First Aid for the USMLE Step 2 CS PDF

First Aid for the USMLE Step 2 CS pdf

Download USMLE Step 2 CS – The USMLE Step 2 CS can be a source of stress and anxiety, especially among international medical graduates (IMGs), who often find themselves at a disadvantage because of their non-U.S. training background.

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First Aid for the USMLE Step 2 CS is our “cure” for this exam. This book represents a virtual medicine bag of high-yield tools for students and IMGs, including:

Features of USMLE Step 2 CS

  • 44 full-length practice cases that simulate the real exam–including pediatric and telephone interviews as well as suggested closing statements for each case
  • A revised and expanded set of minicases representing common complaints, designed to help you rapidly develop a set of differential diagnoses
  • Updated content based on feedback from recent U.S. and international test takers
  • Step-by-step strategies for interacting with standardized patients, including “difficult patients”
  • Detailed descriptions of high-yield physical exam maneuvers that will win you points without costing time
  • Time management advice to maximize your clinical encounters
  • Proven study and exam strategies from students who passed the exam

Table of Content: USMLE Step 2 CS

Contributors ………………………………………………………………………………………..ix
Faculty Reviewers …………………………………………………………………………………xi
Preface………………………………………………………………………………………………xiii
Acknowledgments……………………………………………………………………………….xv
How to Contribute…………………………………………………………………………….. xvii
SECTION 1 GUIDE TO THE USMLE STEP 2 CS 1
Introduction………………………………………………………………………………………… 2
USMLE Step 2 CS—The Basics………………………………………………………………. 2
Preparing for the Step 2 CS…………………………………………………………………… 9
Test-Day Tips …………………………………………………………………………………….. 11
First Aid for the IMG…………………………………………………………………………… 13
Supplement—The USMLE Step 2 CS Travel Guide…………………………………. 21
SECTION 2 THE PATIENT ENCOUNTER 39
Introduction………………………………………………………………………………………. 40
Doorway Information………………………………………………………………………….. 42
Taking the History………………………………………………………………………………. 44
The Physical Exam……………………………………………………………………………… 54
Closure …………………………………………………………………………………………….. 63
How to Interact with Special Patients……………………………………………………. 65
Challenging Questions and Situations ………………………………………………….. 67
Counseling ……………………………………………………………………………………….. 77
The Patient Note ……………………………………………………………………………….. 79
SECTION 3 MINICASES 85
Headache …………………………………………………………………………………………. 87
Confusion/Memory Loss……………………………………………………………………… 89
Loss of Vision…………………………………………………………………………………….. 91
Depressed Mood……………………………………………………………………………….. 92
Psychosis ………………………………………………………………………………………….. 93
vi
Dizziness…………………………………………………………………………………………… 94
Loss of Consciousness………………………………………………………………………… 95
Numbness/Weakness …………………………………………………………………………. 96
Fatigue and Sleepiness ………………………………………………………………………. 98
Night Sweats …………………………………………………………………………………… 100
Insomnia …………………………………………………………………………………………. 100
Sore Throat……………………………………………………………………………………… 101
Cough/Shortness of Breath ……………………………………………………………….. 102
Chest Pain ………………………………………………………………………………………. 105
Palpitations……………………………………………………………………………………… 107
Weight Loss…………………………………………………………………………………….. 108
Weight Gain ……………………………………………………………………………………. 109
Dysphagia……………………………………………………………………………………….. 110
Neck Mass ………………………………………………………………………………………. 111
Nausea/Vomiting……………………………………………………………………………… 111
Abdominal Pain ……………………………………………………………………………….. 112
Constipation/Diarrhea ………………………………………………………………………. 116
Upper GI Bleeding …………………………………………………………………………… 118
Blood in Stool………………………………………………………………………………….. 119
Hematuria……………………………………………………………………………………….. 119
Other Urinary Symptoms…………………………………………………………………… 120
Erectile Dysfunction………………………………………………………………………….. 122
Amenorrhea…………………………………………………………………………………….. 123
Vaginal Bleeding ……………………………………………………………………………… 124
Vaginal Discharge…………………………………………………………………………….. 126
Dyspareunia…………………………………………………………………………………….. 126
Abuse …………………………………………………………………………………………….. 127
Joint/Limb Pain………………………………………………………………………………… 128
Low Back Pain………………………………………………………………………………….. 132
Child with Fever ………………………………………………………………………………. 133
Child with GI Symptoms……………………………………………………………………. 134
Child with Red Eye …………………………………………………………………………… 136
Child with Short Stature…………………………………………………………………….. 136
Behavioral Problems in Childhood……………………………………………………… 137
SECTION 4 PRACTICE CASES 139
Case 1 46-Year-Old Man with Chest Pain………………………………………… 142
Case 2 57-Year-Old Man with Bloody Urine…………………………………….. 152
vii
Case 3 51-Year-Old Man with Back Pain …………………………………………. 161
Case 4 25-Year-Old Man Presents Following Motor Vehicle Accident…. 170
Case 5 28-Year-Old Woman Presents with Positive Pregnancy Test…….. 180
Case 6 10-Year-Old Girl with New-Onset Diabetes…………………………… 189
Case 7 74-Year-Old Man with Right Arm Pain………………………………….. 197
Case 8 56-Year-Old Man Presents for Diabetes Follow-up ………………… 206
Case 9 25-Year-Old Woman Presents Following Sexual Assault …………. 216
Case 10 35-Year-Old Woman with Calf Pain ……………………………………… 225
Case 11 62-Year-Old Man with Hoarseness ………………………………………. 235
Case 12 67-Year-Old Woman with Neck Pain ……………………………………. 243
Case 13 48-Year-Old Woman with Abdominal Pain ……………………………. 251
Case 14 35-Year-Old Woman with Headaches…………………………………… 260
Case 15 36-Year-Old Woman with Menstrual Problems………………………. 269
Case 16 28-Year-Old Woman with Pain During Sex ……………………………. 278
Case 17 75-Year-Old Man with Hearing Loss …………………………………….. 287
Case 18 5-Day-Old Boy with Jaundice……………………………………………… 296
Case 19 7-Month-Old Boy with Fever………………………………………………. 305
Case 20 26-Year-Old Man with Cough……………………………………………… 314
Case 21 52-Year-Old Woman with Jaundice ……………………………………… 323
Case 22 53-Year-Old Man with Dizziness ………………………………………….. 332
Case 23 33-Year-Old Woman with Knee Pain ……………………………………. 340
Case 24 31-Year-Old Man with Heel Pain………………………………………….. 350
Case 25 18-Month-Old Girl with Fever …………………………………………….. 360
Case 26 54-Year-Old Woman with Cough…………………………………………. 369
Case 27 61-Year-Old Man with Fatigue…………………………………………….. 379
Case 28 54-Year-Old Man Presents for Hypertension Follow-up ………….. 388
Case 29 20-Year-Old Woman with Sleeping Problems ……………………….. 397
Case 30 2-Year-Old Girl with Noisy Breathing……………………………………. 407
Case 31 21-Year-Old Woman with Abdominal Pain ……………………………. 416
Case 32 65-Year-Old Woman with Forgetfulness and Confusion………….. 426
Case 33 46-Year-Old Man with Fatigue…………………………………………….. 436
Case 34 32-Year-Old Woman with Fatigue ……………………………………….. 445
Case 35 27-Year-Old Man with Visual Hallucinations ………………………….. 454
Case 36 32-Year-Old Man Presents for Preemployment Physical………….. 463
Case 37 55-Year-Old Man with Bloody Stool …………………………………….. 472
Case 38 66-Year-Old Man with Tremor……………………………………………… 481
Case 39 30-Year-Old Woman with Weight Gain ………………………………… 490
viii
Case 40 6-Month-Old Girl with Diarrhea…………………………………………… 499
Case 41 8-Year-Old Boy with Bed-Wetting ……………………………………….. 507
Case 42 11-Month-Old Girl with Seizures …………………………………………. 515
Case 43 21-Year-Old Man with Sore Throat ………………………………………. 523
Case 44 49-Year-Old Man with Loss of Consciousness ……………………….. 532
SECTION 5 TOP-RATED REVIEW RESOURCES 541
How to Use the Database …………………………………………………………………. 542
Appendix………………………………………………………………………………………… 547
Index………………………………………………………………………………………………. 551
About the Authors……………………………………………………………………………. 573

Acknowledgement – USMLE Step 2 CS

This has been a collaborative effort from the start. We gratefully acknowledge the thoughtful comments, corrections, and advice of the many medical students, residents, international medical graduates, and faculty who have supported the authors in the continuing development of First Aid for the USMLE Step 2 CS. For support and encouragement throughout the process, we are grateful to Thao Pham, Isabel Nogueira, Louise Petersen, and Jonathan Kirsch. Thanks to our publisher, McGraw-Hill, for the valuable assistance of its staff. For enthusiasm, support, and commitment to the First Aid series, thanks to our editor, Catherine Johnson. For outstanding editorial work, we thank Andrea Fellows, our developmental editor. Finally, a special thanks to Rainbow Graphics, especially David Hommel, Tina Castle, and Susan Cooper, for remarkable editorial and production support.

INTERNSHIP OPPORTUNITIES

The author team of Le and Bhushan is pleased to offer part-time and full-time paid internships in medical education and publishing to motivated medical students and physicians. Internships may range from two to three months (eg, a summer) up to a full year. Participants will have an opportunity to author, edit, and earn academic credit on a wide variety of projects, including the popular First Aid series. Writing/editing experience, familiarity with Microsoft Word, and Internet access are required. For more information, e-mail a résumé or a short description of your experience along with a cover letter and writing sample to [email protected]

Introduction: USMLE Step 2 CS

As a prerequisite to entering residency training in the United States, all U.S. and Canadian medical students as well as international medical graduates (IMGs) are required to pass a clinical skills exam known as the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS)—a test involving clinical encounters with “standardized patients.” Even if you are a pro at taking standardized exams such as the USMLE Step 1 and Step 2 Clinical Knowledge (CK), you may find it challenging to prepare for the USMLE Step 2 CS, which distinguishes itself from other USMLE exams by using live patient actors to simulate clinical encounters. Common mistakes medical students and IMGs make in preparing for the Step 2 CS include the following: Panicking because of the unfamiliar format of the test Not practicing enough with mock patient scenarios before taking the actual exam Not developing a logical plan of attack based on patient “doorway information” Failing to understand the required objectives for each patient encounter Managing time poorly during patient encounters Becoming flustered by challenging questions or situations Taking unfocused histories and physical exams Failing to understand how to interact with a patient appropriately Neglecting to carry out easy but required patient interactions This book will guide you through the process of efficiently preparing for and taking the Step 2 CS with five organized sections: Section 1 introduces you to the Step 2 CS. Section 2 reviews critical high-yield steps to take during the patient encounter. Section 3 provides high-yield minicases for common doorway chief complaints to help you rapidly develop focused differentials during the exam. Section 4 offers full-length practice cases to help you simulate the real thing. Section 5 rates other resources that help you prepare for the Step 2 CS

What Is the USMLE Step 2 CS?

The USMLE Step 2 CS is a one-day exam whose objective is to ensure that all U.S. and Canadian medical students seeking to obtain their medical licenses—as well as all IMGs seeking to start their residencies in the United States—have the communication, interpersonal, and clinical skills necessary to achieve these goals. To pass the test, all examinees must show that they can speak, understand, and communicate in English as well as take a history and perform a brief physical exam. Examinees are also required to exhibit competence in written English and to demonstrate critical clinical skills by writing a brief patient note (PN), follow-up orders, and a differential diagnosis.

The Step 2 CS simulates clinical encounters that are commonly found in clinics, physicians’ offices, and emergency departments. The test makes use of “standardized patients” (SPs), all of whom are laypersons who have been extensively trained to simulate various clinical problems. The SPs give the same responses to all candidates participating in the assessment. When you take the Step 2 CS, you will see 12 SPs over the course of about an eight-hour day, including a 30-minute break for lunch. Half of the cases are performed before the lunch break and half afterward. SPs will be mixed in terms of age, gender, ethnicity, organ system, and discipline. For quality assurance purposes, a video camera will record all clinical encounters, but the resulting videotapes will not be used for scoring. The cases used in the Step 2 CS represent the types of patients who are typically encountered during core clerkships in the curricula of accredited U.S. medical schools. These clerkships are as follows: Internal medicine Surgery Obstetrics and gynecology Pediatrics Psychiatry Family medicine Emergency medicine Examinees do not interact with children during pediatric encounters. Instead, SPs assuming the role of pediatric patients’ parents recount patients’ histories, and no physical exam is required under such circumstances.

How Is the Step 2 CS Structured?

Before entering a room to interact with an SP, you will be given an opportunity to review some preliminary information. This information, which is posted on the door of each room (and hence is often referred to as “doorway information”), includes the following: Patient characteristics (name, age, gender) Chief complaint and vitals (temperature, respiratory rate, pulse, blood pressure) You will be given 15 minutes (with a warning bell sounded after 10 minutes) to perform the clinical encounter, which includes reading the doorway information, entering the room, introducing yourself, obtaining an appropriate history, conducting a focused physical exam, formulating a differential diagnosis, and planning a diagnostic workup. You will also be expected to answer any questions the SP might ask, discuss the diagnoses being considered, and advise the SP about any follow-up plans you might have. After leaving the room, you will have 10 minutes to type a PN. Examinees will not be permitted to handwrite the PN unless technical difficulties on test day make the typing program unavailable. If you happen to finish a clinical encounter early, there is no need for you to rush out the door. Once you leave the examination room, you may not reenter it. So if you find yourself running ahead of schedule, you might consider telling the patient that you are organizing your notes, as one or two last-minute questions might pop into mind.

How Is the Step 2 CS Scored?

Of your 12 patient encounters, 10 will be scored. Two people will score each encounter: the SP and a physician. The SP will evaluate you at the end of each encounter by filling out three checklists: one for the history, a second for the physical exam, and a third for communication skills. The physician will evaluate the PN you write after each encounter. Your overall score, which will be based on the clinical encounter as a whole and on your overall communication skills, will be determined by the following three components: 1. Integrated Clinical Encounter (ICE) score. The skills you demonstrate in the clinical encounter are reflected in your ICE score. This score will reflect your data-gathering and data interpretation skills. Data gathering. SPs will evaluate your data-gathering skills by documenting your ability to collect data pertinent to the clinical encounter. Specifically, they will note whether you asked the questions listed on their checklists, successfully obtained relevant information, and correctly conducted the physical exam (as indicated by your performance of the procedures on their checklists). If you asked questions or performed procedures that are not on an SP’s checklist, you will not receive credit—but at the same time will not lose credit—for having done so. Data interpretation. To demonstrate your data interpretation skills, you will be asked to document, as part of the PN, your analysis of a patient’s possible diagnoses and your assessment of how such diagnoses are supported or refuted by the evidence obtained from the history and physical exam. Although in actual practice physicians must develop the ability to recognize and rule out a range of disorders, you will be asked to record only the most likely diagnoses along with the positive and negative findings that support each. Physicians who score the PN make a global assessment based on documentation and organization of the history and physical exam; the relevance, justification, and order of the differential diagnosis; and the initial testing modalities proposed. Your final score will represent the average of your individual PN scores over all 10 scored clinical encounters. 2. Communication and Interpersonal Skills (CIS) score. In addition to assessing your data-gathering abilities, SPs will evaluate your communication and interpersonal skills. According to the USMLE, these include fostering a relationship with the patient, gathering and providing information, helping the patient make decisions, and supporting the patient’s emotions. You will be evaluated on your ability to tailor your questions and responses to the specific needs of the case presented and on your capacity to react to the patient’s concerns. Overall, the CIS subcomponent focuses on your ability to conduct a patient-centered interview (discussed at length in Section 2) in which you identify and respond to the broader scope of the patient’s concerns beyond just the diagnosis. The CIS performance is documented by SPs with checklists. 3. Spoken English Proficiency (SEP) score. This component scores you on pronunciation, word choice, and the degree of effort the SP must make to understand your spoken English. The SEP score is based on SP evaluations that make use of rating scales. The grade you receive on the Step 2 CS will be either a “pass” or a “fail.” Your report will include a graphic representation of your strengths and weaknesses on all three components of the exam. Unlike Step 1 or Step 2 CK, you will not receive a numerical score. To pass the Step 2 CS overall, candidates must pass all three individual components. The good news is that most U.S. and Canadian medical students pass (see Table 1-1). However, the failure rate is higher among IMGs, with approximately one in four examinees failing. Relatively few U.S. students fail the CIS, and even fewer fail the SEP component. If U.S. students fail the exam as a whole, it is most likely due to poor ICE scores. For IMGs, the CIS is the most likely component to cause failure. The SEP is more of a challenge for IMGs compared to U.S. students but is still the least likely component to cause failure. Few IMGs fail all three subcomponents.

About the Author

Tao Le, MD, MHS (Louisville, KY) is Assistant Clinical Professor of Pediatrics in the Division of Allergy and Immunology at the University of Louisville. He is also affiliated with the Division of Allergy and Immunology at The Johns Hopkins University School of Medicine.
Vikas Bhushan, MD (Los Angeles, CA) practices diagnostic radiology in Los Angeles, California.

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