USMLE Step 2 CS (Clinical Skills) - A Short Guide

  

USMLE STEP 2 CS EXAM

– A short Guide by Rizwan Khan

 - Supplementary info for KEMU students for applying by Hassaan Raza Jafri (at the end)

Overview:

Time span -
         Unless you are in a rush of getting it done prior to an upcoming match don’t compromise on the time span . Do spare atleast 3,4 weeks of time for the preparation of this exam . To say that CS is just a practical exam and doesn’t need any kind of studying is absurdity at the least. For the real exam you have to be prepared in every aspect both theoretically and practically so don’t compromise on the preparation.

Clinical rotations -

         For those people on clinical rotations they should utilize their rotations as much as they can to get them prepared for the exam , not just for the studying part but for the hands on experience and the interaction with the patients . Don’t slack off while on rotations , instead in addition to the inpatient patients care , try to tag along with the residents while they see their outpatient appointments too. It would build a lot of confidence in you regarding the interaction with patients and everything else would be a breeze in the prep phase.
For those not having clinical rotations or having rotations in specialties like surgery, paediatrics etc would have to put a little extra effort during the preparation of CS.

Study material -
First Aid is the best book for this exam , u should also buy usmle world and go through it just once (once u are thoroughly done with first aid) , and uworld book at that time won’t take more than 5,6 hours . I recommend that to broaden your views regarding each presenting complaint and all the possible medical conditions related to it. Also do download NEERAJ NOTES from the internet. They are really helpful in getting hang of the basic mnemonics for all the cases.

New Pattern -
The major difference between the old/new patterns is that DATA GATHERING portion of the ICE subcomponent is now graded through your patient note instead of the checklist given to the patient. What that means for you is that even if you asked a relevant question to the patient but forgot to mention that in patient note properly than u r going to lose points for that thing, so in short A GOOD PATIENT NOTE IS VITAL for ur passing , so it should be practiced a lot n shouldn’t be neglected. Secondly now instead of just writing different dds u have to quote 2,3 dds with relevant history/examination points which point to that d/d, and what that means for you is that you should be thoroughly prepared theoretically so that you know all the history/examination points of all the d/ds of a particular presenting complaint , with which the patient presented .


     For cs your preparation should be in a way that whenever u see a presenting complaint all the probable d/ds should flash in ur mind and also the relevant history points regarding all of them and this is where creating mnemonics would help u a lot in the exam. The mnemonics given in NEERAJ NOTES are the baseline mnemonics that u would use in all the cases , but you should also create mnemonics for each individual case so that whenever u see a presenting complaint that mnemonic u created comes in ur mind and without much thinking u write it on the paper before entering the room and u would be knowing all the extra questions you would need to ask other than the ones in those notes.
Practice -
Don’t start practicing a case unless uve gone through it from the book thoroughly and have memorized all the important things , practicing with another person (preferably one who is also preparing for cs) can be very very helpful in building confidence regarding cs protocol and testing yourself and is a vital part of the exam preparation. While practicing do make sure u always time urself and try to decrease the time for practicing purposes e.g try to get done with history and exam in 13 mins and patient note in 8-9 mins , so that u are well prepared to perform fast in the real exam. And also don’t just stick with the practice cases given in first aid book , tell ur friend to be any other possible disease with same presenting complaint (all of which are given in the minicases in firstaid ) , this wont limit ur mind to that one possible dd given in the practice case and would broaden ur mind regarding any kind of possibility in exam which is really important . 

           

                                     SUMMARY

1) Read the CS related info on the USMLE website before starting with anything to get a clear idea about the exam , there is a pdf file related to this exam on the website , do go through it once http://www.usmle.org/step-2-cs/

2)Buy First Aid and get an idea of  different types of cases that could be tested in the exam , and just go through whole book superficially in a day, just to get an idea of what you are going to study

3)Download the Neeraj notes and study its first 10 pages and memorize them all, and keep practicing the mnemonics until u are perfect with them (Do incorporate the REVIEW OF SYSTEM mnemonics I described in this guide with those mnemonics )

4) Start with individual Practice Cases given in the First Aid.
Once you read a practice case do TWO things ,

 First try to memorize the reasons of different diagnosis given at the last of the case and also mark all the questions other than OPDSFC LIQRAAA review of system and PAM FOSS TIA SHO (the mnemonics u are going to prepare from notes and here) , the rest of the questions would be very few .

Secondly open the minicases part of First aid and read all the possible other medical problems with the similar presenting complaint and try to memorize the different history points regarding each individual problem. Once you are done with both these things you are good to go.

5) Focused Questions Mnemonics regarding some cases are given here , if u can memorize them they would help you a lot , you can also make your own focused questions mnemonics.
6)After you are this Good with a particular presenting complaint , go forward and practice with a partner , DON’T start practicing a particular case UNTIL you are this much prepared theoretically about that particular case. Time Yourself Throughout the practice and also write the patient notes.

7)Patient Note : Study the patient notes in First aid and try to copy them , they are perfect regarding the exam , only difference being that you now also have to write history points as well as examination points separately so do practice that on your own , also study first aid about writing the acronyms in the physical exam part
The order of writing different things in patient notes should be
    a) D/ds with history/physical exam points
    b) Lab tests
    c) History
    d) examination

   This is important because even if you get a little over time your d/ds won’t be compromised instead the physical exam portion would be , which u can always shrink if there is less time .

8) Physical Exam : You should practice and practice to get perfect in this part. Watch few videos related to this exam and also read through first aid and neeraj notes , the most time consuming of all is the CNS examination so try to shorten it to roughly 3 minutes and practice ,practice and practice.
9) USMLE WORLD: Once you are done with all the cases in First Aid , and have practiced all of them , open your UWORLD book and go through it in a day . You would find some cases which are either not mentioned in first aid or are a little different in uworld , broaden ur mind with that knowledge , even practice a few and that’s it.

    All of the above points are discussed in more detail in following pages

                                            HOW TO STUDY

The Exam Orientation:

I would highly recommend you to go to the usmle website and read through the step2 cs exam description to get a clear crisp idea of what you are getting into (http://www.usmle.org/step-2-cs/) , secondly there are also some step 2 cs related videos on the internet to help you get started with the concept of exam (in case you don’t know much about this exam)

 The start of preparation:

  Open First Aid and Start studying by going through different cases and understanding their d/ds , and slowly buildup a pace in few days . Don’t start practicing the cases on the very first day.

      Take uworld completely out of picture at start, and don’t open it (even for those FEW cases which are not present in First Aid) until you are so good with first aid that even thinking about any presenting complaint makes its mnemonics and d/ds flash in front of your eyes , and only than bother to open uworld and that too just to test yourself and make your mind more broader for possibilities u can have in the exam . If you are ok at speaking English and can comfortably talk with Americans then you won’t have any trouble communicating with the patients (Do keep in mind though that SPOKEN ENGLISH PROFIENCY is one of the three subcomponents of the exam that you have to pass separately, so do practise your English speaking and understanding skills if you are deficient there )

  Start of encounter:

1) knock twice on the door
2) Open the door LOOK at the patient and IDENTIFY him with his name e.g. MR.SMITH 
3)After speaking his name say GOODMORNING/GOODAFTERNOON/GOODEVENING (Acc. To the time)
4) Approach towards the patient and shake his/her hands while IDENTIFYING YOURSELF " MY NAME IS DR.(last name) AND I AM THE ATTENDING PHYSICIAN/RESIDENT ON DUTY IN THE HOSPITAL TODAY AND I'LL BE TAKING CARE OF YOU TODAY , ITS REALLY NICE TO MEET YOU"
5) Then explain the patient what u are going to do and take CONSENT "So I’ll be asking you few questions followed by a brief examination , is that alright with you?"
6) Then look around the room and ask about his comfort “So first off are you feeling comfortable in this room"
7) Drape the patient ” Can I make you more comfortable by putting this drape over you?" ( if the patient is already draped then say something like "I see u are already draped that’s good " just to score a point in sp's eyes that u knew to drape him/her"
8) Consent for writing and sitting " Do u mind if I Sit down and Write few notes just to make sure I don’t miss out on any important point"
9) First open ended question " SO MR. SMITH COULD U TELL ME WHAT BROUGHT YOU TO THE HOSPITAL TODAY " (if it is something serious than respond by saying "OH IM SO SORRY TO HEAR ABOUT THAT ")
10)Second open ended question " Could u tell me little bit more about your problem "

Than start asking your mnemonics OPDSFC , LIQRAAA , specific questions , THEN FRCS PUB SAWED (ask focused relevant questions out of Review of system) , then PAM FOSS TIA SHOE

Mnemonics:
 For understanding the concept of mnemonics you should first read NEERAJ NOTES , They are great and I won’t be covering most of the things that are present there so u should first go through them and memorize those mnemonics and after that start with these mnemonics (Mine could be a little bit altered so do whatever suits you the best)

Some basic mnemonics that you'll have to use in all the cases (in their order of asking in encounter)

OPDSFC for presenting complaint

LIQRAAA for pain (both present in Neeraj notes)

FOCUSED QUESTIONS (i will mention mnemonics for few cases below and always try to make ur own mnemonics too)

REVIEW OF SYSTEM
Review of systems  (ROS)   THEN FRCS PUB SAWED
T   travel hx
H   headaches
E   edema (swellings on body)
N   Nausea

F     fever
R     racing heart (palpitations)
C     chest pain
S     shortness of breath

P      pain in joints/rash
U     urinary changes recently
B     bowel changes recently

S     sleep changes
A     appetite changes
W    weight changes
E     exercise?
D    dizziness/depressed/lightheaded

(1-The purpose of review of system is to quickly assess whether all other systems are working properly or not , and should be asked after saying this line NOW I WOULD LIKE TO ASK YOU FEW QUESTIONS PRETTY QUICKLY JUST TO MAKE SURE EVERYTHING ELSE IS FINE . These questions often give a great deal of opportunity to us to get some positive points which we might have forgot to ask in the focused questions , and secondly while the preparation of cases you don’t need to remember individually any history point regarding that particular case if it is already present in the review of system , that would make things a lot easier for you and you would just have to memorize those history points not present in review of system
2-Always ask review of system questions once you are done with the FOCUSED QUESTIONS
3-MOST IMPORTANTLY while writing the patient notes try to write all the relevant ROS history points in the history even if they are negative e.g. no chest pain no cough no changes in bowel and urinary habits (this is very important because if u didn’t mentioned the negative relevant history points in the patient note the examiners would never know whether u asked it or not SINCE THE NEW PATTERN tests the data gathering through your patient note)

Once you are done with Review of system questions always remember to summarize main history points (as mentioned in neeraj notes ) and ask him "Do u have anything else to tell me about your problem" and only after that move on to the past history .

TRANSITIONS are very important and get a good hang of it through those notes.

Transition sentence “NOW I WOULD LIKE TO ASK ABOUT UR HEALTH IN THE PAST , IS THAT ALRIGHT WITH U” , than start the mnemonic

PAM FOSS TIA SHO
(This mnemonic is a little different in those notes but I modified it according to my mind , you can do either one)

P      Previous similar complain , Past medical hx , Past Surgical hx
A      Allergies
M     Medications
F      Family Hx
O     Ob/gyn HX
S      Social History – it is TIA
        T tobacco   I Illicit drugs    A Alcohol
S      Sexual hx
H      Household (lives with whom)
O      Occupation

Once again go to those notes and memorize mnemonics , the first 10 pages of those notes are what are important , u r going to use them in almost EVERY PATIENT ENCOUNTER.
Memorize the OPDSFC    LIQRAAA    ABCO    FACESLIPS n all the mnemonics given there and read that part about how to exactly say things to the patients.
There is no review of system there, that is why the PAMFOS has an extra HUGS in it, but don’t bother, for that just remember the PAMFOS>TIA SHO and THEN FRCS PUB SAWED coz it would be more convenient. These mnemonics must b memorized so well that u won’t have to even think what the P in pub is or what R in FRCS is.

FOCUSED MNEMONICS:
This is the part where focused questions related to each case gets mnemonics to help us remember what we have to ask in the encounter, so that we don’t miss out any important question. I highly recommend u guys to make your own mnemonics too for other cases or even these cases. Do whatever can help u remember the questions in all the cases
 *one important point that those focused questions which overlap with REVIEW OF SYSTEM u can drop them from ur focused questions , it could make things a lot easier for you (at least that is what i did) , because at the end you are going to ask the focused questions in all the cases. But if u can put a little extra effort to remember them separately than that would be great (but just don’t ask them again during review of system )


Joint Case :
              DPS ROAST RJW SPRAY tick/hair

D    deformity
P    pain 
S    morning Stiffness

R    redness
O    oral ulcers
A    appetite
S    swelling
T    trauma

R    rashes
J    other Joints swelling 
W   weakness in surrounding muscles

S    Std's hx
P    Photophobia
R   Reynaud’s (response of fingers to cold temp)
A   previous Abortions
Y   alcohol (yellow label lol thats a tea though)
Tick
Hair changes

A weird story to remember this mnemonic (it worked for me , don’t know about you)

           To remember the mnemonic imagine DPS school that has DEFORMED building and the teachers there physically punish them by using sticks on their hands and they feel PAIN due to that and their hands get STIFF with this pain, They have a party in the school with a big ROAST of chicken and everybody eats it but their faces get RED and they get ORAL ULCERS after eating it but there APETITE is also gone , their whole bodies get swollen so in anger they do physical TRAUMA on the roast , A nearby radio station RJ (Radio jockey) hears about this party and wants to go there by Walking but he has a face full of RASHES and his joints and muscles around them are really WEAK so he cannot walk and go there , so he SPRAYS the school and tries to infect the school with all the bad things like STDS,ABORTIONS,ALCOHOL and the students there become afraid of light , but in return the students send a herd of TICKS to the RJ and they eat off his HAIRS

(this story would only help if you try to visualize it not just read it , use ur picture memory )


FOR COUGH :

 FSB DIST

F    fatigue 
S    night sweats
B    blood with

D    day/night cough changes
I    ill contacts/ previous infections
S    Sputum
T    T.b patient contacts/ ppd

Depression (FACE SLIPS) neeraj notes

Hypothyroid (ABCD HV) neeraj notes

Hyper thyroid

TIPS WHIBS

T    tremor
I    irritability
P    palpitations
S    Sweating
W   weight loss
HI   heat intolerance
B    Bowel changes
S    swelling in neck

*Just make sure that whenever u ask any question that is also in review of system than cut that mnemonic syllable on the Review of system pneumonic too so that u won’t ask that question twice , like the palpitations and bowel changes in hyperthyroid pneumonic

Dizziness case
* (the first aid just discusses the vertigo symptom, when patient feels like room is spinning around him, make sure u read the cardiac causes of dizziness , I-e when patient feels he is going to pass out , that case from uworld)

mnemonic for dizziness (vertigo symptom)

IT-PT-HP DP-FS
I    Recent URI (points toward vest. neuronitis / labrynthitis )
T    trauma to head (point toward perilymphatic fistula)
P    dizziness with different POSITIONS of head sitting/standing (point towards bppv)
T    tinnitus
H    hearing loss
P    pressure/FULLNESS in ears

D    discharge from ear
P    pain in ear
F    falls (meniere's disease)
S    syphilis (meniere's disease)

 An IT specialist gets appointed as the PT of a school (Physical Trainer ) , He makes the students to keep their heads in a particular position for long times during training which results in them hearing ringing in their ears (tinnitus) , They also can’t hear their HP laptops due to that ringing and so they bring their ears near the speakers of laptop and their ears get FULL with the laptop.
the IT specialist makes his FSc (an intermediate level in Pakistan) picture as his facebook DP , he FALLS on the road and gets a discharge from his ear as well as pain in his ear on his way home , a girl helps her in this pain by getting him to hospital , he falls for the girl and they start dating but later he contracts syphilis from that girl
          (as stupid as the story sounds it helped me remember the mnemonic really well , if it doesn’t helps u remembering the mnemonic make ur own weird stories )
*Use the story as a crutch for few days until u r so good with the mnemonic that u won’t have to remember the weird story to find out what a particular syllable of the mnemonic meant

Sore throat

ENT RIP

E-  ear pain or discharge
N-  runny Nose
T-  Throat swelling/pain during swallowing

R   rashes (hiv/infectious mononucleosis)
I    ill contacts 
P    Pain in abdomen (inf. mononucleosis)

Hearing loss (quite similar to the dizziness)

ITNF   (Things Acting from outside to the ear)
DPRV  (Things coming outside the ear)
Sound

I    infections
T    trauma
N    noise exposure
F    foreign bodies

D    discharge
P    pain
R   ringing (tinnitus)
V   vertigo

Sound - difficulty in understanding/figuring out words of sound

For headache case simply do the

OPDSFC
LIQRAAA 

than just try to rule out all the causes of headaches by simply asking one question for each (most probably u would have a clear idea by the time uve asked all these questions that what kind of headache is this)

Stress headache-  stressful event in life
Cluster headache-  unilateral redness eyes, nose discharge stuffiness
Migraine-    warning symptoms/flashes of light/family hx
Meningitis/subarachnoid headache-   photophobia-neck stiffness
Tumour- neurological signs GCWNSS (i'll describe this mnemonic with memory loss case)
Temporal arteritis /pseudo tumour cerebri/glaucoma- Vision changes
Sinusitis- flu like symptoms

ONCE AGAIN I CANT STRESS IT ENOUGH THAT PLEASE keeping all the d/d's in mind is the most important thing , as soon as u read headache as a case while practicing all these d/d's should flash in your mind with the history points that might point toward them , so do put alot of energy in studying and remembering them.

Memory loss

1) effect on daily life questions
Driving, shopping , cooking etc
2)  Falls/head (subdural hematoma) trauma/diziness/light headedness
3)  Hypothyroid rule out ABCDHV
4)  neurological questions GCWNSSV

G    gait
C    confusion
W    weakness
N     numbness
S     seizures
S     speech
V     vision changes

5) hx of stroke (vascular dementia)

Loss of consciousness

1)WHAT happened before loss of consciousness

EYE- any visual changes light flashes
Ear- any unusual voice heard
Nose- any unusual smell (the three senses)

Brain- Any dizziness
Heart- any palpitations
Git- any nausea/vomiting ( the three systems)

2) WHAT HAPPENED DURING THE LOSS OF CONSCIOUSNESS reported by other people to him

BSTH 

B    bladder incontinence
S    seizures
T    tongue biting
H    head trauma

(weird story : BSTH----------think about a person who is standing outside GC university , a guys through a basta i-e bag on him (BSTH) , the basta hits his head and he gets a HEAD TRAUMA , he gets a SEIZURE due to it and BITS his TONGUE and falls on ground and PEEs his pants)

3) What happened after regained consciousness
GCWNSV
G   gait changes
C   Confusion
W  weakness
N   Numbness
S   speech changes
V   vision changes

(WEIRD STORY : GCWNSSV---------- vo GC Wich NaSS jata hai , but due to the trauma he is walking awkwardly (GAIT) , and he is confused and dont really know where he is going (Confusion) , A guy touches him but he is WEAK/NUMB and is unable to SPEAK (speech) to him and cannot even see him (VISION) )

Obstructive sleep apnea

 (If it is one of the suspected things like in fatigue or sleep problems ask 4 questions)
1) Snoring
2) Night mares
3) Day time sleepiness
4) Day time Naps

*When Post traumatic stress disorder/Adjustment is one of the suspected ones like fatigue/Sleep disturbance/amenorrhea etc than always ask about any RECENT STRESSFUL EVENT/CHANGE IN LIFE

Hoarseness of voice

OPEN INCH

O    overuse of voice
P    pain in throat
E    exposure to any dust or cold etc
N    Neck swellings

I     recent infections/ill contacts
N    Night sweats
C    CVA
H    Heartburn (Gerd)

DDs in a case like dementia??

Try to keep in mind few points about all the d/d's ,
e.g in  dementia case 
Alziehmer's (old age , progressive decline in memory, suspect in every old patient)
Vascular dementia (Stepwise loss of memory , hx of stroke)
Subdural hematoma(falls,head trauma,cns symptoms GCWNSSV)
Normal pressure hydrocephalous (Cns symptoms GCWNSSV)
Depression (faceslips)
Hypothyroid (ABCDHV)
B12 deficiency Dementia (Hx of colon resection causing decreased b12 absorption) 
that’s how u remember all the d/d's with the hx points , so whenever u have a patient with fall hx think about hematoma , whenever old and slowly progressing dementia suspect Alzheimer’s and so on.

Workup Diabetes

About the DM --- WAR
Last ---------------- SHE MONA
PRESENT---------- FFEWMASS
other diseases------- HHHS

About DM-

W     What meds he is taking
A      Adverse effects to those meds
R      taking REGULARLY or not?

Last (in past )----------

S      last SUGAR level in blood , normal sugar levels usually?
H      last HBA1C 
E      last EYE EXAM
MONA    how does MONITORS at home the sugar level?

Present (right now)------

F    how is FEELING in present
F    how his FOOT in present
E    how is vision(eye) now
W    any weakness/numbness now?
M    any effect on MARRIAGE/WORK now?
A    any anxiety in life right now?
S    any stress in life now?
S    any effect on Sexual life now?

Other Diseases------

H    HTN HX

H    Hyper cholesterol hx
H    heart diseases hx 
S     Stroke hx

All other follow-ups are almost similar e.g. for

HTN follow up it would change to

About the HTN --- WAR
Last ---------------- BE MONA (no H because ho hba1c and B instead of S because its Last BP now)
PRESENT---------- FFEWMASS
Other diseases------- DHHS (D instead of H because hx of DM instead of HTN now)
Similarly can also manage to do the same for any other medical follow up , I hope u get the drill

Paeds hx

In almost all the cases (except enuresis)

Mouth-
S    Swallowing problem
C    cough 
C    Cry (any change in baby crying feeble or more etc)
V    Voice change
D    Drooling of baby
Nose- Runny/stuffy
Ear-

Ear pulling
Ear discharge
Eyes-

Eye discharge

General-

1)  Colour (any change in colour e.g bluish)
2)  Appearance (playful alert or Drowsy)
3)  Seizures (Any shakings of baby u noticed)

ROS: TEN FS PUB SAW

T- TRAVEL (ask following three things in travel part)
1) Ill contacts
2) DAY CARE (does baby goes to day care)
3) Ill contacts in daycare
E-  edema (swellings anywhere )
N-  Vomiting

F- Fever
S- sob ( is child having faster breathing)

P-  Rashes (if present ask full detail)
U-  Urinary changes u noticed ( no. of diapers changes , colour changes etc)
B-  bowel changes ( colour of bowel changes , amount changed )

S-  change in child sleep
A-  Appetite change
W- weight change recently

PAM BDFI

P-  previous such complain/Past medical/surgical
A-  allergies
M-  medications

B-  birth hx 
1) term  (born at term, preterm or post term)
2) C-sec or Normal delivery
3)  Any complications

D- Developmental hx
when had Last checkup , weight and heigth at that time?
Developmental milestones smile,crawl,sit,walk,dressing up etc at normal ages?

F- Feeding Hx 
1) breast fed or not? till what age?
2) Iron supplements and vitamins being given?
3) solid foods at what age?

I- Immunizations
Are immunizations up to date?

*Few things to keep in mind in paediatrics case is that you wont have to do physical exam in the patient so make good use of your time by asking questions in detail as above , and do read all the paediatrics cases and memorize their differentials with history points specific to each one of it (given at end of each practise case) , this would help you to get to a good diagnosis after uve taken above history in detail.

Few questions:
1.order of questioning? If u forget something u can ask it later, or even during physical exam?

2. How can u write the negative points in patient notes?? Like NO FEVER?? Or should you only write positive points?

3. Is it easy to make out DDs? Does making wrong DDs(less probable) affects the scoring???

4. What opening sentence did u use in phone encounter?

5) What to write in the physical exam part under DDs in cases like depression, fatigue etc??

6) What is empathy and how do i incorporate it into my encounter?

1) U can have whatever order u want and ask whatever u want to ask during whole encounter , but being organised would keep u mentally relaxed and the encounter would also be more brief due to that , also whenever u ask a question or the patient is replying to Your question never ever break EYE CONTACT with the patient during that time , as soon as the patient is done answering the question break the eye contact for few seconds and MUST WRITE IT DOWN and only then go to next question , what you will write on the paper is what you will recall while typing patient note so make sure you note it down properly even if it takes a little bit extra time

2) Positive points r a must for the patient note , but the relative negative points are also vital for a good patient note , u also have to negate some of the ROS questions , let me give u an example , if u have a chest pain case than for the HPI , write the OPDSFC in one line and the LIQRAAA in the second line and then any other relevant positive or negative finding in the next line and at the end negate all the important ROS symptoms not present in him 
lets see a hypothetical case
HPI: 60 y/o M c/o single episode of chest pain that started suddenly 10 hours ago while he was cooking food and lasted for 20 mins (opdsfc) . It was a sharp pain of intensity 8/10 located in the middle of the chest and doesn’t radiates anywhere , aggravated by walking but nothing makes it better for him and there are no associated symptoms (LIQRAAA) . The patient also reports weight loss since few weeks and fatigue, the patient denies any shortness of breath ,cough, headache , fever , nausea or any changes in his urinary or bowel habits or any change in his appetite recently. (Negate the important relevant ros symptoms not present)
ROS: negative except as above

3) U'll get most of the d/d's perfectly if you are prepared well , others u might not get spot on , but holding your ground and doing a good patient encounter is more important than figuring out the exact D/D , so don’t panic if u aren’t able to make a good d/d , just be calm and pose to be a confident and good doctor , ask relevant questions and do focused exam and do a diplomatic counselling

4) Phone encounter: Good morning MISS/MR_____ MY name is Dr.______ , I’m the attending physician on duty in the hospital today , how can i help u.

5) Only those exam points which u either find positive in the given VITALS or in the physical exam e.g decreased reflexes of hypothyroid etc
If u can’t find any physical exam finding at all , then just leave it empty
*Keep in mind that vitals like Increased temp. Is a physical exam finding

6) Empathy is and important part of the CIS sub-component of the exam , Empathy simply means that you have to show emotions according to the pain of the patient. You are not supposed to be a robot asking questions , you are supposed to be a concerned doctor who is worried about his/her patients and shows appropriate human emotions while taking care of his/her patients. The best way to show appropriate empathy is by thinking as if it is a real encounter and they are real patients. Some important points of showing empathy are

A) intensity of pain is very high

B) recently lost a family member

C) rape or physical abuse patients

D) post traumatic patients like accidents

E) Any thing which is putting patient under stress

 So in short there can be alot of points where you should be mentally prepared to show proper empathy , and you can show empathy by

a)    With ur facial expressions

b)    Saying words like “i’m so sorry to hear that” “i understand your pain” “that must have been horrible for you” “ u seem to be in a lot of pain , i’ll try my best to get you out of this pain as soon as possible”   and so on

So there can be alot of possibilities and you should be mentally prepared to tackle any of them .
BOTTOMLINE IS: Dont act like a robot , be a human doctor as much as u can in the exam

Physical exam is the easiest part , do the short drills for CNS exam , Resp/cvs/GIT are all really easy , u don’t really need to do a lot of other signs , except fundoscopy/otoscopy/psoas sign/obturator sign/pamburton/kernig. Read the physical exam portion in first aid its helpful, u really need to keep it focused and short . And the most important thing is practice. Practice it as much as u can and TIME YOURSELF.
*Always try to listen to the heart and lungs pretty quickly in the physical exam ( if u have some extra time ), even if it isn’t relevant with the case , it would help u in writing a good patient note by filling both cvs and resp portions in ur P.E part of patient note

A hypothetical sample d/d part of patient note of a chest pain patient

1) Myocardial infarction

Hx points

1- Chest pain
2- pain radiates in arm
3- Positive family hx

2) Angina 

1- Chest pain
2- Pain associated with exertional activity
(If there is no other symptom or exam finding pointing to a third diagnosis than u can leave the third diagnosis part empty , but if even a minor clue to any other medical problem is present u can make another d/d out of it)

3) GERD 
1-Chest pain
2- Patient on ppi for acidity

WHEN U DONT GET ANY PHYSICAL FINDING JUST DONT WRITE ANYTHING

SUMMARY:
1) Read the CS related info on the USMLE website before starting with anything to get a clear idea about the exam , there is a pdf file related to this exam on the website , do go through it once http://www.usmle.org/step-2-cs/
2)Buy First Aid and get an idea of  different types of cases that could be tested in the exam , and just go through whole book superficially in a day, just to get an idea of what you are going to study
3)Download the neeraj notes and study its first 10 pages and memorize them all, and keep practicing the mnemonics until u are perfect with them (Do incorporate the REVIEW OF SYSTEM mnemonics I described in this guide with those mnemonics )
4) Start with individual Practice Cases given in the First Aid.
Once you read a practice case do TWO things ,

 First try to memorize the reasons of different diagnosis given at the last of the case and also mark all the questions other than OPDSFC LIQRAAA review of system and PAM FOSS TIA SHO (the mnemonics u are going to prepare from notes and here) , the rest of the questions would be very few .

Secondly open the minicases part of First aid and read all the possible other medical problems with the similar presenting complaint and try to memorize the different history points regarding each individual problem. Once you are done with both these things you are good to go.

5) Focused Questions Mnemonics regarding some cases are given here , if u can memorize them they would help you a lot , you can also make your own focused questions mnemonics.
6)After you are this Good with a particular presenting complaint , go forward and practice with a partner , DON’T start practicing a particular case UNTIL you are this much prepared theoretically about that particular case. Time Yourself Throughout the practice and also write the patient notes.
7)Patient Note : Study the patient notes in First aid and try to copy them , they are perfect regarding the exam , only difference being that you now also have to write history points as well as examination points separately so do practice that on you own , also study first aid about writing the acronyms in the physical exam part
The order of writing different things in patient notes should be
    a) D/ds with history/physical exam points
    b) Lab tests
    c) History
    d) examination

   This is important because even if you get a little over time your d/ds won’t be compromised instead the physical exam portion would be , which u can always shrink if there is less time .

8) Physical Exam : You should practice and practice to get perfect in this part. Watch few videos related to this exam and also read through first aid and neeraj notes , the most time consuming of all is the CNS examination so try to shorten it to roughly 3 minutes and practice ,practice and practice.
9) USMLE WORLD: Once you are done with all the cases in First Aid , and have practiced all of them , open your UWORLD book and go through it in a day . You would find some cases which are either not mentioned in first aid or are a little different in uworld , broaden ur mind with that knowledge , even practice a few and that’s it.

         Bottom line: Study the book really well. Practice all the cases as much as u can, read mini cases extensively. Broaden your mind for all the possible diagnosis of a particular presenting complaint, work hard, and try to get it done in the first attempt. Pray a lot and believe in yourself. May GOD be with you.

 Rizwan Khan

(King Edward Medical University)

Procedure for applying For KEMU Students by Hassaan Raza Jafri

First you have to make your account on ECFMG,go to website and make your account,you will get a usmle id in 20 days in your mail box

Second,now you have to apply for CS plus get yourself registered with Ecfmg, so go to website again and all detail is there, first you have to complete your identication form where you will add all your details of your three year rotations from your ward card with dates and all necessary information, get a print out after that and give it to Riaz/Sattar saab they know how to do it, you have to paste a photograph on it as well that is same as you give for visa and sattar saab will give you back in a kemu sealed envelope and you have to send it on ecfmg address by yourself,call Ecfmg after four working days to confirm.

Meanwhile also apply online for CS and get your payment done. This is done through credit card, no other way.

After above two steps you will get an email that they have sent conformation to your medical school regarding the details you gave in less than 3 weeks. Then ask rashid saab of kemcaana to send confirmation back and same evening you will get permit and then you can get a date for CS and you are all set

Plus get it all done before you graduate because you will apply online as a student and mention all the dates if you apply online and before receiving permit you graduate you will have to do it all again and apply as graduate and send some other documents and wait for another month meanwhile all dates for june july will be booked so better get it done latest by end of jan/feb so that you have all dates and you can plan your visit accordingly.

Regarding documents for house job and all that clearance stuff, just leave your nic copy, all detailed mark sheets, some passport size snaps both in white and blue background,white is required for pmdc and ask some your friend to do all that you will get a provisional and you are all set for hjob as well if you want to do it.

regarding cs rizwan has written more than enuf,if you do all that properly u will ace it,i just want to stress on ice component that most people couldnt make it.do it properly focus on patient note in proper american style plus practice,practice and practice after giving a good read of first aid.behave as a real doctors,approach patient as you are seeing him in clinic,interact with him not like you are giving exam,spoken english and communication skills is not that issue, just be confident,control on your nerves, thats is key believe me that first encounter is kind of a difficult than whole exam runs very smoothly,do give proper time to prepare like 20-25 days like u study for your prof.thats it plus also enjoy your time over there,best of luck and remember in prayers..