Re: STEP 2CS DOUBTS
adonis123 - 09-14-09 11:47



These r not silly questions at all.These r some of the fundamental questions.
Trauma,sputum r alright to use.
Instead of Sinus tenderness and seizures use the words 'facial tenderness' and 'movements of the body' , respectively.
The word Heartburn can be used , but better use 'pain in the stomach area'.

U can use the words Migraine, Audiometrist .
ABDOMINAL ULTRASOUND, infection of LIVER/COLON/SPLEEN/URINARY TRACT Infection/RESPIRATORY TRACT infection can be used.

Never alarm the patient ,so never use the word cancer or the term heart attack.
Instead of the word heart attack,use the words that the pain can be due some problem with the vessels of the heart.
Instead of the word LFT's and PFT use the words blood tests and the tests of the lung function.
Instead of the word arthritis use the word joint pain due to inflammation or infection or increased uric acid level.But, the word arthritis,gout can also be used.
Always use the simplest words in which u can explain diagnosis,tests,etc. to the patients.

Good Luck!

Re: STEP 2CS DOUBTS
drkims - 09-15-09 06:29

Thanks adonis123.
I have some doubts in Physical Examination:

1.THYROID EXAMINATION:1 method :to stand behind patient & palpate for each lobe &I dont ask him to swallow.
2nd way:stand in front of him & ask him to swallow each time you palpate a lobe.Also to ask if will need water to swallow.

Which is the method followed?2nd takes time.

2.RINNE TEST:done on affected side only or both sides?

3.During Babinski & ACHILLES reflex we touch patients sole.Do we need to again wash hands after these tests if there are other examinations to be done?It takes time.

4.Is it acceptable if we check motor,DTRs,sensation of upper limb & then do all these on LOWER LIMB.This way can do BABINSKI last & avoid washing hands.

5.During exam do examinees actually wash hands with soap & water?OR just run the tap water without wetting hands.I take quite sometime to dry hands using the tissue provided.Also SPs complained that my hands were very cold.I
did rub my hands nicely.

6.Is it acceptable to check muscle strength of both Rt & Lt upper limbs simultaneously?Same for both lower limbs?

7.If pt with say knee pain c/o pain when we check m.strength & DTRs?What to say? should we proceed withthe tests?

Re: STEP 2CS DOUBTS
adonis123 - 09-16-09 20:06



Resort to the first method(i.e., palpate from side or behind) for thyroid examination,and do ask the patient if he/she needs any water to swallow.Most probably, the patient willd not take any water.
U should do Rinne test on both the ears.
U must never touch the patient's sole.Always hold the patient's foot from above between the thumb and fingers on either side.So, u will not need to wash yur hands.
Yes, u can check the power, reflexes,and sensations of upper limbs followed by lower limbs.In my opinion,first check quickly the power in upper limbs and then in lower limbs and then do the same for reflexes and sensations.
Yes, u need to wash hands with soap and water before starting the physical exam.U must always dry yur hands and for that use as much napkin as u may need.Do rub yur hands n order to warm them.This willmake the SP comfortable.
Yes, u can check the muscle strength in both the upper limbs simultaneously and then in both lower limbs simultaneously.It will save alot of time.
If the patient complains of knee pain,then u must start the physical exam on the side which is normal and then go to the painful side.Do not do DTR's on the painful knee. U can check muscle strength on that knee,but do proceed very gently and stop if the patient complains of pain.Do say sorry if the patient feels pain due to any procedure u do on him/her.
Also, refer to my earlier post ,"Adonis's Advice Regarding Step-2CS".
Good Luck!

Re: STEP 2CS DOUBTS
drkims - 09-17-09 07:17

adonis123 Thanks for answering all my doubts.

-But how to check muscle strength of foot without touching the sole.I usually say'can you plz bring your foot up against my hand's resistance,....can you bring it down'.Do give your advice.

-Should the lights be turned off during pupillary exam?

-After introduction should we always ask'Can you plz tell me more about your problem?'There can be many points to be noted then.Or can the 1st question be not open ended & instead ask about the onset?

-Is it ok to ask pt about FH of mental illness/psychiatric illness?

-Pt with COUGH:Do we actually offer glass of water or tissue?Or 1st ask if they want water.Because not v.familiar of US ways,....do we offer tissue or show the tissue box to them?

-Under Counselling :can we REFER the pt eg:for Orthopedic consultation,or to a THERAPIST?


-In Pediatric case: under INVESTIGATION do we write PHYSICAL EXAMINATION as 1 investigation?

-CN346 testing:Do we move finger in 'H' pattern or 'H' with DIAGONAL MOVEMENTS of FINGERS?

-ask for FAMILY H/O RELEVANT MEDICAL illness ?OR mention the disease names for FAMILY H/O?


-Are these abbreviations acceptable....
Ca. for carcinoma,
Pt---patient
&...and
m...month
wks....weeks
yrs....years
Rt/Lt.....right/left


Are these WORDS acceptable under HPI :

SUDDEN or GRADUAL
EPISODES
Any FACTOR that makes it worse..
Was it CONSISTENTLY present...

-Diarrhea case:'do you mean increased frequency or increased vol. or change of stool consistency'.Is it ok to ask 3 related questions in 1 sentence?

Similarly ask Family h/o high BP,high bl sugar.....Or ask each as a separate question?

Re: STEP 2CS DOUBTS
adonis123 - 09-17-09 08:21



Try to do it the same way as I suggested for Babinski sign,but the only difference will be that u will have to hold the foot more tightly.Always try to avoid touching the soles of the feet.If u have no way out , it is better to avoid doing this part than touching the sole of the foot.U can say 'can u please push it down/push/pull it up.
There is no need of turning off the lights in the room because it creates an anxiety in the examinee.Better check pupillary reflexes with lights on.
Yes, u should say'can please tell me more about it.'If even after asking this question the SP does not reveal anything else,u should then ask about onset,etc.
If u have to ask regarding FH, then ask like,'does anyone in yur family have the same problem or anything similar.'I the patient does not reveal anything then u can ask about well know and common diseases.
It is better to first offer and then make the water or tissue available.
Don't refer,because u need the patient come back to u at the time when the patient's test reports r available.
U do not write physical examination as an investigation in case of a pediatric case.
Move the finger in an H-pattern.
Better use full words.But, if u need to use from the above abbreviations,u can use all of them except 'ca' for 'carcinoma'.
U can use the words 'sudden', 'gradual'.
Instead of the word 'episode' ask the patient how many times did they have----- .
Instead of the word any factor' use the simple word 'anything'.
Instead of the word 'consistently' use the word 'always'.
For bowel habits ask the SP 'Has there been any change in yur bowel habits.'Never ask so many in a single sentence,ask them one at a time.
Ask the questions singly like F/H of raised blood sugar,etc.

I m very pleased that u ask such questions.I m sure if u practice all this u will surely pass.
Good Luck and best regards!

Re: STEP 2CS DOUBTS
drkims - 09-17-09 12:24

Thanks a lot.
-I did not understand foot m.strength.U mean if not ok I can avoid checking foot m.strength.I know it is difficult to explain in writing.Can u explain the foot exam: once more?

In upper limb,do we need to check strength of arm & also of forearm .Can I skip arm strength & do forearm strength only?Hope my doubt is clear.

Is ACHILLES done in all neuro :cases?Can I skip it & do other LL DTRs.

- Also do we need to ask PAMHUGSFOSS in all cases,as in some cases bowel movements & sleep questions might have no relevance.

-What to say' before percussion of LIVER' &'before palpating SPLEEN?'

-DO we hurt pts' feelings when we ask h/o MENTAL ILLNESS.So no problem if
we ask this question?Which is better -ask h/o MENTAL ILLNESS or h/o PSYCHIATRIC ILLNESS?

-Is it ok to use 'ABDOMINAL DISTENTION?'

Re: STEP 2CS DOUBTS
adonis123 - 09-17-09 21:49



In the upper limb u can skip checking arm strength and check only forearm strength.
If u have time do Achilles tendon reflex,but if u do not then do the triceps,biceps,knee jerk only.
Ask about bowel habits and Sleep in all the cases because these two r the indicators of the general condition of a person.
Intead of percussion say, 'I am going to tap on----' and instead of palpation say, ' I am going to press lighly/deeply on---'.
U need not to ask about mental illness except in patients with clear psychiatric symptoms.Do not ask about it in all the patients.Use the term 'psychiatric problems' rather than the term 'mental problems' if u cannot avoid using either of them.
However,u can ask about stress in all other patients.
Before asking about distension ask about whether the patient has any swellings anywhere in the body.Then u can ask specifically about distension as well.
Remember, Step-2CS is actually an exam which tests one's communication skills.Physical exam is a very minor part of the Step-2CS exam.I said that it is wise to leave some physical exam instead of compromising yur communication with the patient.Suppose if the time has run out it is better to do closing than keep on doing the physical exam.Always put emphasis on communication with the patient.
About checking muscle strength of the feet,I said it is a lot better to avoid touching the sole if u will need to touch the patient again after that.But, if u do not need to touch the patient again after touching the sole then u can fearlessly do it.In case u need to touch the patient again then u should check the foot muscle strength simply by holding the foot tighty between yur thumb and fingers above it.
Good luck!

Re: STEP 2CS DOUBTS
drkims - 09-20-09 19:31

for romberg test: ask 2 stand with feet together &close eyes/do we need to also ask to stretch arms with palms up ?

for GAIT 'WALK across room?' hOW is it different from GET UP & GO TEST?

Do we help pt while changing position only if pt asks 4 help when i offer help?

Re: STEP 2CS DOUBTS
adonis123 - 09-21-09 12:21



U may r may not ask the SP to stretch his/her arms.
First always offer help and if the SP says 'yes' then help.
In order to check the Gait u simply tell the SP,'Can u walk across the room for me.' U donot follow a proper protocal as u do in case of the 'Get Up and Go test'.

Get up and Go Test :

"Have patient sit in straight-backed chair and ask him/her to:

Get up (without use of armrests, if possible).

Stand still momentarily.

Walk forward 10 feet.

Turn around and walk back to the chair.

Sit back down in the chair.

Any observed change in gait, strength or balance is abnormal.'

The Get Up and Go test can also be timed.

Good Luck!