First Aid for the USMLE Step 2 CS

Section 2. The Patient Encounter

The Patient Note

Once you have completed an encounter, your final task will be to compose a PN (see Figure 2-5 for a detailed overview of the clinical encounter and PN). Toward this goal, you will find a desk with a computer on it immediately outside the encounter room. Remember that all examinees taking the Step 2 CS will now be required to type, not handwrite, the PN. You will be given 10 minutes to type the PN and will be notified when two minutes remain. If you leave the encounter room before the end of the 15-minute period allotted for your patient encounter, you can devote the extra time you have to typing the PN. You are allowed to review the doorway information while you are typing the PN.

FIGURE 2-5. Summary Overview of the Patient Encounter

The PN screen located outside the encounter room will have your identification information and fields for History, Physical Exam, Differential Diagnosis, and Diagnostic Workup. Each field can accommodate only a certain number of characters: The character limits are 950 for History, 950 for Physical Exam, and 100 for each of the fields in Differential Diagnosis and Diagnostic Workup. One benefit of the computer note is that it allows you to delete extraneous information in favor of more pertinent portions of your note if you run out of space, so use this to your advantage, and use the space wisely.

FIGURE 2-5. Summary Overview of the Patient Encounter (continued)

Before you start typing the PN, take a few seconds to review the history, including the chief complaint, how it started, its progression, and the main symptoms. Then take a deep breath and try to relax. If you get nervous and try to rush, your thoughts may become garbled, and you will risk losing the point of your story.

Note that you will not be able to render diagrams such as the neurology stick figure for reflexes. You can simulate typing the PN online at the USMLE Web site.

Writing the Patient Note

You will be required to fill out four main sections in your PN: the history, physical exam, differential diagnosis, and initial diagnostic workup.

Summarizing the history. In writing the history, be clear, direct, and concise, and avoid long and complex phrases. Make sure the history flows in a logical sequence. Also bear in mind that it is not necessary to write a detailed, all-inclusive history.

The components that should be included are as follows:

 Chief complaint (CC)

 History of present illness (HPI)

 Review of systems (ROS)

 Past medical history (PMH)

 Past surgical history (PSH)

 Social history (SH)

 Family history (FH)

When you are summarizing the history, you need to be efficient with your time. One way to save time is to make ample use of abbreviations. Train yourself to use the abbreviations that are listed in the USMLE Step 2 CS orientation materials. You will find a copy of this list on each desk. You are allowed to use any abbreviations that are commonly used in U.S. hospitals. If you are unsure of the correct abbreviation, it is better to spell out the word or phrase.

In general, two styles of writing—narrative and “bullet”—are acceptable as long as your history is both comprehensive and coherent. Two examples can be found in the candidate orientation manual, and multiple examples of both styles are included in this book’s sample cases.

Outlining the physical exam. To summarize the physical exam, write a list of the systems that you examined, outlining all the relevant positive and negative findings. If you did not perform a maneuver that you think was necessary, it is better not to lie and pretend that you did. Be honest and list only the items you examined. For example, do not claim that you saw diabetic retinopathy in a patient with diabetes mel- litus if you did not even get to see the eye fundus. See Figure 2-6 for some examples of how to document physical exam findings.

Developing a differential. In writing the differential, you should use three of the following tables to list your three possible diagnoses and the historical and physical exam data that support them.

Diagnosis  
History Finding(s): Physical Exam Finding(s):
   
   
   

You are not required to list that many if two diagnoses suffice, but in general any common chief complaint will have at least three possible etiologies. It is preferable that your diagnoses be listed in order of probability, from the most to the least probable. Below each diagnosis, you need to list historical and physical findings that support why your diagnosis is likely. You do not need to list three findings for each, and in some cases, such as telephone interactions, you will not have any physical exam data at all.

FIGURE 2-6. Examples of How to Document Physical Exam Findings

Specifying the initial diagnostic workup. In summarizing your workup, list a maximum of eight tests that would help confirm or rule out the diagnoses you listed on your differential. It is best to start with the “forbidden” physical exam maneuvers (eg, rectal exam, pelvic exam) if you feel that such procedures are indicated. Then state the required laboratory and radiologic tests, starting with the most simple and straightforward tests and ending with the most complex. Do not include referrals, treatments, hospitalizations, or consults, as these will not be scored.

Be specific in your orders. Instead of “chem 7,” “thyroid panel,” or “liver function tests,” you should specify “Na, K,” “TSH and total T4,” and “AST and ALT.” You may, however, order electrolytes. Each group of related tests (blood tests, x-rays) should be listed together.

Scoring the Patient Note

The PN will be scored by a physician on the basis of its organization, quality of information, and interpretation of data. The final score will represent the average PN score of all 10 scored encounters.

How to Prepare

The cardinal rule for preparing to write a PN is to practice, practice, and practice. Imagine that you are in the actual exam, and try to type the PN within 10 minutes. When using the cases presented in this book, try to write your PN and then compare your note with ours. Ask yourself the following questions:

 Is the history complete?

 Does it make sense?

 Are the physical exam results complete?

 Is the differential diagnosis correct?

 Are the tests correct and in the right order?

There are two styles you can use both to document the physical exam and to compose the PN. So choose a method, memorize it, and stick with it. In this book, we will give you samples of bullet-style and traditional narrative-style formats so that you can familiarize yourself with both.

If you are running out of time, start from the bottom of the PN. Write down the differential diagnosis, the tests conducted, the physical exam, and then the history and the review of systems (listing only the positives first).





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