| | 1 Documentation of case
After the announcement has been made to leave the examination room, you will have 10 minute complete the documentation of each case. If you leave the room early, you may use the extra time for decimation , bit be aware that you may not re-enter the patient room once you have left.
For each case, document the most relevant hisser and physical examination findings. Note that you are not expected to perform of document a comprehensive history and physical examination, and you should emphasized the most important positive and negative findings that would be needed for medical decision making. You will than list the most likely diagnosis (up to 3 ), along with the clinical findings that support each possibility. Finally, you will list any diagnosis test that are needed to rule in or rule out each possible diagnosis. You may include any physical examination maneuvers that are prohibited in USMLE Step 2 CS (eg , female breast examination) , bit you should not include treatment options , referral/consultations , or patient dispositions (eg , admit to hospital).
Your documentation will be reviewed and scored by trained raters who are also licensed physicians. Factors considered in scoring include:
. Use of correct medical terminology
. Listing the possible diagnosis in order of likelihood
. Providing appropriate supporting findings (i.e., include only clinical findings form the history and physical examination you actually performed)
Throughout the documentation of each case, it is recommended that you remain as focused and specific as possible . If a component of the examination is normal , you should state your specific findings ; for example , you would write “ lungs show good air movement with on crackles , dullness , or egophony “ rather than “lung examination is normal.” For diagnostic studies, you should also be specific; for example , you would write “ electrolytes , glucose , creatinine : rather than “ metabolic panel. “ A list of standard abbreviations is provided in this section; if you are uncertain about the use of a certain abbreviation, write in full term.
You findings must be entered into a standardized documentation template. you may choose to document your findings in either a narrative format or a “bullet pain t” list , but information should be presented in a logical , coherent order. The history and physical examination fields allow a maximum of 950 characters (15 lines 0 each , and a progress bar is provided at the bottom for you to judge how much space is reminding. In the data interpretation section , you will enter each possible diagnosis along with up to 8 rows of history and physical examination findings to support each. You may also enter up to 8 diagnostic studies (note that some cases may not require any diagnostic studies).
The following sections provide guidance for documentation of each case . Additional information is available in the History Taking section. Note that the chief complaint will generally be provided at the beginning of the encounter , but you should be alert for more important issues that the patient may not immediately disclose . the subsequent section of the history and examination should be intelligently presented to tell a coherent story of the patient’s primary problem.
Documentation of history
Patient identification and chief complaint (cc)
. Age, gender , and any relevant ethnic or social identifiers
. Primary reason for the encounter
History of present illness (HPI)
Include all the following features that apply:
. Location of primary symptom
. Quality/ character
. Severity (numeric or descriptive)
. Onset/duration
. Course over time
. Triggering/ modifying factors
. Context
. Associated symptoms (both positive and negative)
Review of systems
. Include pertinent positive and negative symptoms
. Focus on related and adjacent systems
Past medical history (PMH)
. Significant chronic and past medical conditions
. Significant psychiatric conditions
. Birth ad developmental history in children
. Reproductive history (as appropriate)
Past surgical history (PSH)
. Previous operations (including cesarean section)
Medications
. Prescription and over-the-counter medications
Allergies
. Drug and environmental allergies (including the patient’s reaction)
Family history
. Emphasize first-degree relatives (include more distant relatives only if relevant)
. If space is lim,tied , list only condition directly related to the patient’s problem
. If space is every limited and family dose not affect decision making , write : “ FHx noncontributory”
Social history
. Occupation(if present)
. Living situation and support system
. Tobacco , alcohol , illicit drugs
. Outside stressors, if pertinent (eg, “ recently homeless”)
Documentation of physical examination
Begin with a list of vital signs. Give a brief comment about the patient;s general appearance , and then provide a systematic list of physical examination findings. Include all abnormal and any relevant normal findings but only those that you personally noted during the examination.
Emphasize the primary system and nay adjacent/related systems . Note that simulated patins in Step 2 CS may have feigned examination findings (eg, abdominal tenderness ) or real abnormalities (eg , visible skin lesion) that are apparent on examination; both should be documented as appropriate.
You may be give a telephone encounter , in which the pasting is not present in the room , In this cases , leave the physical examination section blank.
The following table includes suggested terminology for normal findings , although you should include additional , specific negative findings that narrow the differential diagnosis . Normal findings in systems not related to the patient’s primary problems that do not factor into medical decision making do not need to be documented . However , any findings that you reference in the diagnosis section of the documentation should be included.
Normal examination findings
- HEENT
Head
. Normocephalic and atraumatic
Eyes
. Pupils equally round and reactive to light (PERRLA)
. Visual acuity 20/20 with intact visual fields
. Extra ocular muscles intact (EOMI)
. Funds without papilledema, lesions, or exudates
. Conjunctiva without erythema
. No icterus
Ear
. Pinnae without inflammation or tenderness
. Tympanic membranes intact without erythema or effusion
. Weber midline , Rinne with air conduction > bone conduction
. Hearing grossly intact bilaterally
Nose
. Septum midline with patent nares
. No nasal polyps or lesions
. No sinus tenderness to palpation
Throat
. Oropharynx clear without tonsillar erythema or exudates
. Uvula midline
. Normal dentition and gums without ulcer or lesion
- Neck
. Supple without lymphadenopathy or thyromegaly
. Carotid pulse 2+ without jugular venous distension (JVD)
. Trachea midline without accessory muscle use
- Lungs/chest
. No chest wall lesion s, scars , or tenderness to palpation
. Fremitus symmetrical
. Resonant to percussion bilaterally
. Clear to auscultation bilaterally with vascular breath sounds
. No wheezes , crackles , or rhonchi
- Heart
. No visible heaves or lifts
. Point of maximal impulse at 5th intercostal space in left midclavicular line
. Normal S1 and S2 without murmurs , gallops , or rubs
- Abdomen
. Non distended without scars , bruises , or visible pulsations
. Normative bowel sounds throughout without bruits
. Tympanic to percussion in all 4 quadrants
. Soft and contender with no rebound tenderness or peritoneal signs
. No hepatosplenomegaly
. No costalvertebral angel tenderness
- Extremities
. No cyanosis ,clubbing , or edema
. Pulses 2+ bilaterally throughout
- Neurologic
. Patient is alert and oriented to person , place , and time
. Cranial nerves II-XII intact
. Motor strength 5/5 bilaterally in all muscle groups
. Sensation grossly intact bilaterally
. Deep tendon reflexes (DTR) 2+ bilaterally
. Gait fluid with normal speed and balance
. Normal Romberg test
- Musculoskeletal
. No pain or tenderness to palpation in all joints
. Normal range of motion (ROM) in all joints
. No abnormalities in spine or par spinal tenderness to palpation
Documentation of diagnosis
List up to 3 possible diagnosis for the patient’s primary problem with the most likely diagnosis first. Succinctly list supporting findings form the history and physical examination. In the “Diagnostic Study/ Studies” section , list the diagnostic tests (if any_ that are needed to rule in or rule out the possible diagnosis you have listed , as well as nay tests necessary to fully characterize the condition . However , do not include any unnecessary or “ routine “ tests , and do not take a “ Shotgun” approach of wording low-yield tests to rule out unlikely disorders. A list of the most common diagnostic studies for Step 2 CS is included in the Case Investigation section of the Step 2 CS course
The following guiltiness are recommended for documentation of the diagnostic studies
. List tests in order of priority
. Use specific terms, and only use approved abbreviations
. Write related test on a single line (eg , urinalysis and culture; CT of the abdomen and pelvis)
. Do to include referral or consultations.
. Do not include patient disposition (eg , send to hospital).
. Do not include treatment or drug prescriptions.
. If any of the prohibit examinations (eg, female breath examination) are required, you may list them here.
Example documentation of patient encounter
The following example of case documentation illustrates the clinical reasoning and level if detail appropriate for Step 2 CS . Additional examples are provide in the Step 2 CS Practice Materials section of the USMLE website. In addition w e have provided a list of common scenario in the Sample Cases section of the Step 2 CS course , Which include suggestions for the most important clinical findings that show;ld be documented in each case.
History
A 21 -year-old woman comes for the evaluation of an acute cough , She has had 5 days go a moderate nonproductive cough with associated wheezing but uno dyspnea . Symptoms have worsened in the last 24 hours . Symptoms are worse when outside , and are triggered by deep breaths. The patient is not using ant inhalers and has no history of asthma.
Review f the system : Positive for nasal congestion and rhinorrhea . Negative for fever , chills , otalgia , sinus pain , cervical adenopathy . sore throat , palpitations , pedal edema , and heartburn.
PMHx : Positive for seasonal allergies . No hospitalizations.
Meds : None
Allergies : NKA
FHx : Sister with asthma diagnosis age 18
SHx : Single , College student living alone . No tobacco , alcohol , or illicit drugs.
Physical examinations
T 36.8, BP 118/76, HR 86 , R 22
Patient a[p[eras comfortable without labored breathing or other signs of distress. Nasa; mucosa edematous and pale ,. oropharynx clear without tonsillar erythema or exudates . Heart shows regular rate and rhythm ; normal S1 and S2 with no murmurs , gallops , or rubs . No pedal deem a. sings show mild tachypnea withy np accessory muscle use . no audible wheezes , crackles or rubs , no dulness or egophony . Abdomen soft and no distended with normative bowel sounds
Data interpretation
Diagnosis #1
Asthma exacerbation(new diagnosis)
History findings
. cough and wheezing
. worse when outdoors
. history of allergies
. family history of asthma
Physical exam findings
. mild tachypnea
. no signs of consolidation
Diagnosis #2
Acute viral bronchitis
History findings
. cough and wheezing
. nasal congestion and rhinorrhea
Physical exam findings
. mild tachypnea
. nasal muscosa edema
. no signs of consolidation
Diagnosis workup
. peak flow
. chest x-ray
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2018/10/16 08:26pm 
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