We are writing this to help you pass your Clinical Skills exam in a more organized and stress free way. During the exam, we get stressed out and tend to leave out many questions in the history. Thus, we have come up with a mnemonic for history taking. If you follow this mnemonic you will easily cover about 70 to 80% of the important points in history taking and the remaining 20% of questions will come with practice.

You need to ask about 65% of questions in the patient’s check list to pass the exam. Remember that practice is the key! If u practice the cases in First Aid for CS at least two times you will be in good shape for the exam. First Aid for CS is more than enough and you need not do anything else. Average preparation time is 2 – 3 weeks.

We recommend that you prepare for CS with a doctor and time yourself to simulate the real exam. If there is nobody to prepare with you, you can prepare with your siblings or in front of the mirror.

First of all register for the exam five to six months before your intended date, because the seats fill really quickly and then it is difficult to find a desired date. CS exam can be taken in five different cities of U.S. namely Atlanta, Chicago, Houston, Los Angeles and Philadelphia. All centers are alike; it does not matter where you take the exam.

There will be 12 cases in the exam. 15 minutes are for the patient encounter whereas 10 minutes are given for writing the patient note. Please remember to watch the orientation video available at www.usmle.org

Outside the door is the Doorway Information. It contains the name, chief complaint and the vitals of the patient. Before entering the room, we recommend that you write the mnemonic on the paper provided to you, and list the differentials based on the presenting complaint. It may take over a minute but this is time well spent as using the mnemonic to take the history will decreases the number of pauses and covers up for the time spent outside the door. An example of how you should write the mnemonic is given on page 3

The reason that you should make a list of Differential diagnosis is that the mnemonic does not cover everything. When we reached the A for associated symptoms, we asked the questions associated to the presenting complaints, which are not covered in the mnemonic. For example, if a patient presents with headache, you may consider migraine as one of the possibilities. You should ask if there was an aura as one of the associations, so this way the rest of the questions can be covered.

As part of closure of the patient encounter, you have to counsel the patient if he smokes, uses excessive alcohol, uses recreational drugs or practices unsafe sex. One may forget to, due to the stress of the exam, so it is easier to remember if you write it down under the counseling box. Write the DDs before you enter the room, whereas write the counseling section as you take down the history as counseling depends on the patient’s lifestyle. At the end, you can just look at it and counsel for everything that’s in the box. We have written how you should go about the encounter.

Sara Palin, 32yr old female, Headache

Vitals: Normal

O                                                          R

P                                                           L

F                                                          Q

A                                                         S

A

A

P

F

F                                                          L

R                                                          M

A                                                         P

W                                                        R

S                                                          T

////// (transition sentence)                       V

R                                                          C

A                                                         S

M                                                         P

P                                                          A

////// (transition sentence)                       P

SEX

S

O

D

A

T

L

A

D.D Counseling:

Migraine                                                           Safe sex

Tension headache                                             Smoking

Cluster headache                                              Alcohol

Subarachnoid Hemorrhage                                Recreational drugs

Trauma                                                 Diet, exercise, compliance with medication

(Mnemonic created and devised by Adnan Saleem Polani, DMC Batch 2007. Currently working as Resident at Marshfield Clinic, Wisconsin)

The Patient Encounter

Knock Knock (Knock loudly so that the patient can hear it)

Mr. / Mrs. / Miss _________________ ???

Good morning (SMILEJ!! Your voice should have confidence. Greet warmly and shake hands firmly, maintain eye contact while walking from the door to the SP) I am Dr. ___________ and I shall be your physician today. Is everything fine in the room for you sir/ ma’am? Let me make you a bit more comfortable (put the drape on the simulated patient (SP). I would be asking you a few questions and would be taking down some notes, is that ok with you?

So, tell me ma’am / sir, what brings you here today? He/ she will say the chief complaint. SHOW EMPATHY!! for pain or whatever the patient has presented with for example say something like…I see (pause for 2 seconds) that must be bad for you…(and you should not be smiling then) would you like to tell me more about it ? SP will tell u how it started, use the mnemonic

OPF, AAA   PFF, RAWS RAMP  Sex, SODA TLA

• Onset: How did it start or when did it start (you may not need to ask this question        if the  SP tells you beforehand)

.

• Progression: How it has progressed since then?

• Frequency: Is it continuous or does it come and go? How many times does it occur in a day? How long do these episodes last?

• Aggravating factors: Does anything make it worse?

• Alleviating factors: Does anything make it better?

• Associated factors: Use dd approach (explained above) Ask questions related to the differentials. Say if suspecting TB, ask for blood in sputum, ask for the last PPD, ask for night sweats (assuming chronic cough being the chief complaint)

If pain is the chief complaint, also use the following four, otherwise, go ahead with the mnemonic. RLQS

• Radiation: Does the pain go anywhere?

• Location: Where, exactly is the pain located sir/ maam?

• Quality: What is the quality of the pain? Is it burning? Dull? Stabbing?

• Severity Scale: If I were to give you a severity scale from 1 to 10, with 10 being the most severe pain of your life, how would you rate this particular pain?

(Based on the severity, like something above 6/10, you should show empathy again and say …oh! that must be terrible for you? I’ll try to do my best to relieve you of the pain)

Then keep on following the mnemonic.

• Previous episodes: Have you ever had this previously?

• Fever: Are you running a fever? Or any fever?

• Fatigue: Have you been feeling fatigued lately?

• Rash: Are you experiencing a rash on your body? (Cover skin changes, hair changes? any bruises?

• Appetite: Any changes in appetite? What does your diet consist of?

• Weight changes: Have you noticed any changes in weight recently? Do you exercise?

• Sleep: Any changes in sleep pattern?

Transition sentence: Now I would ask you few questions about your health in general. Is that ok with you?

• Review of systems:

For Respiratory system and CVS: Any complaints of cough, shortness of breath, chest pains (ask one by one)

For GIT: Did you notice any change in your bowel movements? Any blood in your stools?

For Neuro: Any headaches? Any numbness? Tingling?

For Urinary: Any problems with urination? Any blood in urine?

For Musculoskeletal: Any Body pain? Joint pain?

*Always Ask if pain anywhere else in the body too apart from the presenting complaint.

• Allergies: Are you allergic to any medication or anything else? Or do you have any known allergies?

• Medications: Are you taking any medications currently?

• Past History: This heading covers three topics.

Past Medical: – Do you have any chronic illnesses? Any hospitalizations?

Past Surgical: – Any previous surgeries

Family History: – Any illnesses in the family? Does anyone suffer from the same condition that you are suffering from?

Are your parents alive? YES: okay, so are they healthy? If NO: Oh I’m sorry to hear that (pause for around 2 seconds), so how did they expire/pass away?

*if u suspect infectious diseases/child patient … ask any close contact who have suffered from a similar illness?

If female use the following mnemonic but ask a transition question.

Transition sentence: Now I would ask you about your Gynecological and Obstetric history. Is that ok with you?

LMP RTV CS PAP

• Last Menstrual period: When was your last menstrual period?

• Menarche: At what age did you start menstruating?

• Periods last how long: How long do your periods last?

• Regular / Irregular cycles: Are your cycles regular?

• Tampons used: How many tampons/pads do you use on your heaviest day?

• Vaginal discharge: Any vaginal discharge?

• Cramps during menses: Any cramps during menstruation?

• Spotting b/w periods: Any spotting b/w periods?

• Pap smear: Do you get regular pap smear screening done? When was your last pap smear and was it normal?

• Abortions: Any abortion history?

• Pregnancies: Any pregnancies?

Transition sentence: Now I would ask you some personal questions. Is that ok with you?

• Sex: Are you sexually active? May I ask with whom? Since how long?

*If patient has multiple sexual partners ask how many partners he/she has had over last one year. Do you use condoms (if male)? Do you use contraception? (If female)

Also ask, are you active with men, women or both? Have you ever suffered from a sexually transmitted disease? Have u ever been tested for HIV?

• Smoking: Do you smoke? How many cigarettes a day and for how long?

• Occupation: What do you do for a living? (We always asked this question while washing hands)

• Drugs (recreational): Do you use any recreational drugs? If yes: since when? When was the last time you used it?

• Alcohol: Do you drink alcohol? How much? Since when? Ask the CAGE questions?

• Travel: Any recent travel history?

• Living conditions: Whom do you live with? (If some elderly and you suspect abuse ask. How’s your relationship with your son/daughter/wife? Also in depression cases you can ask them this (also see mnemonic below for depression)

• Anything else: Is there anything else you would like to tell me about your symptoms? (IMPORTANT! The SP can drop a hint regarding anything you have missed)

FOR CHILDREN:

Replace the Sex SODA with BDID-C

• Birth History: Can you tell me about your son/daughter’s birth? Was he/she born at term? Were there any complications? Did he/she cry immediately after birth? Was there any jaundice? (enquire about the health of the mother during pregnancy)

• Developmental history: Did your child achieve milestones at proper ages?

• Immunization history: Is your child’s vaccination complete

• Diet: (you can merge this with appetite) ask what does your child’s diet consist of? How frequently do you feed him/her?

• Check up: Does your child get routine checkups? When was his/her last checkup? How was his/her health then?

*FOR PSYCHIATRIC COMPLAINTS:

There is a special set of questions you should ask:

DEPRESSION:

SIGEM CAPS

• Sleep
• Interest
• Guilt
• Energy level
• Mood
• Concentration
• Appetite
• Psychomotor retardation
• Suicidal ideation (imp!) if the answer is a yes: ask if the patient has a plan? Any previous attempts?

MANIA:

DIGFAST

• Distractibility
• Insomnia
• Grandiosity
• Flight of ideas
• Activity (goal oriented)
• Speech (extreme talkativeness)
• Thoughtlessness (high risk behavior)

Now that your history is complete you proceed to physical examination.

“Okay sir/mam I have completed the history taking and would like to proceed with the physical examination with your permission (a pause of three seconds so that SP can say yes) but before that I would wash my hands.”

Go wash hands and dry them properly with tissues.

Start the examination doing the relevant system first. Do the rest only if you have time. By the time the warning sounds that you have five minutes left, you should be halfway through the examination. If you are not then speed it up and don’t do an unnecessarily detailed examination. If your physical examination is not proper due to short of time then it’s not a problem but if your counseling is not complete then you have almost surely failed the case.

Now, comes the closure. This is one of the most important parts of your case where the patient has to be explained briefly what has happened and what tests and treatments he should expect in the coming visit.

You should summarize the history very briefly. Then explain your initial diagnostic impression (just two or three most likely DDs will suffice) and tell the SP about a few tests or examination that you would like to run. Since you cannot do rectal, breast, pelvic and rectal examination you should mention that you will do so later but you must mention it. We have included some sample closures that should help you.

Sample Closures

Mr. ________________ on the basis of your history and physical examination, my initial diagnostic impression is that your symptoms may be caused by a no. of medical conditions. They can be due to THIS or THAT, so I would like to run few tests on you which would include some blood tests, an ultrasound (it is a test where we use sound modalities for imaging your belly) a CT (a highly sophisticated Imaging test) an MRI       (imaging technique using magnetic waves), then I would be in a better position to tell you as to what is causing your symptoms. So as soon as your test results are back we shall meet up again and discuss the treatment options. Is that ok with u? Do u have any more questions for me? Alright sir it was a pleasure meeting you, Goodbye (shake hands firmly with a smile).

Alcohol counseling

“Sir, I would like to talk about your alcohol usage, because I believe that your current consumption of alcohol is above the safe limits of alcohol usage. So as a concerned physician, I would strongly recommend that you cut down on your drinking habit as it might be the cause of your symptoms or it might exacerbate / worsen your symptoms. Do you think u r ready for it”? If the SP says yes tell him “I am glad about your decision, I shall refer you to Alcohol Anonymous and I shall always be here to see your progress and guide you through the process.”

If he says no then say “Ok sir whenever you think you are ready for it please come to our hospital, as I shall always be here to help you through the process.”

Smoking counseling

“Sir I would like to talk about your smoking habit, as you know smoking is injurious to health and is a major cause of serious illnesses like cancer. So as a concerned physician I would strongly recommend you to quit smoking (as it might be the cause of your current condition). Do you think you are ready for it?” If the SP says yes tell him ” I am glad about your decision, we have excellent quit smoking program in our hospital and I shall refer you there also I want to assure you that I shall always be here to help you through the process.

If the SP says no then say ”Ok sir whenever you think you are ready for it please come to our hospital, as I shall always be here to help you through the process.”

Safe sex counseling

“Sir I would like to talk about your sexual history now, as you told me that you have had multiple sexual partners in the past year and you don’t use condoms in your sexual encounters.  This behavior puts you at risk for acquiring sexually transmitted diseases and even life threatening STDs like HIV. So as your concerned physician I would strongly advise you to use condoms in your sexual encounters. It has multiple advantages; can prevent sexually transmitted diseases and unwanted pregnancies in your partner”

Challenging Questions

During your encounter, every patient will ask you one or more “challenging questions”. Your reactions and answers to these questions will be scored. You should expect every SP to throw in such questions as they are meant to assess your presence of mind and ability to handle stressful situations.

When answering these questions, try to remember the following:

• Be honest and diplomatic
• Don’t give the patient a final diagnosis. Instead, tell the patient about your initial impressions and about the workup you have in mind to reach a conclusion.
• Do not give false reassurances
• If you do not know the answer to the patient’s question, say that you will refer him to a senior

We have given some examples of challenging questions and how you should answer them:

*SP: Doctor, I am in terrible pain. Can’t you just give me pain meds, so I can leave?

Answer: Well, Mr. ________, I realize that you are in pain. But I need to know what’s causing your pain in order to give you the appropriate treatment. After I am done with my evaluation, we can decide on the best way to help manage your pain.

*SP: Doctor, do I have cancer/stroke?

Answer: Well, Mr. _______ this is one of the possibilities, but there are other explanations for your symptoms that we should rule out before making a diagnosis. For that I will need to take a complete history, do a physical examination and run some tests to be sure of what is causing your symptoms.

*SP: Doctor, I want to go to the Swiss Alps with my wife. Can’t we do these tests after I come back? (Especially, if a patient has a serious problem)

Answer: Well, Mr. _________, I understand that you don’t want to put off your trip, but you may be having a serious problem that may benefit from early diagnosis and treatment. So I would like to run these tests before you go for your trip.

During your encounter, try not to use medical words like abdomen , palpate etc … just say belly for abdomen, press gently for palpate, tap for percuss, listen for auscultate, first menstrual period for menarche etc. The patient might just stop to ask you what that particular word means

After you are done with your patient encounter, you are given 10 minutes to write a patient note. The patient note covers four areas:

• the history
• physical examination
• differential diagnosis
• initial diagnostic workup

You should practice writing these patient notes, every time you do a case. There are many abbreviations which you should make yourself familiar with and use while writing the patient note. For more information, you can check the website www.ecfmg.org for sample patient notes.

We hope that our way of going about the CS exam will be helpful for you for your CS preparation. We will upload this and other information about the other USMLE exams on www.pakmeds.com so you may access it easily. Take care and best of luck for your exam.

Dr Muhammad Ali Khan

Dr Faraz Khan Luni

Dr Isra’a Khan

(Dow Medical College, Batch of 2008)

6^th July, 2010

MORE ABOUT THE MNEMONIC

Faraz Khan Luni

Some people are having trouble remembering the mnemonic written by us. To remember this we used the lines mentioned below (Altered to make it less perverted than the one we used

OPF AAA

O Papa Fries!! AAAaaaaaaaaa

PFFRAWS

Pakistani French Fries are RAWS

As to get every good thing in the world we have to work hard. So we climb a

RAMP

And say

SEX

SODA

Tou Lay Aao (TLA)

I hope this senseless story makes sense to you Best of luck