STEP 2 CS Patient Note

CS EXAM Patient note

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USMLE Step 2 CS Exam patient note

HISTORY: Describe the history you just obtained from this patient.  Include only information (pertinent positives and negatives) relevant to this patient’s problem(s).
Ms. Bingham is a 24 yo woman who complains of worsening sore throat since yesterday morning. She has never had a similar problem in the past. She has no difficulty swallowing, but notes that swallowing makes the pain worse. Nothing makes it better. There is no SOB or sensation of choking or dysphagia. She has fatigue and has had some anorexia since the symptoms began. She has had some subjective fevers at home but has not taken her temperature. She has had no cough or rhinorrhea. There are no sick contacts at home or at work. She denies seasonal allergies and post-nasal drip.  ROS: No chest pain, cough, wheezing, abdominal pain, N/V, headache  PMHx: none Meds: none; Allergies: none PSHx: none FHx: father with HTN SHx: married with 2 children, No ETOH or drugs, monogamous with husband
PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of examination you performed in this encounter.
She is in no acute distress, throat clear, abdomen soft, nontender and without distension. There is no notable splenic or hepatic enlargement or tenderness.
DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.).
DIAGNOSIS #1: Viral Pharyngitis
HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) Sore throat Tender submandibular lymph nodes Subjective fever   
Pain with swallowing  
DIAGNOSIS #2: Bacterial Pharyngitis/Retropharyngeal Abscess
Appropriate supporting information is drawn from the history and PE section above and used to support a likely diagnosis
Including a diagnosis without supporting information would result in a lower score even if the diagnosis is likely. Including two diagnoses on the same line would result in a lower score.  
The physical exam includes a cursory examination of the throat. A higher level of detail such as specific mention of erythema or exudate, and evaluation for regional lymphadenopathy would result in a higher score.
Copyright ©2014-16 by the National Board of Medical Examiners (NBME) and the Educational Commission for Foreign Medical Graduates (ECFMG).
Throat Culture Head/neck CT with Contrast
 “Head/neck CT with contrast” is overly aggressive and costly in this clinical scenario, and would result in a lower score. Watch your USMLE Step 2 CS Exam. High Yield USMLE Step 2 CS Videos Audios ICE CIS SEP that match the 5 th ed of First Aid. Pass USMLE Step 2 CS Exam in 30 days Ace your USMLE CS EXAM  with the Gold Standard with Brand new HD videos that intimately simulate the actual CS exam. Audios, timed patient notes, new patient encounters with new standardized patients 100+ new products and updated classic CSEVideos and  Assessment exam. 24/7 unlimited access  to your membership.24/7 tech support. Discount renewal rates study guides, mnemonics and much much more. One stop for all your USMLE Step 2 Clinical Skills Exam Find
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