First Aid for the USMLE Step 2 CS

Section 2. The Patient Encounter

How To Interact With Special Patients

The following guidelines can help you deal with atypical patients and uncommon encounters.

 The anxious patient: Encourage the patient to talk about his feelings. Ask about the things that are causing the anxiety. Offer reasonable reassurance. You can also validate the patient’s response by saying, “Any patient in your situation might react in this way, but I want you to know that I will do my best to address your concerns.”

 The angry patient: Stay calm and don’t be frightened. Remember that the patient is not really angry; he is just acting angry to test your response. Let the patient express his feelings, and inquire about the reason for his anger. You should also address the patient’s anger in a reasonable way. For example, if the patient is complaining that he has been waiting for a long time, you can validate his feelings by saying, “I can understand why anyone in your situation might become angry under the same circumstances. I am sorry I am late. The clinic is crowded, and many patients had appointments before yours.” Reassure the patient that now that it is his turn, you will focus on his case and take care of him.

 The crying patient: Allow the crying patient to express his feelings, and wait in silence for him to finish. Offer him a tissue, and show him empathy in your facial expressions. You may also place your hand lightly on the patient’s shoulder or arm and say something like “I know that you feel sad. Would you like to tell me about it?” Don’t worry about time constraints in such cases. Remember that the patient is an actor and that his crying is timed. He will allow you to continue the encounter in peace if you respond correctly.

 The patient who is in pain: Show compassion for the patient’s pain. Say something like “I know that you are in pain.” Offer help by asking, “Is there anything I can do for you to help you feel more comfortable?” Do not repeat painful maneuvers. If the patient does not allow you to touch his abdomen because of the severe pain he is experiencing, tell him, “I know that you are in pain, and I want to help you. I need to examine you, though, to be able to locate the source of your pain and give you the right treatment.” Reassure the patient by saying, “I will be as quick and gentle as possible.”

 The patient who can’t pay for the tests or for treatment: Reassure the patient by saying, “Not having enough money doesn’t mean you can’t get treatment.” You might also add, “We will refer you to a social worker who can help you find resources.”

 The patient who refuses to answer your question or let you examine him:

Explain to the patient why the question or the physical exam is important. Tell him that they are necessary to allow you to understand the problem and arrive at a diagnosis. If the patient still refuses to cooperate, skip the question or the maneuver, and document his refusal and your counseling in the PN.

 The hard-of-hearing patient: Face the patient directly to allow him to read your lips. Speak slowly, and do not cover your mouth. Use gestures to reinforce your words. If the patient has unilateral hearing loss, sit close to the hearing side. If necessary, you can also write your question down and show it to him.

 The patient who doesn’t know the names of his medications or is taking medications whose names you don’t recognize: Ask the patient if he has a prescription or a written list of the medications he is currently taking. If not, ask him to bring this list with him as soon as possible.

 The confused patient: If the patient is forgetful or confused, he will likely answer your questions by stating, “I don’t know” or “I can’t remember.” In such cases, ask your patient, “Is there anyone who does know about your problem, and may I contact him to obtain some information?”

 The phone encounter: The Step 2 CS may include a telephone encounter. As with other encounters, patient information will be posted on the door before you enter the examination room. Once you are inside, sit in front of the desk with the telephone, and push the speaker button by the yellow dot to be connected to the patient. Do not dial any numbers or touch any other buttons. You are permitted to call the SP only once. Treat this like a normal encounter and gather all the necessary information. To end the call, press the speaker button above the yellow dot. As in the pediatric encounter, there is no physical exam, so leave this portion of the PN blank.



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