USMLE®
Step2CS
LectureNotes
2019

PatientCases+ProvenStrategies


USMLE đ isajointprogramoftheFederationofStateMedicalBoards(FSMB)andtheNationalBoardof
MedicalExaminers(NBME),whichneithersponsornorendorsethisproduct.
Thispublicationisdesignedtoprovideaccurateinformationinregardtothesubjectmattercoveredasofits
publicationdate,withtheunderstandingthatknowledgeandbestpracticeconstantlyevolve.Thepublisher
isnotengagedinrenderingmedical,legal,accounting,orotherprofessionalservice.Ifmedicalorlegal
adviceorotherexpertassistanceisrequired,theservicesofacompetentprofessionalshouldbesought.This
publicationisnotintendedforuseinclinicalpracticeorthedeliveryofmedicalcare.Tothefullestextentof
thelaw,neitherthePublishernortheEditorsassumeanyliabilityforanyinjuryand/ordamagetopersons
orpropertyarisingoutoforrelatedtoanyuseofthematerialcontainedinthisbook.
â2019byKaplan,Inc.
PublishedbyKaplanMedical,adivisionofKaplan,Inc.
750ThirdAvenue
NewYork,NY10017
AllrightsreservedunderInternationalandPan-AmericanCopyrightConventions.Bypaymentofthe
requiredfees,youhavebeengrantedthenon-exclusive,non-transferablerighttoaccessandreadthetextof
thiseBookonscreen.Nopartofthistextmaybereproduced,transmitted,downloaded,decompiled,reverse
engineered,orstoredinorintroducedintoanyinformationstorageandretrievalsystem,inanyformorby
anymeans,whetherelectronicormechanical,nowknownorhereinafterinvented,withouttheexpress
writtenpermissionofthepublisher.
ISBN:978-1-5062-4310-8

Editors
MarianaCuceu,MD
SherineElsayegh,MD
PhyllisLevine,MD
Contributor
EdwardKalpas,MD
CurriculumEditor
IlonkaS.RinconPortas,MD
HEAAssociateDirectorofFacilitationandClinicalSkills
KaplanMedical


Wewanttohearwhatyouthink.WhatdoyoulikeornotlikeabouttheNotes?
Pleaseemailusat


TableofContents
PartI:USMLE ® Step2ClinicalSkillsExam
Chapter1:AbouttheUSMLEStep2ClinicalSkills(CS)Exam

PartII:CommunicationandInterpersonalSkills(CIS)
Chapter2:CommunicationandInterpersonalSkills(CIS)

PartIII:SpokenEnglishProficiency(SEP)
Chapter3:SpokenEnglishProficiency(SEP)

PartIV:IntegratedClinicalEncounter(ICE)
Chapter4:FocusedHistory-Taking
Chapter5:FocusedPhysicalExam
Chapter6:PatientNote

Chapter7:DifferentialDiagnosis

PartV:PuttingItAllTogether
Chapter8:PuttingItAllTogether:CIS,SEP,andICE
Case1:Fatigue,Cough,andChestPain
Case2:BackPainandFever


Case3:BloodyStools
Case4:ChestPain
Case5:IrregularPeriods
Case6:SoreThroat
Case7:HearingLoss
Case8:“SomethingIsWrongwithMyDad”
Case9:SevereHeadache
Case10:SevereAbdominalPain
Case11:ChronicDiarrhea
Case12:AbdominalPainandYellowSkin
Case13:Cough
Case14:BloodinUrine
Case15:PediatricDiarrhea
Case16:Dizziness
Case17:DifficultySwallowing
Case18:ShortnessofBreath
Case19:AdultNosebleed
Case20:AdolescentWeightLoss
Case21:PediatricVomitingandDiarrhea
Case22:LackofEnergy
Case23:ChestPain
Case24:KneeandGreatToePain

Case25:SevereChestPain
Case26:ConfusionandBlurryVision
Case27:LifeInsuranceRequest
Case28:Pre-EmploymentPhysical


Case29:MedicationRefill
Case30:BreakingBadNews
Case31:Weakness

PartVI:Appendix
CommonMedicalAbbreviations


PARTI

USMLE ® Step2
ClinicalSkillsExam


AbouttheUSMLEStep2
ClinicalSkills(CS)Exam

1

The 3-step USMLE examination required for medical licensure in the United
States assesses a physician’s ability to (a) apply knowledge, concepts, and
principles, and (b) demonstrate fundamental patient-centered skills which
constitute the basis of safe and effective patient care. Each of the 3 steps
complementstheothers.

Step1assesseswhetheronecanunderstandandapplyimportantconceptsofthe
sciences basic to the practice of medicine. It is based on an integrated content
outlinewhichorganizesbasicsciencematerialalong2dimensions:system and
process.Itisa1-daymultiple-choiceexam.
Step 2 assesses whether one can apply medical knowledge, skills, and
understandingofclinicalscienceessentialfortheprovisionofpatientcareunder
supervision. It includes emphasis on health promotion and disease prevention.
Thereare2componentsofStep2.
Step2CK(ClinicalKnowledge)isbasedonanintegratedcontent
outlinethatorganizesclinicalsciencematerialalong2dimensions:
physiciantaskanddiseasecategory.Step2CKusesa1-daymultiplechoiceformattotestclinicalknowledge.
Step2CS(ClinicalSkills)isa“handson”examtotestone’sabilityto
gatherinformationfrompatients,performphysicalexaminations,and
communicatefindingstopatientsandcolleagues.
Step3assesseswhetheronecanapplymedicalknowledgeandunderstandingof
biomedical and clinical science essential for the unsupervised practice of
medicine,withemphasisonpatientmanagementinambulatorysettings.Itisthe
finalexaminationintheUSMLEsequence.


Note
TheStep2CSexammeasuresskillsessentialtopatientcarethatcannotbemeasuredbya
traditionalmultiple-choiceexam.

EXAMOVERVIEW
Step 2 CS is a 1-day live examination which resembles a physician’s typical
workday in a clinic, doctor’s office, ER, and/or hospital setting in the United
States.TheexamisadministeredatregionalClinicalSkillsEvaluationCenters
(CSEC)inAtlanta,Chicago,Houston,Philadelphia,andLosAngeles.
Thefocusofmedicalhistoryyouneedtoobtainineachcasewillbe

determinedbythenatureandcomplexityofthepatient’spresentation.
Noteverypartofthehistoryneedstobetakenforeverypatient.Some
patientswillhaveacuteproblemswhileotherswillhavemorechronic
ones.
Youwillnothavetimetodoacompletephysicalexamoneverypatient,
norisitnecessarytodoso.Pursueafocusedphysicalexaminationbased
onthepatient’scomplaintandinformationobtainedduringthehistorytaking.
TheCSexamblueprintisdesignedtogiveyouafairrepresentationofcasesthat
a physician is likely to encounter in clinical settings in the United States.
Examineeswillberequiredtodemonstrateclinicalskillsmostcomparabletothe
levelofexperienceofafirst-yearmedicalresident.
Step2CSStrategy
Itisimpossibletodoafullphysicalexamandlengthypatienthistoryin15minutes.Thekeywords
forthistime-criticaltaskare“pertinenthistory”and“focusedphysicalexamination.”

Most cases are designed to test the type of history-taking and focused
examination that demonstrates your ability to list and pursue plausible
differential diagnoses in acute and non-acute situations. Some cases, however,
mayfocusonlyonhistory-taking,physicalexam,orcounseling.Somescenarios,
suchasphonecases,mayinvolveaparentofachildorafamilymemberofan
elderlypatientwhowillnotbepresentintheroom.Inthesesituationsaphysical
examination of the patient will not be required; however, you will still be
expectedtotakeahistory,counsel,articulateadifferentialdiagnosishypothesis,


andwriteaPatientNote(carefullyreadthedoorwayinformationinstructionsso
youknowthetasksthatyouareexpectedtoperform!).
Note
Eventhoughthisisasimulatedexam,makesureyouperformphysicalexaminationmaneuvers
correctlyandexpectthatsomeencountersmayhavepositivephysicalfindings.Acceptany

positivefindingsasrealandfactorthemintoyourevolvingphysicaldiagnoseshypothesis.

Clinicalcasecategoriesinclude,butarenotlimitedto:
Cardiovascular

Neurologic

Elderlycare

Pediatriccare

Endocrine

Preventivehealth

Gastrointestinal

Psychiatry

Genitourinary

Respiratory

Musculoskeletal

Women’shealth

EXAMSPECIFICS
The exam will include 12 patient encounters. (A very small number of nonscoredpatientencountersareincludedforresearchpurposes,butthosecasesare
integratedintotheexam.)

TheEvaluationCenterwheretheexamisgivenwillsimulateahealthcare
environmentcomparablewithalargemedicalclinic.Whenyouenterthe
testingarea,youwillhave12stationssetupasfullyequipped
examinationrooms.
Eachexamroomdoorwillpostaninstructionsheet(“doorwayinformation”),containingbasicinformationaboutthecase:patient’sname,
age,gender,reasonforthevisit,vitalsigns,andtasksthatexamineesare
expectedtoperform.
Atthestartofeachencounteryouwillhearanannouncementsuchas,


“Examineesyoumaybeginyourencounter.”
– Readtheinstructionsheet,takenotesonthescrappaper,knockonthe
door,andbeginyourencounter,justasyouwouldwitharealpatient.
Asecondcopyoftheinstructionsheetwillbeaccessibleintheexam
room.
Youwillconduct12examinations(15minuteseach)ofa“standardized
patient”(SP)chosenfromabroadrangeofageandethnicbackgrounds,
andtrainedtoportrayapatientwithahighdegreeofreliability.
– YoumustcommunicatewiththeSPsinaprofessionalandempathetic
manner,toestablishagooddoctor-patientrapportwhile
simultaneouslyelicitingpertinenthistoricinformationand
performingafocusedphysicalexamination.
– YoumustaddressalltheSP’sconcerns,explainandjustifythe
diagnosesthatarebeingconsidered,providecounselingwhen
appropriate,informandgetthepatient’sagreementonplanned
diagnostictests.
Aftereachencounter,youwillhave10minutestorecordpertinenthistory
andphysicalexamfindingsobtainedduringtheencounter,tolist
diagnosticimpressions(maximumof3intheorderoflikelihood)with
supportforeach,andtooutlinethediagnosticstudiesplanned.

Step2CSataGlance
TotalExamLength:

8hoursincluding2breaks

PatientEncounters:

12

LengthofEachPatientEncounter:

15minutes

TimeAllottedforWritingEachPatientNote: 10minutes

STRATEGYANDTIMEMANAGEMENT
Time management is critical during the CS exam, factoring in the success of
yourperformance.
Patient Encounter: You will be expected to perform 15-minute patient


encountersfor12SPsduringyourexam.
Eachexamroomdoorwillhavepostedthepatient’sbasicinformation
(name,age,presentingcomplaint,pertinentvitalsigns,etc.);youmust
reviewthisinformationbeforewalkingin.
Assumealldoorwayinformationisaccurateanduseitwhengenerating
yourdifferentialdiagnosishypothesis.
Typically,vitalsignsshouldnotberepeated,butifyoudorepeatthem,
refertothedoorwayinformationwhendevelopingyourdifferential
diagnosis.

Because the exam is standardized, all examinees receive the same information
whentheyaskSPsthesameorsimilarquestions.TheSPsyouencounterduring
theexamaretrainedtodocumentyouractionsinafairandconsistentmanner.
Immediately following each patient encounter, the SP fills out checklists to
document questions you asked, maneuvers you performed, and your demeanor
and communication skills including proficiency with the English language
duringtheencounter.
Basedonthepatient’spresentingcomplaint,doorwayinformation,and
additionalinformationyouobtainduringthehistory,considerthemost
likelypossiblediagnosesandthenexploretherelevantonesastime
permits.
Tomonitorgoodtimemanagement,dothefollowing:
– Duringthepatientinterview,rememberthatyourcommunicationand
interpersonalskillsareevaluatedbasedonyourobservablebehaviors
andyourresponsetothepatient’sneeds.
– Demonstrateprofessionalismandgoodinterpersonal/communication
skills.Professionalismandpublictrustgohand-in-handandthey
havebeenviewedasawaytoimprovepatientcareandpreservethe
doctorpatient-relationship.
– Addressthepatientinaclearmanner;yourEnglishproficiencyisan
equallyimportantsubcomponentoftheCSexam.
– Demonstrateappropriateclinicalskillstoobtainacompetenthistory,
conductafocusedphysicalexam,andgenerateadifferential
diagnosisandinitialwork-upusingappropriatetimemanagement.
Note that certain parts of the physical exam must not be done: rectal, pelvic,


genitourinary,femalebreast,cornealreflex,inguinalhernia,andthroatswab.If
youbelievesuchexamsareindicated,include themintheproposeddiagnostic
workup.

Patient Note: After each encounter, you will have 10 minutes to record a
completePatientNotethatshouldinclude:
Allrelevanthistorytaken
Physicalexaminationsperformed
Diagnosticimpressions(inorderoflikelihood)andtheirsupportingdata
Diagnosticworkupforinitialevaluation
Onceyouleavetheexamroom,youarenotpermittedtore-enter,sobesureyou
have obtained all necessary information before leaving. However, if you leave
thepatientencounterearly,youcanusetheadditionaltimetostartyourPatient
Note.Inthecaseoftechnicaloradministrativeproblems,typingthenotesonthe
computer may not be an option. If that happens, you will be required to write
yournotesbyhand.Therefore,bepreparedtowriteoneormorePatientNotes
on the day of your exam. These notes need to be legible or they cannot be
scored.

EXAMCOMPONENTS
TheCSexamiscomposedof3subcomponents:
CommunicationandInterpersonalSkills(CIS)
SpokenEnglishProficiency(SEP)
IntegratedClinicalEncounter(ICE)
TheCISsubcomponentassesses:
Fosteringtherelationship:listenattentivelyandshowinterest,care,
concern,andrespect
Gatheringinformation:establishchronologyoftheprimaryproblem,
identifypatientconcerns,andassessimpactofhealthissueonpatient
Providinginformation:explainthemostlikelydiagnosis,encourageand
answerquestions
Helpingthepatientmakedecisions:outlinewhatshouldhappennext



linkedtoarationale,assesspatient’slevelofagreementandabilityto
carryoutnextsteps
Supportingemotions:seekclarificationofpatient’sfeelingstobesure
youarecorrectlyinterpretingthem,demonstrateunderstanding,empathy,
andsupport
TheSEPsubcomponentassesses:
ClarityofspokenEnglishcommunicationwithinthedoctor-patient
encounter
Frequencyofpronunciationorwordchoiceerrorsthataffect
comprehension
Listenereffortrequiredtounderstandtheexamineesquestionsand
responses
Minimizingtheneedtorepeatquestionsorstatements
TheICEsubcomponentassesses:
Datagatheringskills:patientinformationcollectedbyhistorytakingand
physicalexaminationreflectingyourperformanceduringtheencounteras
wellasthedocumentedsummaryofthesefindingsinyourPatientNote
Datainterpretationskills:completionofaPatientNotesummarizingthe
findingsofthepatientencounter,diagnosticimpressionandjustification,
andpatientdiagnosticstudies

EXAMSCORING
The Step 2 CS exam is a pass/fail exam. You are scored in each of the 3
subcomponents: ICE, CIS, and SEP. You must pass all 3 subcomponents on
the same day in order to pass. Failure in one subcomponent will result in
failureontheentireexam.

CISSubcomponentScoring
Checklists assessing your CIS performance based on observable behaviors are
assessedbySPsonall5CISsubdivisions:

Fosteringtherelationship


Gatheringinformation
Providinginformation
Helpingthepatientmakedecisions
Supportingemotions

SEPSubcomponentScoring
Standardized patients (SP) use rating scales to assess the examinees SEP
performance.

ICESubcomponentScoring
PhysicalExaminationchecklistsscoredbySPs
GlobalratingsofPatientNotescoredbytrainedphysicians
A committee of clinicians and medical school clinical faculty develop the
checklists.
For your score report, you will receive a Performance Profile covering the
strengthsandweaknessesofyourperformanceacrossthe3subcomponents.The
PerformanceProfileisprovidedsolelyforyourbenefit;itwillnotbereportedto
anythirdparties.

ONTESTDAY
TheCSexambeginswithanonsiteorientationexplaininguseofthediagnostic
equipmentavailableintheexamrooms,testrules,andtestprocedures.Besure
nottomissthissession.Attheorientationyouwillhavetheopportunitytoask
questions.
Theexamlastsabout8hours,whichincludes2shortbreaksplusalunch
break.
Alightmealisprovided.Youmaybringyourownfood,providedthatno

refrigerationorpreparationisrequired.
Therearevendingmachinesfordrinks.
Westronglyencourageyoutoreviewtheorientationvideoinadvanceavailable
ontheUSMLEwebsite.Inaddition,werecommendthefollowing:


Arriveatthetestcenter30minutesbeforethescheduledexam.
BringyourSchedulingPermitandtheConfirmationnotice.
Anunexpiredgovernment-issuedformofidentification(driver’slicenseor
passport)thatalsohasyoursignature.Ifthenamesprintedonthe2
documentsaredifferent(exceptformiddlenames),contactUSMLEwell
aheadofTestDay.Withoutacceptablelevelofidentificationyouwillnot
bepermittedtotakethetest.
Wearcomfortable,professionalclothing,andacleanwhitelaborclinic
coat.
Bringanunenhancedstandardstethoscope.
Keepyourwalletanddriver’slicenseinyourpantorcoatpocketatall
times.

OTHERPOINTSTONOTE
WearingawatchisprohibitedduringtheCSexam;aclockisonthewall
insideofeachpatientroom,enablingyoutofollowyourtime.
Eachexamcentercontainsalockedstorageareawithsmallcubiclesfor
storageofnecessarypersonalitems;youwillberestrictedfromthatarea
fortheentireexam,includingbreaks.
Oncetheon-siteorientationhasstarted,youmaynotleavethatareauntil
theexamisover.
Youmaynotdiscussthecaseswithyourfellowexamineesatanytime.
Conversationamongexamineesandwithpatientsinanylanguageother
thanEnglishisprohibitedatalltimes.

Proctorswillmonitorallexamineeactivity.
Onthedayoftheexam,youmaybeaskedtosigndocumentsintendedto
confirmyourunderstandingandwillingnesstoabidebyUSMLEpolicies
andprocedures.Youmayalsobeaskedtocompletedemographicand
feedbacksurveysaftertheexam.


PARTII

Communicationand
InterpersonalSkills
(CIS)


Communicationand
InterpersonalSkills(CIS)

2

Thepatient–physicianrelationshipshouldbethecenterandfocusofallclinical
medicine. Excellent communication skills have been shown to improve patient
outcomes,patientsatisfaction,aswellasphysiciansatisfaction.Contrarytothe
beliefs of some physicians, using more appropriate skills does not prolong the
encounter.Theseskillscanbelearnedifsufficienttimeisdedicatedtopractice
andfeedback.
Effective communication on the exam will allow you to efficiently obtain the
informationneededduringthebriefencounter.Expectthestandardizedpatients
(SPs) to respond in a realistic way within the confines of their behavioral
profiles.Thetypeofresponsesyoureceivewillsometimesdependonyourown
personality and characteristics. Following the cooperative responses of the

patient,youcandeterminewhichbodysystemstofocusonduringthephysical
exam(PE).Thepatientwillbecomelessanxiousandmorecompliantwithyour
requestswhenyougiveclearinstructions,explainwhatyouaredoingeachstep
oftheway,andassurethepatientthateachmaneuverismedicallyimportant.
Likewise, in closing the encounter, summarize your findings from the history,
confirmingtheiraccuracywiththepatient.PertinentfindingsfromthePEmight
bementionedinthesummaryaswell.Answeringanyquestionsthepatientmay
have also gives you a final opportunity to reinforce your competency. Finally,
armed with adequate positive and negative findings from the history and
physical,youwillbeabletoproducethePatientNotemorequickly,withbetter
organization,andwithgreateraccuracy.
Thecommunicationskills,alongwiththePE,arescoredbyanSPwhochecks
offitemsonacomputerizedlistassoonasyouleavetheroom.TheCISscoreis


anaverageofthe12scoredencounters;therefore,youcouldperformawkwardly
orineffectivelyin1or2encountersyetstillsucceedontheexam.
Usingtheinterpersonalskillschecklist,theSPratesyourskillsininterviewing
and collecting information, counseling and delivering information, establishing
rapport,andmaintainingapositivepersonalmanner.Eachskillareainvolvesa
handfulofkeycharacteristicsthatareimportantforeffectivecommunicationin
general.Masteryineachareacanbeachievedbyplentyofpractice.Todeepen
and expand self-awareness, seek feedback from the role-playing patient
regardinghisperceptionofyourinterpersonalskills.
Note
Foreachencounterontheexam,youwillgetawarningthatonly5minutesremain.Youshould
beinthemiddleofperformingthePEwhenyougetthisannouncement.

TIMINGTHEPATIENTENCOUNTER
TimemanagementontheStep2CSiscrucial.Forencountersthatrequirebotha

historyandphysicalexamination,werecommendthatyouspendupto1minute
outside the room reviewing the doorway information. Spend 6–7 minutes
greeting the patient, eliciting the chief complaint, history of present illness
(HPI), and relevant past medical history (PMH), asking about any visible
physical findings and related review of systems. Spend 15–30 seconds handwashing,andthentake3-4minutestoperformafocusedphysicalexam.Finally,
take 3-4 minutes to explain to the patient your findings, counsel, address
concerns,andansweranyquestions.
Note
Awallclockispresentineachroom;youmaywanttowritethetimeofentrysoyoucankeep
trackofthecriticaltimepointsnotedinthetable.Pacingyourselfisveryimportantforahighertest
score.

1min

Readdoorwayinformation;copiesareintheroomand
adjacenttothedeskwhereyouwritethenote.
Startthinkingofadifferentialdiagnosislist,andwrite
downseveralofthemostlikelyones.Jotdowna
mnemonicifneeded.


Knockandenterpatientroom.
At71/2min

Endinterview(criticalpoint)includingwritingdown
keypoints.Thiswritteninformationwillensure
accurateandthoroughnotes.

From71/2–8min


Washhandsandstartexamination.
Continuethehistory-takingduringthePE.

At111/2min

EndPEandifneeded,writedownkeypoints.This
writteninformationwillensureaccurateandthorough
notes.

From 11 1/2–15
min

Doclosingincludingcounselingandendthevisit.

From15–25min

Writenote.

EVALUATIONOFCIS
The following pages present a detailed description of the evaluation of
interpersonalandcommunicationskills.
1.Knockedbeforeentering
Knock before going into the examining room. By knocking first, you alert the
patientthatsomeoneisabouttoenter.Knockingisafirststepinbuildingtrust
and showing respect. Knock 3 times, wait 3 seconds, open the door and then
entertheroom.Donotbetimid.EvenifyouareunsurethatyouheardtheSP
say“comein,”enterafter3seconds.Donothesitateandwastevaluabletime.
Creditwillalwaysbegivenifyouknock.InsomecasestheSPhasbeentrainedtoNOTrespond
totheknock,toseeifyouwillenterorjustkeepknocking(factorswhichwillaffectyouruseof
timeandalsotherelationship).


2.Introduction—usedlastnameandtitle


Setatoneoffriendlinessandpositiverapportbymakingacordialintroduction.
Youwillbegiven creditforintroducingyourselfbyname,greeting the patient
byname,andidentifyingyourroleinthehospital.
Itispropertointroduceyourselfusingtitle,firstandlastname,ortitleand
lastnamealone.ChooseeitherDr.SusanSmithorDr.Smith.
Neverrefertoyourselfortoapatientbyfirstnameonly.
Remainawareofwordsyouareusingduringallphasesoftheinterview.It
isoftendisquietingtopatientsifphysiciansusestatementsthataretoo
informal,anditmaydetractfromprofessionalism.
– Ifthereisanyambiguityinyourrole,suchasyourstatusasastudent,
explainyourrelationtothepatient’scare.Ifappropriate,youcan
refertoyourselfasaseniormedicalstudentorresidentonservice.
Manypatientswillbecomfortablereceivingahandshakeupon
introduction.Shakehandsifyoufeelcomfortabledoingso.Awelcoming
handshakecanservetorelaxananxiouspatient.
– However,thisformofgreetingmaynotalwaysbeappropriate.Ifa
patientisindiscomfort,distress,orseverepain,offeringahandshake
duringintroductionmaynotbeappropriate.Instead,focusonthe
patient’scomfortbyofferingtohelphimmovetoamorecomfortable
position.
EstablisheyecontactwiththeSPbeforeyouintroduceyourself.Ifyoudoextendyourhandand
hedoesnottakeit,donotforcehimtoshake.Justwithdrawyourhandandcontinueyour
introduction.AlwaystakeyourcuefromtheSP.Itshowshowwellyouarefocusedandpaying
attention.

3.Establishedpatient’spreferredtitle

Addressallpatientsas“Mr,”or“Ms,”or“Dr”iftheyhaveanadvanceddegree
suchasanMD,aDDSorPhD.Thenconfirmthatthisistheirpreferredtitle.
Donotusefirstnamesonlyunlessthepatientrequeststhatyoudoso.
Referringtoapatientusingalevelofformalitylowerthanthelevelused
torefertoyourselfwouldplacethepatientinanunequalandinferior
position.
– Theexceptionwouldbeacaseofanadolescentorchild;inthatcase
itisacceptabletouseafirstname.Ifyouareunsureaboutthe


pronunciationofyourpatient’sname,alwaysconfirmthatyou
pronounceditcorrectly.
AsktheSPwhatshewouldprefertobecalledorhowtopronouncehernameifneeded.Make
suretousehernameperiodicallythroughouttheencounter.

4.Clarifiedrole
Explaintothepatientyourroleandyourunderstandingofwhythepatienthas
come to be seen by a doctor. This statement informs the patient what will be
occurringduringthe15-minuteencounter.
Forexample,“HelloMr/MsJones.I’mDr.Smith,theclinicoremergency
roomphysicianassignedtoyourcaretoday.Iunderstandyouhavecome
herebecauseyouxxxxxx(couldhavepain,arereturningforfollow-upor
annualcheck-up,wanttogettestresults,aretryingtodetermineifyour
treatmentisworking).Iwillbeaskingyousomequestionsandexamining
you,andthendiscussingmyfindingsandimpressionswithyou.”
Itisalsohelpfultoalignthepatientandyourexpectationsabouttheencounter.
Forexample,“Isthatyourexpectationaswell?”or“Isthatcorrect?”
Thisisalsoagoodopportunitytoacknowledgethatyouwillbetakingnoteson
important details of the history and physical exam. This will ensure accurate
recording of all pertinent information and will help in writing a good Patient

Note.
Tohelpestablishrapport,starttheinteractionbyaskinghowthepatientisdoing
today.
Forexample,“Howareyoufeelingrightnow?”Ifthepatientpreviously
hadachangeinthetreatmentplan(startedanewmedication,startedona
diet),youcanaddthattoyourinquiry.“Howhaveyoubeendoingsince
youstartedonx?”
5.Hadprofessionalappearanceindress,grooming,andhygiene
A physician’s appearance can influence the success of an interview. Patients
have an image of what they expect regarding the appearance of a clinician. If
you meet those expectations it will build confidence in your medical abilities.


Patientsformtheirfirstimpressionofyoubasedonyourappearanceasyouenter
theroom.
Surveysshowpatientsprefermedicalpersonneltodressinwhitecoatsand
wearshoesinsteadofsneakers.Makesureyourwhitecoatiscleanand
neat.
Wearcomfortable,conservativeclothing.Itissuggestedthatmenwear
trousers,adressshirt,atie,anddarkshoes,whilewomenwearslacksora
skirt,low-heeledandclosed-toeshoes,andconservativejewelry.
Avoidwearingjeans,sneakers,orsandals.
Pullyourhairbackawayfromyourface,trimyournails,anduseno
productswithscents(suchashairspray,perfume,orcologne).Youwould
neverwanttoinitiateanyallergicreactioninyourSP.
Makesuretherearenobodyormouthodorsorstaleclothingodors.
Professionalappearanceshowsthatyoutakeprideinyourself,whichinstillstheSP’sconfidence
inyou.

6.Showedcareandconcernforpatient

Itisimportanttocreateanimpressionthatyoutrulycareaboutthepatient.
Youroverallgoalmustbetoputthepatientateaseanddiminishthelevel
ofanxietypresentattheonsetoftheencounter.Thiscanbeaccomplished
withbothverbalandnon-verbal(bodylanguage).
Besideschoosingappropriatewordsandphrases,attempttouseafacial
expression,posture,andtoneofvoicethatconveysthesamemessageof
concern.
– Lookdirectlyatthepatient(especiallywhenpatientistalking).
– Avoidwritingvoluminousnoteswhileconversing.
– Donotstandduringtheinterview/discussion,becauseitcanmakethe
patientfeelyouarecontrollinginsteadofpartneringwithhimorher.
– Keepanappropriatedistancefromthepatientsoyouarenottooclose
butalsoarenotacrosstheroom.
– Makesuretoappropriatelyrespondtowhatyourpatientissaying.If
heistalkingaboutlosingajoborlovedone,sharingthatheisin
pain,acknowledgeyourconcernandempathywithastatementsuch
as,“I’msosorry”or“Thatmustbeverydifficult.”