AC Class Material Presentation PDF

BY: Christian Rodriguez, MD
Abelardo Quiñones, MD
ORIENTATION
INFO. GATHERING
MINICASES
DAY 1
Copyright © 2015-2016
• Step 2 CS uses standardized patients to test
medical students and graduates on their ability
to be patient-centered, to address the
diagnostic challenges posed, to prepare the
patient for the next steps, and to document
the encounter appropriately.
• Your Step 2 CS administration will include
twelve patient encounters. These include a
slight number of non-scored patient
encounters, which are added for pilot testing
new cases and other research purposes. Such
cases are not counted in determining your
score.
Exam Format:
The examination session lasts
approximately 8 hours. You will have 50 minutes of
break time:
• 10-minute break after the 3rd patient encounter
• 30-minute break (which includes a light lunch)

after the 6th patient encounter
• 10-minute break after the 9th patient encounter

Each encounter:
(15 minutes of Patient Encounter)
(10 minutes of Patient Notes)
3 COMPONENTS OF EVALUATION:
- ICE: Integrated Clinical Encounter.

- CIS: Communication and Interpersonal Skills.
- SEP: Spoken English Proficiency
• ICE:
-Data Gathering and Data Interpretation
Skills.
-The Patient Note (History and Physical
Examination)
- Diagnosis Impression
- Justification of The Potential diagnosis
- It is Evaluated by MDs
• CIS:
-Assessment of the patient-centered
communication skills of fostering the relationship.
-Gathering information.
-Providing information.
-Helping the patient make decisions about the
next steps and supporting emotions.
-It is evaluated by SP.
CIS Functions
• Fostering the Relationship
- Express Interest in the Pt as a person
- Treat the Pt with respect
- Listen and Paid Attention to the Pt
• Gathering Information
- Encourage the Pt to tell his/her story
- Explore the Pt’s reaction to the illness or problems
• Providing Information
- Provide information related to the working diagnosis
- Provide Information of next steps.
• Making Decisions: Basic
- Elicit the Pt’s perspective on the Dx and next steps.
- Finalize plans for the next steps.
• Supporting Emotions
- Facilitate the expression of an implied or stated emotion or
something important to Him/Her
• SEP:
-Assessment of clarity of spoken English
communication within the context of the Doctor-Pt
encounter.
-Pronunciation.
-Word Choice
-Minimizing the needs to repeat questions or
statement.
-It is evaluated by the SP
EVALUATION
ICE
CIS
SEP
INTRODUCTION
TIME MANAGEMENT
- DOOR INFORMATION (30 SEC)
- HISTORY TAKING (7-8 MINS)
- PHYSICAL EXAMINATION (5 MINS)
- CLOSURE (2-3 MINS)
2 Rules:
1) Not Pretend
2)Always tries to help the Pt’s
Needs.
INFORMATION GATHERING FOR EACH
COMPLAIN
FOR EVERY COMPLAIN THE FIRST QUESTION THAT YOU WILL ASK IS:
HOW CAN I HELP YOU TODAY?
OR
WHAT BRINGS YOU IN TODAY?
DIVISION OF THE INTERVIEW
CHIEF COMPLAINT
REVIEW OF SYSTEM
PAST MEDICAL HISTORY
PAIN
OLIQRAAPP
O: ONSET:
1- When did it start?
2- Did you have similar episodes in the past?
3- Is the pain present all of the time or just comes and goes?
-if comes and goes ask –How long does it last? / How many episodes during the
day?/ Is it presents through the day or at one specific hour?
L: LOCALIZATION:
- Would you please show me exactly with one finger where your pain is?
I: INTENSITY:
- On a scale from 1 to 10, 10 being the worst pain in your life, how would you rate it?
Q: QUALITY:
- Would you please describe it for me? Is it like a burning, sharp, pounding,
throbbing...?
PAIN
OLIQRAAPP
R: RADIATION:
- Does the pain move elsewhere?
A: ALLEVIATING FACTORS:
- Does anything make it better?
A: AGGRAVATED FACTORS:
- Does anything make it worse?
P: PRECIPITATE EVENT:
- What were you doing when the pain started?
P: PROGRESSION:
- Since the pain began, it is getting better or worse?
COUGH

2- Since it started, it is getting better or worse?
4- Did you remember anything that brought on your cough?
5- Is the cough presents through out the day?
6- How long have you had the cough?
7- How often do you cough?
8- Do you cough at night?
9- Does anything come up when you cough or is a dry cough?
-If something came up, then you need to ask:
A: AMOUNT: Can you estimate how much comes up? (Teaspoon or tablespoon)
B: BLOOD: Is there any blood in it?
C: COLOR: What color is it?
C: CONSISTENCY: What does it look like?
O: ODOR: Any bad odor in it?
10- Does anything makes the cough better?
11- Does anything makes it worse?
BLOODY URINE
2- Since it started is it getting better or worse?
4- Did you remember anything that brought on the blood in your
urination?
5- Is the blood present all of the time that you urinate?
6- Is it present at the beginning, during or at the end of urination?
7- How often do you urinate during the day?
8- Do you need to push during urination?
9- Do you have any pain or burning during urination?
10- Do you noticed any weakness in your stream? Any dribbling?
11- Do you wake up at night to urinate?
BLOODY STOOL
4- Did you remember anything that brought on the blood in your stools?
5- Is the blood present all of the time that you have bowel movements?
6- Is it present at the beginning, during or at the end of your bowel movements?
7- Do you have any pain when you have bowels movement?
8- Any mucus in your stool?
9- Do you have Diarrhea or constipation? If say yes then you need to ask:
- For how long?
- How many bowels movement per day?
- Description?
HEARING LOSS
4- Is the hearing loss present through both of your ears?
4- Is your hearing lost for all sounds or for anything specific?
5- Have you ever tried hearing aids?
6- Have you had any ear aches?
7- Any Discharge? Any Blood?
8- Do you have dizziness?
9- Have you been hearing any unusual sounds like ring?
10- Have you been exposed to loud noises?
CONFUSION/MEMORY LOSS
4- Are you having difficulties? : DEATH SHAFT
Dressing, Eating, Ambulating, Toilet, Hygiene, Shopping, House-
keeping, Accounting, Food preparation, and Transportation.
5- How is your mood today?
6- Have you lost consciousness?
7- Any recent injury, falls or accident?
8- Any shaking or seizures?
9- Any Visual Changes?
10- Do you feel safe at home?
FOLLOW UP DIABETES/HTN
1- How long have you had this condition?
2- What medication are you using?
3- Do you use your medication as prescribe?
4- Any medication side effect?
5- Do you remember your last sugar/BP reading?
6- When was your last HBa1c? Result?
7- When were your last eyes checked?
8- How are you feeling today?
PEDIATRIC CASE
REVIEW OF SYSTEM
F/C, N/V, SOB/COUGH/ST, ΔGI, ΔGU, WADES,
H/W/N/T/F/D, PAIN(C,A,J)
PAST MEDICAL HISTORY
PAM H FOSS
• PMH: Do you have any serious illness? ... Like DM, HTN, High Cholesterol or Asthma.
• ALLERGIES: Are you Allergic to something?
• MEDICATION: What medication are you currently taking?
• Hospitalization: Have you ever been hospitalized before? / Have you had any
surgeries?
• FAMILY Hx: Are you parents alive? Are they in good health?
• OB/GYN: When was your LMP? / Any change in it?
• SOCIAL Hx: 1-What do you do for a living?
• 2- Do you Drink?... If say yes then ask the CAGE questions
• 3- Do you Smoke?... if say yes then ask: -How many packs per day? / How
long have you been smoking? / Have you ever tried to quit smoking?
4- Do you use any recreational drug?
• SEXUAL Hx: 1- Are you sexually active?
• 2- With man, woman or both?
• 3- Do you use condoms or any protection?
• 4- How many sexual partners have you had for the past year?
• 5- Any STD in the past?
OLIQRAAPP
F/C, N/V, SOB/COUGH/ST, ΔGI, ΔGU WADES,

H/W/N/T/F/D, PAIN(C,A,J)
PAM H FOSS
MINICASES
• A 32 y/o lawyer M presents with Rt temporal
headaches associated with ipsilateral
rhinorrhea, eye tearing , and redness. Episodes
have occurred at the same time every night for
the past week and last for 45 minutes.
??????????????????????????
• DDx: - Epiphora and Redness
1- Cluster headache
- Male WORKUP:
- Eye Redness and epiphora CBC w/ diff, electrolytes
- Ipsilateral Rhinorrhea CT head
- R temporal Cephalea MRI brain
- Episodes occurred at the same time
2- Tension Headache
- Stressful Job (lawyer)
- Cephalea
- Episode occurred at the same time
- Eye redness
3- Migraine
- R temporal headache
- Episodes last for 45 minutes
• A 70 y/o F presents with sudden severe
headache, vomiting, fever, confusion, left
hemiplegia, and nuchal rigidity.
???????????????????????????
• DDx: - Emesis
1- Subarachnoid Hemorrhage (SAH) - Severe Headache
- Confusion - L hemiplegia
- Suddenly Severe Headache 4- Intracranial Tumor
- L hemiplegia - Elderly
- Elderly - Confusion
- Emesis
2- Meningitis - Severe Headache
- Pyrexia - L hemiplegia
- Confusion
- Emesis WORKUP:
- Nuchal rigidity CBC w/ diff., electrolytes
- Severe Headache LP/CSF analysis
3- Migraine CT head
- Confusion MRI head
• A 81 y/o M presents w/ progressive confusion
for the past several years accompanied by
forgetfulness and clumsiness. He has Hx of
HTN , DM, and 2 strokes w/ residual Lt
hemiparesis. ??????????????????????????
• DDX: - Multiple Risk Factor
1- Vascular Multi-infarct Dementia - L Hemiparesis
- Elderly 4- MDD
- Progressive Confusion - Elderly
- Forgetfulness - Progressive Confusion
- Multiple Risk Factor - Forgetfulness
- Hx of 2 strokes
- L Hemiparesis WORKUP:
2- Alzheimer Disease - MSE
- Elderly - CBC w/ diff. Electrolytes
- Forgetfulness - CT head
- Progressive Confusion - MRI brain
- Multiple Risk Factor
3- Intracranial Tumor
- Elderly
- Progressive Confusion
• A 75 y/o Insulin –dependent diabetic M
presents with episodes of confusion , dizziness,
palpitation, diaphoresis, wt loss, and
weakness. ??????????????????????????????
• DDx:
1- Hypoglycemia
- Palpitations 4- TIA
- Diaphoresis - Palpitations
- Dizziness - Confusion
- Weakness - Elderly
- Hx of Insulin use - Diaphoresis
- Confusion - Weakness
2- Panic Attack WORKUP:
- Palpitations - CBC w/ diff. Electrolytes
- Diaphoresis - Glucose Level
- Dizziness - TSH
- Confusion - FT4 FT3
3- Hyperthyroidism - Doppler U/S Carotid
- Palpitations - CT head
- Diaphoresis
• A 68 y/o M presents w/ a 2-month hx of crying
spells, excessive sleep, poor hygiene, and a 7kg wt
loss, all following his wife’s death. He cannot
enjoy time with his grandchildren and reluctantly
admits to thinking he has seen his dead wife in
line at the supermarket or standing in the kitchen
making dinner.
?????????????????????????????????
• DDx: - Sleeping problems
1-Normal Bereavement - 7kg Unintentional Wt loss
- Sleeping problems - Symptoms started after his wife’s
- Hx of his wife dead death
- 7kg Unintentional Wt loss 4- Thyroid Diseases:
- Poor Hygiene - Sleeping problems
- Crying Spells - 7kg Unintentional Wt loss
- Visual hallucination about his dead - Elderly
wife
2- MDD WORKUP:
- Crying Spells - Mental Status Exam
- Poor Hygiene - Mood Disorder Questionnaire
- Sleeping problems - PHQ9
- Hx of his wife dead - QIDS-SR16
- 7kg Unintentional Wt loss - CBC w/ diff. Electrolytes
3- Adjustment Disorder with Depressed - TFTs
Mood
- Hx of his wife dead
• A 18 y/o F c/o seeing bugs crawling on her bed
for the past 6 days and hearing loud voices
when she is alone in her room. She reports
that she did not have many friends in high
school. She has never experienced anything
similar in the past. She recently ingested an
unknown substance. ??????????????????????
• DDx: - Young
1- Substance Induced Psychosis
- Hx of recent substance use WORKUP:
- Visual Hallucination - Mental Status Exam
- Auditory Hallucination - CBC w/ Diff. electrolytes
-No previous episodes. - Urine toxicology
2- Brief Psychotic Disorder - CT head
- Visual Hallucination
- Auditory Hallucination
- No previous episodes
- Symptoms started 6 days ago
3- Schizoid Personality Disorder
- She not have many friends
- Symptoms started in her room
alone
• A 30 y/o F presents with weakness, loss of
sensation, and tingling in her left leg that
started this morning. She is also experiencing
right eye pain, decreased vision, and double
vision. She reports feeling “electric shocks”
down her spine upon flexing her head. She
uses OCP.
?????????????????????????????????
• DDx: - Blurred Vision and Diplopia
1- MS
- Woman
- Hypoesthesia WORKUP:
- Rt eye pain CBC w/ Diff. Electrolytes
- Decreased vision PT/PTT
- Blurred Vision and Diplopia Lipid Panel
2- Stroke LP/CSF Analysis
- Hypoesthesia Carotid US
- Asthenia and paresthesia in her CT Head
L leg MRI spinal
- Hx of OCP uses
- Diplopia and Blurred Vision
3- Intracranial Tumor
-Asthenia and paresthesia in her L leg
- Hypoesthesia
• A 26 y/o F presents w/ sore throat, fever,
severe fatigue, and decreased appetite for the
past week. She also reports epigastric and LUQ
discomfort. She has cervical LAD and a rash.
Her boyfriend recently experienced similar
symptoms. ????????????????????????????
• DDx: 3- Acute HIV Infection
1- Infectious Mononucleosis - Sore throat
- Sore throat - Hyporexia
- LUQ Discomfort - Cervical LAD
- Hyporexia - Sick Contact
- Cervical LAD - Pyrexia
- Sick contact - Fatigue
- Pyrexia WORKUP:
- Fatigue - CBC w/ diff. Electrolytes
2- Viral or Bacterial Pharyngitis - Monospot test
- Sore throat - Throat Culture
- Hyporexia - HIV Antibody
- Cervical LAD - HIV Viral Load
- Sick Contact - CD4 count
- Pyrexia - CT ABD.
• A 65 y/o M presents with worsening cough for
the past 6 months accompanied by
hemoptysis, dyspnea, weakness, and wt loss.
He is a heavy smoker. ?????????????????????
• DDx: - Dyspnea
1- Lung CA - Asthenia
- Cough - Hx of Heavy Smoke
- Wt loss 4- Acute HIV Infection
- Hemoptysis - Cough
- Dyspnea - Wt loss
- Asthenia - Hemoptysis
- Hx of Heavy Smoke - Dyspnea
2- COPD - Asthenia
- Cough
- Wt loss WORKUP:
- Hemoptysis - CBC w/ Diff. Electrolytes
- Dyspnea - PPD/QuantiFERON-TB
- Asthenia - HIV antibody
- Hx of Heavy Smoke - HIV Viral Load
3- TB - CD4 Count
- Cough - Sputum gram stain and culture
- Wt loss - PFTs
- Hemoptysis - CXR
• A 60 y/o M presents w/ dull epigastric Pain
that radiates to the back, accompanied by wt
loss, dark urine, and clay-colored stool. He is a
heavy drinker and smoker.?????????????????
• DDx:
1- Pancreatic CA WORKUP:
- Dull Epigastric Pain - Rectal Exam
- Wt loss - CBC w/ Diff. Electrolytes
- Acolia - Amylase and Lipase
- Choluria - U/S ABD
- Hx of heavy Drinker and Smoker - CT Abd.
- Elderly - Endoscopy
2- Chronic Pancreatitis
- Dull Epigastric Pain
- Wt loss
- Acolia
- Choluria
- Hx of heavy Drinker and Smoker
3- PUD
- Wt loss
- Hx of heavy Drinker and Smoker
- Epigastric Pain
• A 32 y/o F presents w/ sudden onset of L lower
Abd. pain that radiates to the scapula and back
and is associated w/ vaginal bleeding. Her last
menstrual period was 5 weeks ago. She has a
Hx of pelvic inflammatory disease and
unprotected intercourse.
??????????????????????????????????
• DDx:
1- Ectopic Pregnancy WORKUP:
- LLQ pain - Pelvic Exam
- LMP was 5 weeks ago. - CBC w/ diff. electrolytes
- Hx of PID - HCG
- Sexually active without - Pelvic – Abd Sonogram
protection
- Vaginal Bleeding
2- Ovarian Torsion
- Suddenly LLQ pain
- Vaginal Bleeding
- LLQ pain that radiates to the
back
3- Ruptured Ovarian Cyst
- Suddenly LLQ pain
- Vaginal Bleeding
- LLQ pain that radiates to the
back Copyright © 2015-2016
PHYSICAL EXAMINATION
CLOSURE
DAY 2
PHYSICAL EXAMINATION
• VS: WNL
• GA: NAD , AAO X3
• HEENT: NC/AT, NON TENDER. NO PALLOR, EOMI, PERIPHERAL VISION
INTACT, PERRLA, FUNDOSCOPY INTACT B/L, VISUAL ACUITY 20/20 B/L.
AC>BC B/L, WEBER NO LATERALIZED, EAC INTACT B/L. NO POLYPS, NO
DISCHARGE OR RUNNY NOSE, NO SEPTUM DEVIATION. MMM, NO
TONSILLAR ERYTHEMA, EXUDATES OR ENLARGEMENT. NO LAD, THYROID
INTACT, NO JVD, NO CAROTID BRUITS.
• RS: SYMMETRIC, NON-TENDERNESS, NO TACTILE FREMITUS, NORMAL
RESONANCE, NO DULLNESS, CTA B/L.
• CVS: RRR, S1S2 HEARD, NO M/G/R, PMI NOT DISPLACED.
• ABD: NO SCAR, BS(+), SOFT, ND/NT, NO HSM, CVA(-) , (SIGN).
• EXT: NO ECC, ROM INTACT, NON TENDER, DP 2+ B/L , DTR 2+ B/L, SILT.
• NEURO: CN 2-12 INTACT, STRENGTH 5/5, BABINSKI(-), GAIT INTACT,
ROMBERG(-), FINGER TO NOSE INTACT.
• MMSE: AAOX3, DISTANT AND SHORT MEMORY INTACT, 3/3 RECALL AT THE
3 TIME, COMPLETED 3 STEP COMMAND, CONCENTRATION INTACT.
CLOSURE
1) Recap
5) Follow Up 2) Diagnosis
Questions Impression
Remember The
4 Step!!!! Is so 3) Detailed
IMPORTANT!!!! Workup
!!
4) PREVENTIVE
COUNSELING
• Mr…thank you for letting me examine you. Now I
would like to discuss my impression with you. Based
on the information that I gathered, I'm very
concerned about your ...., before I can give you a final
diagnosis, I need to run some blood and imaging test
to get a better assessment of your condition. When I
get the results back of those test, we will meet again
to discuss them, along w/ the final diagnosis and the
treatment plan. Also Mr..., I strongly recommend you
that...; Mr ... do you have any question?... okay Mr...
it was nice meeting you!
PATIENT NOTES
PRACTICING CASES WITH SP
DAY 3
PATIENT NOTES
HPI
DOORWAY INFORMATION
Anthony Jefferson a 73 y/o male presents to the emergency
department with complaints of chest pain.
Temp. 98.6⁰F , BP. 150/100, HR 95/min, RR 20min.

Task
1. Obtain a history pertinent to this patient’s problem.
2. Perform a relevant physical examination (Do not perform a breast,
pelvic, genital, corneal reflex or rectal examination)
3. Discuss your impressions and any initial plans with the patient.
4. After leaving the room, complete your patient notes on the given
computer.
Chief Complain
•PP
2nd Complain
ROS
Denies
ROS: Neg. Except as Above/ PMH/ PSH/ ALLERGIES/ MED/

FH/ OBGYN/ SH
• A ____ y/o (M or F) came to the ____ c/o ____. Started ____ ago for the
____ time while he was doing ____ and since it started it is getting ____.
Describes it as ____, ____, ____, ____that improves with ____ and
worsens with ____. Also he reports ____that describes it as ____, presents
through ____ , ____ episodes per day that started ____ago and since it
started it is ____. Refers episodes of ____during the ____ and __ episodes
of ____ this ____. Denies ____, ____, ____ , ____, ____, ____, ____, ____,
____, ____ or ____.
ROS: ________
PMH:________
PSH: ________
ALL: ________
MED: ________
FH: ________
SH: ________
• A 73 y/o M came to the ED c/o generalized chest pain. Started this morning
for the first time while he was doing exercise and since started it is getting
worse. Describes it as constant, 7/10 in severity, sharp, radiates to the Lt
arm that improves with aspirin and worsens with movement and cough.
Also he reports a non-productive cough present through the day, 2-3
episodes per day, that started 3 days ago and since it started is getting
worse. Refers episodes of fever during the night and 2 episodes of
yellowish vomits this week. Denies chills, SOB, bowel or urination changes,
nose bleeding, wt loss, poor appetite, sleeping problems, recent travels,
night sweats or recent sick contacts.
• ROS: Neg. Except as above;
• PMH: HTN -5 years;
• PSH: None
• All: NKDA
• Med: HCTZ
• FH: Father died of MI at 65y/o and mother has DM
• SH: Engineer, smoke 1PPD for 25 years, no EtHO or illicit drugs, sexually
active with his daughter without protection, no STD in the past.
PRACTICE TIME

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BY: Christian Rodriguez, MD

• 30-minute break (which includes a light lunch)

• 10-minute break after the 9th patient encounter

- ICE: Integrated Clinical Encounter.

PAST MEDICAL HISTORY

1- When did it start?

F/C, N/V, SOB/COUGH/ST, ΔGI, ΔGU WADES,

Temp. 98.6⁰F , BP. 150/100, HR 95/min, RR 20min.

ROS: Neg. Except as Above/ PMH/ PSH/ ALLERGIES/ MED/

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