USMLE STEP 2 Clinical
Skills Basic CS Notes
Authors: Majid T. Aized & XAK
Revised & Edited by: R. Khalid & M. Shoaib
, Approach to USMLE Step 2CS Cases
USMLE CS has two parts
Encounter: It is what you want to do with the standardized patient (SP). You should not use medical
terminology during this. The main goal is to finish your checklist ticks! It has 5 parts. Each part has its
respective weightage.
o Opening (6 Points)
o History = OFDP(LIQR)AAA + DDs (Variable)
o General Question = PAMHUGSFOSSS (6-8 Points)
o Physical Examination (Variable Points)
o Closure (6 Points)
Patients Notes: There are 3 major portions and 2 minor portions of the notes by weightage.
o Major = HOPI with denials + DDs with bullet points + Labs
o Minor = Rest of HOPI + Physical Examination
(NOTE: Any significant physical finding gets more weightage so do not forget to write it down)
RedFlags
Red Flagsof
ofCS:
CS:
Assoon
As soonasastime
timeends,
ends,you
youLEAVE
leave the
THEroom.
ROOM.
Do not
Don’t bebe disrespectfulwith
DISREPCTFUL withthethePROCTORS.
proctors.
Do not
Don’t share/discuss your
SHARE/DISCUSS your cases
CASEsonline.
ONLINE.
Donot
Do notfabricate
fabricatestuff
material
in CS.inIfCS.
didIfnot
notasked,
asked,leave
leaveit.it.
At Doorway:
Note the following things:
1. Age (if >50 years, write PMDC)
2. Name of Patient (Last name with Mr. for male and Miss for Female)
3. Chief Compliant
4. Vitals (write only if some finding is abnormal like high BP or fever etc.)
Encounter
You must get 25 to 30 ticks checked from the list. They are divided into five portions. Say the patient's name
at the start of each portion. Use normal speed for opening, transitional sentences for general questions,
commands for physical exam and closure. For the rest, be swift and fast.
, OPENING
Six points of Opening
1. Greeting (Hello/Hi, Mr./Miss. XYZ + Good morning/evening)
2. Introduction (Last name with your designation + what you are going to do with him/her)
3. Comfortability
4. Permission for note writing
5. Open-ended Question
6. Rephrase
(NOTE:
(NOTE:InInER
ERcases,
cases,comfortability
comfortabilityprecedes
precedesthe
theintroduction
introductionand
andgreetings
greetingsare
areusually
usuallyskipped)
skipped)
Knock Knock. (Don’t say patients name outside the room because it will go against HIPAA’s confidentiality
guidelines. Wait for the patient’s response. (Red flags: Don’t barge into the room)
When you enter the room, remember to SMILE Remember to pause throughout your intro and be
slow (it’ll make the patient feel comfortable).
You: Mr./Miss XYZ?
SP: Yes.
You: Hi, my name is Dr. ABC and I am your physician here today and I will be asking you some questions
regarding your health followed by a brief physical examination. Is that OK with you?
SP: Yes, sure.
You: Thank you for allowing me to do that. It seems that you are nicely draped, is there anything I can do to
make you more comfortable?
SP: No, that’s fine.
You: Okay, alright. I hope you don’t mind if I take my notes while talking to you.
SP: Sure.
You: So, how can I help you Mr./Miss XYZ?
SP: Dr, I am having _________ problem.
You: Oh, I am so sorry to hear that, but let me assure you that I am here to help you as much as I can and
you do not need to worry. You are in safe hands. So, can you please tell me more about it?
(Note: If the patient gives you a vague complaint like not feeling well, feeling dizzy or winding then before
asking details question, first ask what do you mean by that/complaint? Then, ask about the details)
SP: SP will tell you a story in more than 80% of cases with giving details about the 1st differential. Listen
carefully to the story while the patient finishes and do not interrupt.
You: Thank you so much for sharing this valuable information with me. Let me rephrase what you have told
me so far? Repeat the patient’s story. After repeating, ask the patient: Is this correct?
SP: Yes etc.
You: Alright, let me make a note of it.
After writing down important information:
You: I want to ask more questions so that I can have the better idea what’s going on wrong with you?
, HISTORY
OFDP(LIQR)AAA
OFDP(LIQR)AAA+ DDs
+ DDs
Most of the OFDPAAA will be told by the patient already, so ask the rest of questions out of OFDPAAA.
OFDPAAA is used almost in each and every case (with little variability in some cases). In cases of pain, use
OPDPLIQRAA. Use signs that are shown rather than using the whole word. It will save more time with
maximum eye contact with the patient.
O: How did this start? S-sudden, G-gradual
F: Is it Continuous (C) or Episodic (E)?
(If episodic then ask: have you experienced similar episodes in the past? What is the duration of each
episode? When was the last episode?)
D: For how long have you are having this problem? (D-days, m-minutes, M-months)
P: Since it started has it been the same or getting worse? (↑=Progressive, →=Non-Progressive, ↓= Getting
better)
(In cases of episodes, progression is either increased in duration or increased in frequency of episodes. So
ask, if there any difference between this episode and previous episodes)
L: Can you exactly locate your pain?
I: On scale 1-10, how will you grade your pain; with 1 being the minimum and 10 being the maximum?
Q: Can you please describe the quality of your pain?
R: Does this pain go anywhere else?
A/↓: Anything making it better?
A/↑: Or worse?
A: Anything associated with it? If yes, ask details too (Atleast OFDP)
(In MSK-musculoskeletal cases, associated features are WRSS WNT
Warmth + Redness + Swelling + Stiffness + Weakness + Numbness + Tingling)
After that, move to your DDs portion and first ask most probable differentials to rule in DDs based on
OFDPAA. Then, ask the rest of DDs to rule out other differentials as well.
DD1 In ER cases, on entering when patient is in immediate distress, say:
DD2 Mr./Miss XYZ, it seems that you are in much discomfort. Is there anything I can do to
DD3 make you more comfortable? (After that say/add) Let me assure you that I am here to
help you. (Like switching off lights in case of SAH)
DD4
DD5 If patient’s name is difficult, ask from him/her in beginning that am I pronouncing
DD6 your name correctly?
DD7
DD8 If patient is coughing, offer a napkin and a glass of water (NOT IN CASE OF BELLY
PAIN). If patient takes napkin or holding one already, (at the end of encounter say) you
need it to get phlegm examined.
Skills Basic CS Notes
Authors: Majid T. Aized & XAK
Revised & Edited by: R. Khalid & M. Shoaib
, Approach to USMLE Step 2CS Cases
USMLE CS has two parts
Encounter: It is what you want to do with the standardized patient (SP). You should not use medical
terminology during this. The main goal is to finish your checklist ticks! It has 5 parts. Each part has its
respective weightage.
o Opening (6 Points)
o History = OFDP(LIQR)AAA + DDs (Variable)
o General Question = PAMHUGSFOSSS (6-8 Points)
o Physical Examination (Variable Points)
o Closure (6 Points)
Patients Notes: There are 3 major portions and 2 minor portions of the notes by weightage.
o Major = HOPI with denials + DDs with bullet points + Labs
o Minor = Rest of HOPI + Physical Examination
(NOTE: Any significant physical finding gets more weightage so do not forget to write it down)
RedFlags
Red Flagsof
ofCS:
CS:
Assoon
As soonasastime
timeends,
ends,you
youLEAVE
leave the
THEroom.
ROOM.
Do not
Don’t bebe disrespectfulwith
DISREPCTFUL withthethePROCTORS.
proctors.
Do not
Don’t share/discuss your
SHARE/DISCUSS your cases
CASEsonline.
ONLINE.
Donot
Do notfabricate
fabricatestuff
material
in CS.inIfCS.
didIfnot
notasked,
asked,leave
leaveit.it.
At Doorway:
Note the following things:
1. Age (if >50 years, write PMDC)
2. Name of Patient (Last name with Mr. for male and Miss for Female)
3. Chief Compliant
4. Vitals (write only if some finding is abnormal like high BP or fever etc.)
Encounter
You must get 25 to 30 ticks checked from the list. They are divided into five portions. Say the patient's name
at the start of each portion. Use normal speed for opening, transitional sentences for general questions,
commands for physical exam and closure. For the rest, be swift and fast.
, OPENING
Six points of Opening
1. Greeting (Hello/Hi, Mr./Miss. XYZ + Good morning/evening)
2. Introduction (Last name with your designation + what you are going to do with him/her)
3. Comfortability
4. Permission for note writing
5. Open-ended Question
6. Rephrase
(NOTE:
(NOTE:InInER
ERcases,
cases,comfortability
comfortabilityprecedes
precedesthe
theintroduction
introductionand
andgreetings
greetingsare
areusually
usuallyskipped)
skipped)
Knock Knock. (Don’t say patients name outside the room because it will go against HIPAA’s confidentiality
guidelines. Wait for the patient’s response. (Red flags: Don’t barge into the room)
When you enter the room, remember to SMILE Remember to pause throughout your intro and be
slow (it’ll make the patient feel comfortable).
You: Mr./Miss XYZ?
SP: Yes.
You: Hi, my name is Dr. ABC and I am your physician here today and I will be asking you some questions
regarding your health followed by a brief physical examination. Is that OK with you?
SP: Yes, sure.
You: Thank you for allowing me to do that. It seems that you are nicely draped, is there anything I can do to
make you more comfortable?
SP: No, that’s fine.
You: Okay, alright. I hope you don’t mind if I take my notes while talking to you.
SP: Sure.
You: So, how can I help you Mr./Miss XYZ?
SP: Dr, I am having _________ problem.
You: Oh, I am so sorry to hear that, but let me assure you that I am here to help you as much as I can and
you do not need to worry. You are in safe hands. So, can you please tell me more about it?
(Note: If the patient gives you a vague complaint like not feeling well, feeling dizzy or winding then before
asking details question, first ask what do you mean by that/complaint? Then, ask about the details)
SP: SP will tell you a story in more than 80% of cases with giving details about the 1st differential. Listen
carefully to the story while the patient finishes and do not interrupt.
You: Thank you so much for sharing this valuable information with me. Let me rephrase what you have told
me so far? Repeat the patient’s story. After repeating, ask the patient: Is this correct?
SP: Yes etc.
You: Alright, let me make a note of it.
After writing down important information:
You: I want to ask more questions so that I can have the better idea what’s going on wrong with you?
, HISTORY
OFDP(LIQR)AAA
OFDP(LIQR)AAA+ DDs
+ DDs
Most of the OFDPAAA will be told by the patient already, so ask the rest of questions out of OFDPAAA.
OFDPAAA is used almost in each and every case (with little variability in some cases). In cases of pain, use
OPDPLIQRAA. Use signs that are shown rather than using the whole word. It will save more time with
maximum eye contact with the patient.
O: How did this start? S-sudden, G-gradual
F: Is it Continuous (C) or Episodic (E)?
(If episodic then ask: have you experienced similar episodes in the past? What is the duration of each
episode? When was the last episode?)
D: For how long have you are having this problem? (D-days, m-minutes, M-months)
P: Since it started has it been the same or getting worse? (↑=Progressive, →=Non-Progressive, ↓= Getting
better)
(In cases of episodes, progression is either increased in duration or increased in frequency of episodes. So
ask, if there any difference between this episode and previous episodes)
L: Can you exactly locate your pain?
I: On scale 1-10, how will you grade your pain; with 1 being the minimum and 10 being the maximum?
Q: Can you please describe the quality of your pain?
R: Does this pain go anywhere else?
A/↓: Anything making it better?
A/↑: Or worse?
A: Anything associated with it? If yes, ask details too (Atleast OFDP)
(In MSK-musculoskeletal cases, associated features are WRSS WNT
Warmth + Redness + Swelling + Stiffness + Weakness + Numbness + Tingling)
After that, move to your DDs portion and first ask most probable differentials to rule in DDs based on
OFDPAA. Then, ask the rest of DDs to rule out other differentials as well.
DD1 In ER cases, on entering when patient is in immediate distress, say:
DD2 Mr./Miss XYZ, it seems that you are in much discomfort. Is there anything I can do to
DD3 make you more comfortable? (After that say/add) Let me assure you that I am here to
help you. (Like switching off lights in case of SAH)
DD4
DD5 If patient’s name is difficult, ask from him/her in beginning that am I pronouncing
DD6 your name correctly?
DD7
DD8 If patient is coughing, offer a napkin and a glass of water (NOT IN CASE OF BELLY
PAIN). If patient takes napkin or holding one already, (at the end of encounter say) you
need it to get phlegm examined.
