urine toxicology screens.
Diarrhea rotavirus enzyme immunoassay, Stool leukocytes,
culture, ova, parasites and PH, AXR, electrolytes, cl. Difficile toxin.
Hearing loss audiometry, tympanometry, brain stem auditory evoked
potential, VDRL or RPR(syphilis cause menier’s), CT head.
Back pain XR lumber sine, MRI lumber spine, PSA, Calcium,
BUN/CR, serum and urine protein electrophoresis. (Multiple Myeloma).
Any neurological or psychological case electrolytes, serum and urine
Any cardiological case, DM and HTN Lipid profile.
Enuresis genital exam, renal US, UA and culture, first morning urine
Shortness of breath CXR, ABG, pulse oximetry, sputum gram stain,
AFB and cultures.
Any bleeding Postural BP and HR measurement, PTT/PT/INR, BMP
(Na, K, co2, CL, HCO3,PH).
Impotence TSH, PRL, Testosterone, Nocturnal penile tumescence test.
Any DD with peptic ulcer H.plyori serology, upper GI endoscopy.
First prenatal visit TORCH screen, hepatitis B/C screen, HIV screen,
Blood typing and grouping, UA and culture, abdomen US.
Maximum of 5.
Written in descending order of likelihood.
Thyroid problems and drug induced disorder are common in DD.
Mostly will be diseases from the mental check.
Any DD could be divided into systems and then categories:
1- Systems: neurological, chest, heart, abdomen, musculoskeletal and HEEENT.
2- Categories: functional, traumatic/mechanical, inflammatory/allergic,
metabolic/endocrine, neoplastic, vascular/blood, psychological, drug induced.
DD in cases like (bilateral leg pain, unilateral leg pain, bilateral arm/UL pain, unilateral
UL pin…..etc) will be divide into:
1- Structures: skin, bone, muscle, nerves, arteries and veins.
2- Categories: as before.
DIFFERENTIAL DIAGNOSIS OF IMPORTANT PRESENTATIONS
DD OF IMPORTANT PRSENTATIONS:
(The aim of this list is to help you make a DD in your mind before the encounter; it is
not conclusive of all the DD of each symptom)
1. Heart: MI, angina, pericarditis, arrhythmias.
2. Lung: PE, pleuritis, pneumonia.
3. Chest: costochondritis.
4. Esophagus: GERD, perforation, obstruction.
5. Aorta: dissection
6. Psychiatric: panic attack.
ACUTE COUGH (<3weeks):
1. Common cold
2. Acute sinusitis
3. Acute bronchitis
4. Bronchial Asthma
8. Drugs: ACEI.
ACUTE SHORTNESS OF BREATH:
3. COPD exacerbation
4. Bronchial Asthma
5. Anxiety, Panic attack.
COUGH AND CHEST PAIN:
2. Pleuritic pain
4. Lung cancer
1. Posterior nasal drip
2. Chronic bronchitis
5. Lung cancer
ENRANCE, CLOSURE AND COUNSELLING
Knock and enter
You: “Hallo Mr/Mrs …… I am dr ….. I am ……, are the room settings
You: “ok Mr/Mrs …… how may I help you?”
SP: “I have back pain”
You: “oh I am so sorry to hear that, ok Mr/Mrs ….. First we will talk about
your problem then I will need to do a brief physical examination and I will be
as fast and as gentle as possible, ok?”
SP: “ok doctor, thank you”
You: “could you tell me more about your problem please?”
You: “Thank you Mr/Mrs …… for your cooperation, let me give you my
impression, you told me you have …..(give a very short to the point briefing
of the history)… is that right”
You: “and from the physical exam, I am thinking your problem may be related
to ….(give the most likely disease)… which is …..(give brief explanation)….
But we can not be sure yet we will have to run some tests first, then I will sit
with you again to explain the results, tell you the final diagnosis and agree on
a management plan, is that ok?”
SP: “yes doctor”
You: “do you have any questions or concerns?”
SP: will give you the challenging question if he hasn’t already or will say “no
doctor thank you”
Shake hands saying “it was nice meeting you, I will do my level best to help
you” and leave the room.
COUNSELLING IN SPECIAL SITUATIONS:
COUNSELING IN DOMESTIC VIOLENCE: (spousal, child or geriatric abuse)
Mr/Mrs ……. I am concerned about your safety.
I am always available for help and support whenever you need it.
Every thing we discuss is confidential but I have to involve child protective
services if your children are being abused.
We have a lot of resources to help you like support groups, I will give you
their contact information, do you have any questions or concerns?
COUNSELLING IN ENURESIS:
Don’t worry Mrs …… this is a common problem in children.
However it can be embarrassing to the child and stressful to the family.
Most cases can be treated with life modifications without the need for drugs,
here what I want you to do:
1. monitor fluid/day
2. limit fluids before sleep
3. bathroom before sleep
4. wake 2-3 hrs after sleep to go to bathroom
5. make him/her change his/her pajamas
6. give reward for the dry nights
7. bedwetting alarm that rings at the beginning of bedwetting
COUNSELLING IN OBESITY:
Restrict fatty food
Radical change in diet habits is not recommended
Read books about obesity and loosing weight
Consult a dietitian
SMOKING AND ALCOHOL COUNSELLING:
You: “Mr/Mrs …… I am concerned about your smoking/alcohol drinking,
smoking causes a lot of health hazards like heart attacks, strokes, lung cancers,
urinary cancers and stomach ulcers among users/alcohol cause a lot of health
hazard like liver cirrhosis, pancreatitis, gall bladder stones and stomach ulcers
among others, Are you willing to quit smoking/alcohol drinking?”
You: “ok Mr/Mrs ….., I understand you are not ready now to quit
smoking/alcohol drinking, when you decide to quit I will be here to offer you
all the support you need, also, we have a lot of resources to help you quit
through our social workers”
You: “I am glad you made that decision, I will be here to offer you all the
support that you need, also, we have a lot of resources to help you quitting and
I will make you an appointment with one of our social workers, ok?”
SP: “ok, thank you doctor”
COUNSELLING IN ANY PSYCHIATRIC CASE SHOULD INCLUDE:
I am willing to talk to your family to be more supportive if you want.
I will be here to offer you all the support that you need during treatment.
COUNSELLING IN PEDIATRIC CASES SHOULD INCLUDE:
Mrs ….. I am concerned about your child problem and I want you to bring
him/her to the hospital as soon as possible to examine him/her and to order
some tests, if you are not able to bring him/her to the hospital I can arrange
someone to pick him/her up from home.
Meanwhile I would like you to …. (Give him Tylenol and cold compresses if
he has fever for example)…
COUNSELLING IN TERMINAL CANCERPATIENTS:
Mr/Ms….. I understand what you are going through. I will be giving you
something to relieve your pain and I am always here to be of any support to
you at any time.
I want you to be aware of things that will be necessary later on in your life:
1. Living at home or nursing home?
2. Hospice: completely supervised medical, psychological and physical
support that is provided at home at terminal stages of disease to let
patients live as comfortable, pain free and as full as life as possible.
3. Advance directive: living will that enable the patient to say how he or
she want to be treated at terminal stages of his/her illness when no
more able to make decisions.
COUNSELLING IN DIAGNOSED OR HIGH RISK HIV CASES:
Safe sexual practice (use of condoms regularly, inform partner, avoid high risk
sexual behavior like multiple partners)
Treatment, side effects and management
Vaccinations (only killed vaccines, e.g. Influenza, Hepatitis A)
COUNSELLING IN DM:
Diet, exercise and medications
COUNSELLING IN FIRST PRENATAL VISIT:
Work up: HIV consent, TORCH, blood typing and grouping, hepatitis
Supplements: iron, vitamins, nutritious diet, calcium
Safe sexual practices
Regular antenatal visits
COUNSELLING HEEL/FOOT PAIN:
RICE (rest for 3 days, immobilization, cold compresses 30min/d,
Avoid exercise or weight bearing
Soft heel pads
Padded foot splint during sleep