How to Prepare for USMLE CS

HOW TO PREPARE FOR THE USMLE STEP2 CS?

CSR

C

S: smile, silence(不打断病人), support(扶病人上下床，保护病人走路)

R: response

*一切根据 priority

Three critical thinking moments

Doorway information: 30-45s, 整理思路

Washing hands: 可长可短，不聊天，整理思路

Chest & CV exam: 整理思路

One piece of paper

Mental checklist

3O + 2P + 2Q AAA

PAMHUGFOSS WA

Most important DDx

Life-threatening complication: 由缓到急

Side-effect: 医源性

Important associations

Diabetes mellitus

Hyper/hypothyroidism

Depression

Gastrointestinal tumors

Infections

Some physical examinations

Neurological exams

Gait

Romberg

指鼻试验

面部刺激

Shoulder 刺激

握拳

抬腿

Reflex

Mini-mental examination

Orientation (person, place, time)

Memory (3-word)

Attention (spelling)

Family history (2): Family, close contact

Social habit (5): Smoking, alcohol, illegal drugs, diet & diabetes / hypertension

For the mini-cases, the focus with be on 4 separate sections:

1. Differential Diagnosis

2. History

For the “Main” section, capital letter means a must ask question.

3O =

3O + 2P =

3O + 2P + 2Q =

LIQR =

ABCO =

AAA =

WA =

PAMHUGFOSS =

3. Physical Exam

4. Workups

---------------------------------------------------①-------------------------------------------------------

Headache

Differential Diagnosis

Migraine (complicated)

Cluster headache

Temporal arteritis (giant cell arteritis)

Sinusitis

Tension headache

Subarachnoid hemorrhage

Meningitis (bacterial)

Pseudotumor cerebri

Trigeminal neuralgia

History

Main：3O LIQr AAA PAMHugFoss

Associated syndromes:

Fever → confusion, rigid neck

Confusion / loss of consciousness

Weakness / numbness

Visual change → nausea / vomiting

Runny nose → tearing

Pain with chewing

Physical exam

HEENT exams

Neurological exams

Abdominal pain


Nephrolithiasis

Pancreatic cancer

Acute pancreatitis

Acute cholecystitis

Ascending cholangitis

Acute hepatitis

Peptic ulcer disease

Peptic ulcer perforation

Splenic rupture

Intestinal obstruction

Mesenteric ischemia / infarction

Ovarian torsion

Diverticulitis

Acute appendicitis

Irritable bowel syndrome

Pelvic inflammatory disease

History

3O 2P LIQR AAA WA PAMHUGFosS


Relation to meals

Nausea / vomiting

Domestic violence

Physical exam

Cardio and pulmonary exams

Abdominal exams (guarding, Murphy sign, psoas and obturator signs)

Chest pain


Myocardial infarction (MI)

Sickle cell disease-pulmonary infarction

GERD

Angina

Pericarditis

Costochondritis

Pulmonary embolism

Aortic dissection

History

3O 2P LIQR AAA WA PAMHUgFosS


Sweating

Palpitation

Cardiac risk factors

Pulmonary embolism risk factors

Physical exam

Blood pressure (both arms)

Complete cardiovascular exams (JVD, PMI, chest wall tenderness, heart sounds,

pulses, edema)

Pulmonary and abdominal exams

Joint / limb pain


Joint pain

Systemic lupus erythematosus (SLE)

Rheumatoid arthritis

Psoriatic arthritis

Osteoarthritis

Septic arthritis

Limb pain

Domestic violence

Carpal tunnel syndrome

Hip fracture

Hip dislocation-traumatic

Stress fracture

Plantar fasciitis

Tennis elbow (lateral epicondylitis)

Disseminated gonorrhea

Peripheral vascular disease (intermittent claudication)

Deep venous thrombosis

Angina / MI

Shoulder dislocation

Rhabdomyolysis due to simvastatin or clofibrate

History

3O 2P LIQR AAA PAMHUGFOSS


Swelling, redness, warmth of involved joints

Red eye

Oral or genital ulceration

Rash

Focal numbness / weakness

Recent trauma

Physical exam

Musculoskeletal exams

Relevant neurovascular exams

Low back pain


Disk herniation

Lumber muscle strain

Lumbar spinal stenosis

Malingering

History

3O 2P LIQR AAA PAMHUGFOSS


Context (moving furniture, trauma)

Physical exam

Neurologic exam

Back palpation and range of motion

Hip exam

Cough / Shortness of breath


Asthma

COPD-chronic bronchitis

Pneumonia

Atypical pneumonia

Lung cancer

COPD exacerbation (bronchitis)

Tuberculosis

Congestive heart failure

History

3O AAA WA PAMHUgFOSS


Sputum

Chest pain / heartburn

Exposures

Physical exam

ENT exams


Lymph node exams

Extremities exams

Night sweats


Tuberculosis (Acute HIV infection, lymphoma, leukemia, hyperthyroidism)

History

3O aaA WA PAMHUGFOSS

*Severity, frequency, timing, pattern


Cough → hemoptysis, chest pain

Lymphadenopathy

Fever

Rash → itching

Malaise

Nausea / vomiting

Menstrual history → peri-menopause

Physical exam

HEENT exams

Abdominal exams (hepatosplenomegaly)


Dysphagia


Esophageal cancer

Plummer-Vinson syndrome

Achalasia

Esophagitis

History

3O 2P AAA WA PAMHUGFosS

Solids or liquids vs. both solids and liquids


Drooling

Regurgitation

Odynophagia

History of Raynaud phenomenon

Physical exam

Head and neck exams


Skin exams

Upper GI bleeding


Bleeding peptic ulcer

Gastritis

History

3O ABCO AAA PAMHugFosS


Context (severe vomiting, alcohol ingestion)

Nausea

Abdominal pain

Physical exam

ENT exams


Abdominal exams

Blood in stool


Colorectal cancer

Ulcerative colitis

Diverticulosis

History

3O ABCO AAA WA PAMHuGFosS

*Melena vs. bright blood


Abdominal / rectal pain

Nausea / vomiting

Trauma

Physical exam

Abdominal exams

Rectal exams

Hematuria


Bladder cancer

Polycystic kidney disease

Renal cell carcinoma

History

3O ABCO AAA PAMHUgFoSS


Renal colic

Dysuria

Voiding symptoms

History of vigorous exercise

Physical exam

Lymph node exams

Abdominal exams

Genitourinary exams

Loss of Consciousness (LOC)


Complex tonic-clonic seizure

Drug-induced orthostatic hypotension (causing syncope)

Cardiac arrhythmia (causing syncope)

History

3O aaA PAMHugFosS

Emphasize on CONTEXT


Preceding symptoms

Nausea

Palpitation

Associated symptoms

Tongue biting

Incontinence

Prolonged confusion

Physical exam

Neurological exams

Carotid exams


Dizziness


Méniѐre disease

Orthostatic hypotension due to dehydration

Drug-induced orthostatic hypotension

Benign positional vertigo

Vestibular neuronitis

Labyrinthitis

History

Main：3O AAA PAMHUGFosS

Lightheadedness vs. vertigo


Auditory symptoms → hearing loss, tinnitus

Visual symptoms

Nausea / vomiting

Physical exam

Neurological exams (Romberg test, tilt test, gait)

Auditory tests (Hearing, Weber and Rinne tests)

Cardiovascular exams

Erectile dysfunction (ED)


Drug-related ED (Hypertension ED, DM ED, psychogenic ED)

History

3O AAA PAMHUgFoSS


±nocturnal erections

±libido

Stress or depression

Physical exam


Genitourinary exams

Rectal exams

---------------------------------------------------②-------------------------------------------------------

Other urinary symptoms


Benign prostatic hyperplasia (BPH)

Prostate cancer

Urethritis

Acute pyelonephritis

Stress incontinence

Urge incontinence

History

3O AAA WA PAMHUgFoSS


Obstructive symptoms

Hesitancy

Diminished stream

Sense of imcomplete bladder emptying

Straining postvoid dribbling

Irritative symptoms

Urgency

Frequency

Nocturia

Physical exam

Abdominal exams

Genitourinary exams

Rectal exams

Fatigue and sleepiness


Depression

Posttraumatic stress disorder

Colon cancer

Hypothyroidism

Diabetes mellitus

Obstructive sleep apnea

Sleep deprivation

History

3O AAA WA PAMHUGFosS


Sleep associated

Snoring

Witnessed apnea

Emotion associated

Stress

Depression

Work or life style changes

Other associated

Hypothyroidism

Bleeding or anemia

Physical exam

ENT exams

Extremity exams


Confusion / Memory loss


Vascular (“multi-infarct” dementia)

Alzheimer disease

Normal pressure hydrocephalus

Creutzfeldt-Jakob disease

Hypoglycemia

Subdural hematoma

History

MUST INCLUDE history from family members / caregivers

Main：3OP AAA WA PAMHUgFoSS


Fall → hit head

Palpitation → weakness

Depression

Cold intolerance

Infection → HIV, syphilis, prion

Physical exam

Neurological exams

Mini-mental status exams

HEENT exams

Nausea / vomiting


Pregnancy (gastritis, hypercalcemia, diabetes mellitus, UTI, depression)

History

3O ABCO AAA PAMHuGFosS


Abdominal pain

Relation to meals

Sick contacts

Possible food poisoning

Possible pregnancy

Physical exam

ENT exam

Abdominal exam

Constipation / diarrhea


Colorectal cancer

Low-fiber diet

Irritable bowel syndrome

Infectious diarrhea (gastroenteritis)-bacterial, viral, parasitic, protozoal

Pseudomembranous (Clostridium difficile) colitis

Traveler’s diarrhea

Lactose intolerance

Crohn disease

History

3O ABCO AAA WA PAMHuGFosS


Abdominal pain

Sense of incomplete evacuation

Diet (fiber and fluid intake)

Sick contacts / recent travels

Physical exam

Thyroid / endocrine exams

Abdominal exams

Rectal exams

Numbness / Weakness


Transient ischemic attack (TIA)

Stroke

Guillain-Barré syndrome

Multiple sclerosis

Diabetic peripheral neuropathy

Myasthenia gravis

Todd paralysis

History

3O 2P AAA PAMHUGFosS

LOCATION (unilateral, bilateral, proximal, distal)


Pain → head pain / neck pain

Visual changes → Eye pain

Neurologic symptoms → loss of senses, slurred speech

Physical exam

Orthostatic vital signs

Neurologic exams

Weight loss


Hyperthyroidism (cancer, HIV infection, anorexia nervosa, malabsorption)

History

3O aaA PAMHuGFosS

*Amount


±intention

Body image

Anxiety or depression

Hyperthyroidism (palpitation, tremor, diarrhea)

Physical exam

Thyroid exam (exophthalmos, lid retraction, lid lag, gland size, bruit, tremor)

Cardiovascular exam

Weight gain


Smoking cessation (drug side effect, hypothyroidism, Cushing syndrome, Polycystic

ovary syndrome, diabetes mellitus, atypical depression)

History

3O aaA PAMHuGFosS

*Amount


Relation to medication changes, smoking cessation, depression

Diet history

Hypothyroidism (fatigue, constipation, skin changes)

Menstrual irregularity

Physical exam

*Brief exam based on the diagnosis

---------------------------------------------------③-------------------------------------------------------

Palpitations


Hypoglycemia

Panic attack

Social phobia

History

3O aaA PAMHUGFosS

*Gradual vs. acute onset/offset


Context (exertion, caffeine, anxiety)

Light-headedness

Dyspnea

Hypothyroidism symptoms

Physical exam

Thyroid exam (exophthalmos, lid retraction, lid lag, gland size, bruit, tremor)

Cardiovascular exam

Sore throat


Infectious mononucleosis

HIV, acute retroviral syndrome

Pharyngitis

Hepatitis

History

3O aaA wA PAMHugFosS


Fever

ENT symptoms (ear pain, nasal or sinus congestion)

Odynophagia

Swollen glands

Cough

Rash

Sick contacts

HIV risk factors

Physical exam

ENT exams

Pulmonary exams

Skin exams

---------------------------------------------------Ob/Gyn-------------------------------------------------------

Amenorrhea


Pregnancy

Polycystic ovary syndrome

Amenorrhea secondary to prolactinoma

Menopause

Sheehan syndrome

Anorexia nervosa

Anxiety-induced amenorrhea

History

3O aaA PAMHugFoSS

*Primary vs. secondary


Relationship to menstrual period

Menopausal symptoms

Pregnancies

Eating disorders (anorexia nervosa, excessive dieting, vigorous exercise)

Physical exam

Breast exams

Complete pelvic exams

Vaginal bleeding


Dysfunctional uterine bleeding

Endometrial cancer

Cervical cancer

Spontaneous abortion

Ectopic pregnancy

History

3O ABCO AAA WA PAMHugFoSS

Pre- vs. postmenopausal


Relationship to menstrual period

Discharge

Pelvic or abdominal pain

History of Pap smears

Physical exam

Abdominal exams

Pelvic exams

Vaginal discharge


Bacterial vaginosis

Vaginitis-candidal

Vaginitis-trichomonal

History

3O ABCO AAA PAMHugFOSS


Vaginal burning, pain, pruritus

Sexual activity + protection

History of STD

Sick contacts

Physical exam

Abdominal exams

Pelvic exams

Dyspareunia


Atrophic vaginitis

Endometriosis

History

3O AAA PAMHugFoSS


Vaginal discharge

Painful menses

Menopausal symptoms (hot flashes)

Adequacy of lubrication

Physical exam

Abdominal exams

Pelvic exams

---------------------------------------------------Ped-------------------------------------------------------

*Some important things in Ped

√SID= Sick contacts + Immunization + Day care

√NO diabetes or BP is needed

√NO occupation information is needed

√NO sexual information is needed

√If younger than 9 years old, then social history is NOT needed

Child with fever


Neonatal sepsis

Acute otitis media

Measles (or other viral exanthem)

Gastroenteritis (viral, bacterial, parasitic)

History

3O aaA WA PAMHUGFS


SID

Severity

Localized symptoms

Rash

Physical exam

HEENT exams


Abdominal exams

Skin exams

Child with GI symptoms


Pyloric stenosis

Hirschsprung disease

Intussusception

Somatoform disorder

Colic

History

3O 2P LIQR AAA WA PAMHUGFS


SID

Association with food

Physical exam


Abdominal exams

Rectal / pelvic exams (women)

Child with red eye


Bacterial conjunctivitis (viral conjunctivitis, keratitis, uveitis, seasonal allergies)

History

3O AAA PAMHUGFS


SID

Eye discharge / pain

Difficulty open of eye

Physical exam

HEENT exams

Child with short stature


Familial short stature (growth hormone deficiency, hypothyroidism, chronic renal

insufficiency, genetic disorder)

History

3O aaA PAMHUGFS

Prenatal and birth history

Growth history

Physical exam

Height / weight

HEENT exams


Abdominal exams

Neurological exams

Behavioral problems in childhood


Attention-deficit hyperactivity disorder (ADHD)

Adjustment disorder

Substance abuse

Age-appropriate behavior

History

3O aaA PAMHUGFS

Developmental history

Physical violence or use of weapons

Substance use

Changes in environment

School performance

Physical exam

Neurologic exams

---------------------------------------------------Psy/Consult-------------------------------------------------------

Psychosis


Schizophrenia

Substance-induced psychosis

Schizoaffective disorder

History

Main：3O aaA WA PAMHugFoss


Positive (Delusions, disorganized thought, disorganized behavior)

Negative (Social withdraw, decreased motivation, decreased speech / thought)

Physical exam

Mental status exams

Depressed mood


Normal bereavement

Major depressive disorder

Bipolar I disorder

History

Main：3O aaA WA PAMHUGFOSS

SUICIDE risk assessment


Stress

Sleep pattern → Fatigue

Manic episode

Decreased social function, interest, energy, concentration

Physical exam

Mental status exams

HEENT exams

Abuse


Domestic violence

Rape

History

*Establish Confidentiality

3O aaa PAMHugFOSS


Physical, sexual, or emotional abuse

Fear

Safety

Backup plan

Physical exam

Complete exam

Insomnia


Stress-induced insomnia

Obstructive sleep apnea

Insomnia related to major depressive disorder

History

3O aaA WA PAMHugFosS

Description: trouble falling asleep vs. multiple awakenings vs. early-morning

awakening


Medical problems keeping patient awake

Arthritis (pain)

Diabetes (polyuria)

Daytime sleepiness

Snoring

Nightmares

Depression

Caffeine use

Work or lifestyle changes

Stress

Physical exam

Mental status exams

Documents

How to Prepare for USMLE CS