HOW TO PREPARE FOR THE USMLE STEP2 CS?

CSR
C
S: smile, silence(), support()
R: response
* priority
Three critical thinking moments
Doorway information: 30-45s,
Washing hands:
Chest & CV exam:
One piece of paper
Mental checklist
3O + 2P + 2Q AAA
PAMHUGFOSS WA
Most important DDx
Life-threatening complication:
Side-effect:
Important associations
Diabetes mellitus
Hyper/hypothyroidism
Depression
Gastrointestinal tumors
Infections

Some physical examinations

Neurological exams
Gait
Romberg


Shoulder


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
----------------------------------------------------------------------------------------------------------

Headache

Differential Diagnosis
Migraine (complicated)
Cluster headache
Temporal arteritis (giant cell arteritis)
Sinusitis
Tension headache
Subarachnoid hemorrhage
Meningitis (bacterial)
Pseudotumor cerebri
Trigeminal neuralgia
History
Main3O 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

Differential Diagnosis

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
Associated syndromes:
Relation to meals
Nausea / vomiting
Domestic violence
Physical exam
Cardio and pulmonary exams
Abdominal exams (guarding, Murphy sign, psoas and obturator signs)

Chest pain

Differential Diagnosis
Myocardial infarction (MI)
Sickle cell disease-pulmonary infarction
GERD
Angina
Pericarditis
Costochondritis
Pulmonary embolism
Aortic dissection
History
3O 2P LIQR AAA WA PAMHUgFosS
Associated syndromes:
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

Differential Diagnosis
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
Associated syndromes:
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

Differential Diagnosis
Disk herniation
Lumber muscle strain
Lumbar spinal stenosis
Malingering
History
3O 2P LIQR AAA PAMHUGFOSS
Associated syndromes:
Context (moving furniture, trauma)
Physical exam
Neurologic exam
Back palpation and range of motion
Hip exam

Cough / Shortness of breath

Differential Diagnosis
Asthma
COPD-chronic bronchitis
Pneumonia
Atypical pneumonia
Lung cancer
COPD exacerbation (bronchitis)
Tuberculosis
Congestive heart failure
History
3O AAA WA PAMHUgFOSS
Associated syndromes:
Sputum
Chest pain / heartburn
Exposures
Physical exam
ENT exams
Cardio and pulmonary exams
Lymph node exams
Extremities exams

Night sweats

Differential Diagnosis
Tuberculosis (Acute HIV infection, lymphoma, leukemia, hyperthyroidism)
History
3O aaA WA PAMHUGFOSS
*Severity, frequency, timing, pattern

Associated syndromes:
Cough hemoptysis, chest pain
Lymphadenopathy
Fever
Rash itching
Malaise
Nausea / vomiting
Menstrual history peri-menopause
Physical exam
HEENT exams
Abdominal exams (hepatosplenomegaly)
Cardio and pulmonary exams

Dysphagia

Differential Diagnosis
Esophageal cancer
Plummer-Vinson syndrome
Achalasia
Esophagitis
History
3O 2P AAA WA PAMHUGFosS
Solids or liquids vs. both solids and liquids
Associated syndromes:
Drooling
Regurgitation
Odynophagia
History of Raynaud phenomenon
Physical exam
Head and neck exams
Cardio and pulmonary exams
Skin exams

Upper GI bleeding

Differential Diagnosis
Bleeding peptic ulcer
Gastritis
History
3O ABCO AAA PAMHugFosS
Associated syndromes:
Context (severe vomiting, alcohol ingestion)
Nausea
Abdominal pain

Physical exam
ENT exams
Cardio and pulmonary exams
Abdominal exams

Blood in stool

Differential Diagnosis
Colorectal cancer
Ulcerative colitis
Diverticulosis
History
3O ABCO AAA WA PAMHuGFosS
*Melena vs. bright blood
Associated syndromes:
Abdominal / rectal pain
Nausea / vomiting
Trauma
Physical exam
Abdominal exams
Rectal exams

Hematuria

Differential Diagnosis
Bladder cancer
Polycystic kidney disease
Renal cell carcinoma
History
3O ABCO AAA PAMHUgFoSS
Associated syndromes:
Renal colic
Dysuria
Voiding symptoms
History of vigorous exercise
Physical exam
Lymph node exams
Abdominal exams
Genitourinary exams

Loss of Consciousness (LOC)

Differential Diagnosis
Complex tonic-clonic seizure

Drug-induced orthostatic hypotension (causing syncope)

Cardiac arrhythmia (causing syncope)
History
3O aaA PAMHugFosS
Emphasize on CONTEXT
Associated syndromes:
Preceding symptoms
Nausea
Palpitation
Associated symptoms
Tongue biting
Incontinence
Prolonged confusion
Physical exam
Neurological exams
Carotid exams
Cardio and pulmonary exams

Dizziness

Differential Diagnosis
Mnire disease
Orthostatic hypotension due to dehydration
Drug-induced orthostatic hypotension
Benign positional vertigo
Vestibular neuronitis
Labyrinthitis
History
Main3O AAA PAMHUGFosS
Lightheadedness vs. vertigo
Associated syndromes:
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)

Differential Diagnosis
Drug-related ED (Hypertension ED, DM ED, psychogenic ED)
History

3O AAA PAMHUgFoSS
Associated syndromes:
nocturnal erections
libido
Stress or depression
Physical exam
Cardio and pulmonary exams
Genitourinary exams
Rectal exams

----------------------------------------------------------------------------------------------------------

Other urinary symptoms

Differential Diagnosis
Benign prostatic hyperplasia (BPH)
Prostate cancer
Urethritis
Acute pyelonephritis
Stress incontinence
Urge incontinence
History
3O AAA WA PAMHUgFoSS
Associated syndromes:
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

Differential Diagnosis
Depression
Posttraumatic stress disorder
Colon cancer
Hypothyroidism

Diabetes mellitus
Obstructive sleep apnea
Sleep deprivation
History
3O AAA WA PAMHUGFosS
Associated syndromes:
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
Cardio and pulmonary exams

Confusion / Memory loss

Differential Diagnosis
Vascular (multi-infarct dementia)
Alzheimer disease
Normal pressure hydrocephalus
Creutzfeldt-Jakob disease
Hypoglycemia
Subdural hematoma
History
MUST INCLUDE history from family members / caregivers
Main3OP AAA WA PAMHUgFoSS
Associated syndromes:
Fall hit head
Palpitation weakness
Depression
Cold intolerance
Infection HIV, syphilis, prion
Physical exam
Neurological exams
Mini-mental status exams
HEENT exams

 Nausea / vomiting

Differential Diagnosis
Pregnancy (gastritis, hypercalcemia, diabetes mellitus, UTI, depression)
History
3O ABCO AAA PAMHuGFosS
Associated syndromes:
Abdominal pain
Relation to meals
Sick contacts
Possible food poisoning
Possible pregnancy
Physical exam
ENT exam
Abdominal exam

Constipation / diarrhea

Differential Diagnosis
Colorectal cancer
Low-fiber diet
Irritable bowel syndrome
Infectious diarrhea (gastroenteritis)-bacterial, viral, parasitic, protozoal
Pseudomembranous (Clostridium difficile) colitis
Travelers diarrhea
Lactose intolerance
Crohn disease
History
3O ABCO AAA WA PAMHuGFosS
Associated syndromes:
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

Differential Diagnosis
Transient ischemic attack (TIA)
Stroke

Guillain-Barr syndrome
Multiple sclerosis
Diabetic peripheral neuropathy
Myasthenia gravis
Todd paralysis
History
3O 2P AAA PAMHUGFosS
LOCATION (unilateral, bilateral, proximal, distal)
Associated syndromes:
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

Differential Diagnosis
Hyperthyroidism (cancer, HIV infection, anorexia nervosa, malabsorption)
History
3O aaA PAMHuGFosS
*Amount
Associated syndromes:
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

Differential Diagnosis
Smoking cessation (drug side effect, hypothyroidism, Cushing syndrome, Polycystic
ovary syndrome, diabetes mellitus, atypical depression)
History
3O aaA PAMHuGFosS
*Amount
Associated syndromes:
Relation to medication changes, smoking cessation, depression
Diet history
Hypothyroidism (fatigue, constipation, skin changes)

Menstrual irregularity
Physical exam
*Brief exam based on the diagnosis

----------------------------------------------------------------------------------------------------------

Palpitations

Differential Diagnosis
Hypoglycemia
Panic attack
Social phobia
History
3O aaA PAMHUGFosS
*Gradual vs. acute onset/offset
Associated syndromes:
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

Differential Diagnosis
Infectious mononucleosis
HIV, acute retroviral syndrome
Pharyngitis
Hepatitis
History
3O aaA wA PAMHugFosS
Associated syndromes:
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

Differential Diagnosis
Pregnancy
Polycystic ovary syndrome
Amenorrhea secondary to prolactinoma
Menopause
Sheehan syndrome
Anorexia nervosa
Anxiety-induced amenorrhea
History
3O aaA PAMHugFoSS
*Primary vs. secondary
Associated syndromes:
Relationship to menstrual period
Menopausal symptoms
Pregnancies
Eating disorders (anorexia nervosa, excessive dieting, vigorous exercise)
Physical exam
Breast exams
Complete pelvic exams

Vaginal bleeding

Differential Diagnosis
Dysfunctional uterine bleeding
Endometrial cancer
Cervical cancer
Spontaneous abortion
Ectopic pregnancy
History
3O ABCO AAA WA PAMHugFoSS
Pre- vs. postmenopausal
Associated syndromes:
Relationship to menstrual period
Discharge
Pelvic or abdominal pain
History of Pap smears
Physical exam
Abdominal exams
Pelvic exams

 Vaginal discharge

Differential Diagnosis
Bacterial vaginosis
Vaginitis-candidal
Vaginitis-trichomonal
History
3O ABCO AAA PAMHugFOSS
Associated syndromes:
Vaginal burning, pain, pruritus
Sexual activity + protection
History of STD
Sick contacts
Physical exam
Abdominal exams
Pelvic exams

Dyspareunia

Differential Diagnosis
Atrophic vaginitis
Endometriosis
History
3O AAA PAMHugFoSS
Associated syndromes:
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

Differential Diagnosis

Neonatal sepsis
Acute otitis media
Measles (or other viral exanthem)
Gastroenteritis (viral, bacterial, parasitic)
History
3O aaA WA PAMHUGFS
Associated syndromes:
SID
Severity
Localized symptoms
Rash
Physical exam
HEENT exams
Cardio and pulmonary exams
Abdominal exams
Skin exams

Child with GI symptoms

Differential Diagnosis
Pyloric stenosis
Hirschsprung disease
Intussusception
Somatoform disorder
Colic
History
3O 2P LIQR AAA WA PAMHUGFS
Associated syndromes:
SID
Association with food
Physical exam
Cardio and pulmonary exams
Abdominal exams
Rectal / pelvic exams (women)

Child with red eye

Differential Diagnosis
Bacterial conjunctivitis (viral conjunctivitis, keratitis, uveitis, seasonal allergies)
History
3O AAA PAMHUGFS
Associated syndromes:
SID
Eye discharge / pain

Difficulty open of eye

Physical exam
HEENT exams

Child with short stature

Differential Diagnosis
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
Cardio and pulmonary exams
Abdominal exams
Neurological exams

Behavioral problems in childhood

Differential Diagnosis
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

Differential Diagnosis
Schizophrenia
Substance-induced psychosis
Schizoaffective disorder

History
Main3O aaA WA PAMHugFoss
Associated syndromes:
Positive (Delusions, disorganized thought, disorganized behavior)
Negative (Social withdraw, decreased motivation, decreased speech / thought)
Physical exam
Mental status exams

Depressed mood

Differential Diagnosis
Normal bereavement
Major depressive disorder
Bipolar I disorder
History
Main3O aaA WA PAMHUGFOSS
SUICIDE risk assessment
Associated syndromes:
Stress
Sleep pattern Fatigue
Manic episode
Decreased social function, interest, energy, concentration
Physical exam
Mental status exams
HEENT exams

Abuse

Differential Diagnosis
Domestic violence
Rape
History
*Establish Confidentiality
3O aaa PAMHugFOSS
Associated syndromes:
Physical, sexual, or emotional abuse
Fear
Safety
Backup plan
Physical exam
Complete exam

Insomnia

Differential Diagnosis
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
Associated syndromes:
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