Step 2 C.S. Made Easy - Compiled by Dr. Varshil Mehta 1

COMPILED BY DR. VARSHIL MEHTA

CREDITS- WWW.MEDICAL-INSTITUTION.COM

Step 2 C.S. Made Easy - Compiled by Dr. Varshil Mehta 2

SEXUAL ASSAULT

OTHER IMPORTANT QUESTIONS TO ASK: Assault Rape Mnemonic

Loss of consciousness, Dizziness Weakness/Numbness Vaginal bleeding Changes in vision Blood in urine/stool

PHYSICAL EXAMINATION for Assault Rape Mnemonic

Head & Neck exam: Inspection, Palpitation (Look for signs of head trauma) Mouth exam: Inspection Cardiovascular exam: Auscultation Pulmonary exam: Inspection, Auscultation, Palpation, Percussion. (Especially in a patient with SOB &

Chest pain) Abdominal exam: Inspection, Auscultation, Palpation Neurologic exam: Mini Mental Status Exam, Cranial nerves (2-12), Gross Motor & Sensory Musculoskeletal exam: Inspection, Palpitation (look for bruises and trauma)

DIFFERENTIAL DIAGNOSIS for Assault Rape Mnemonic

This section depends on patient’s Chief Complaint. For example Chest pain, Abdominal pain, Headache, Loss of consciousness and

ALWAYS include the following in your Differential Diagnosis:

Sexually Transmitted Infection Pregnancy

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DIAGNOSTIC WORK UP for Assault Rape Mnemonic

Pelvic exam Urine Beta-hCG Wet mount, KOH prep, Cervical Culture, Vaginal pH XR-Skeletal survey HIV antibody, VDRL, HBV antigen Chest X-ray\

IMPORTANT NOTE: Assault Rape Mnemonic

Make sure to show empathy. If patient is crying offer her tissue & water and let her finish crying. Support the patient by letting her know that you are here for her and that what happened to her was not

her fault and could have happened to anyone. Encourage her to report the incident to the police if she/he hasn’t already done so. Offer her emergency contraceptives. Let her know that you are going to let the social worker come and talk to her and provide her with

phone numbers for support groups and other resources.

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HEARTBURN

PHYSICAL EXAMINATION for Dysphagia Mnemonic

HEENT: Check throat for erythema and exudate

Neck exam: Check for lymphadenopathy, thyromegaly Cardiovascular exam: Auscultation Pulmonary exam: Auscultation Abdominal exam: Inspection, auscultation, palpation, percussion. Skin: check for signs of scleroderma/CREST.

DIFFERENTIAL DIAGNOSIS for Dysphagia Mnemonic

Esophageal cancer (Dysphagia starts with Solids and progresses to liquids. Hx of chronic alcoholism, smoking & weight loss )

Achalasia (Dysphasia for BOTH solid and liquids) Esophagitis (Pain on swallowing. Immunocompromised ―e.g. HIV, Corticosteroids‖) Systemic Sclerosis (Look for CREST syndrome) GERD (Cough at nights, Hoarseness, sore throat) Plummer-Vinson syndrome (Iron deficiency anemia, sore throat, craving ice, dirt, clay…) Zenker diverticulum (Halitosis, regurgitation) Pill-induced esophagitis (e.g. Bisphosphonates) Mitral Stenosis (look for an immigrant or a pregnant female)

DIAGNOSTIC WORKUP for Dysphagia Mnemonic

CBC Serum iron, ferritin, TIBC Throat culture HIV antibody and viral load, CD4 count Chest X-ray Barium swallow Endoscopy Esophageal manometry Chest CT

Step 2 C.S. Made Easy - Compiled by Dr. Varshil Mehta 5

ENURESIS

Differential Diagnosis for Enuresis mnemonic

Primary nocturnal enuresis (monosymptomatic) Secondary enuresis (a/w stress such as: life or environmental changes, major illness or abuse) UTI Diabetes mellitus Functional bladder disorder

Diagnostic Work up for Enuresis mnemonic

Genital Exam Urinalysis HbA1c Urine culture Renal Ultrasound

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HEADACHE

PHYSICAL EXAMINATION for Headache Mnemonic

HEENT: Palpation of the Sinuses & Temporomandibular joints, Funduscopic exam, Nose, Mouth, Teeth & Throat

Neck Examination: Inspection, palpation Cardiovascular exam: Auscultation Pulmonary exam: Auscultation Neurology exam: CN 2-12, Muscle strength, DTRs, Kernig’s sign & Brudzinski sign

DIFFERENTIAL DIAGNOSIS for Headache Mnemonic

Migraine headache Tension headache Cluster headache Pseudotumor cerebri Sinusitis Meningitis Temporal arteritis (Giant cell arteritis) Subarachnoid hemorrhage Intracranial mass

DIAGNOSTIC WORKUP for Headache Mnemonic

CBC ESR CT of head Brain MRI Lumbar puncture CT of Sinuses

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HEARING LOSS

PHYSICAL EXAMINATION for Hearing loss Mnemonic

HEENT: Test hearing by speaking with back turned, Rinne & Weber, Whisper test, Otoscopy, Funduscopic exam,

CV exam: Auscultation. Pulmonary exam: Auscultation. Neuro: CN 2-12, Sensation, Motor, DTRs, Cerebellar: Finger to nose, Heel to shin.

DIFFERENTIAL DIAGNOSIS for Hearing loss Mnemonic

Presbycusis Cochlear N. damage due to loud noise Otosclerosis Ménière disease Ototoxicity (Loops, Antibiotics & Aspirin in the History)

DIAGNOSTIC WORKUP for Hearing loss Mnemonic

Audiometry Tympanography Brain stem auditory evoked potentials CT-Head VDRL/RPR (r/o Meniere disease)

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HEMATURIA

Physical Examination for Hematuria:

Cardiovascular exam: Auscultation Pulmonary exam: Auscultation Abdominal exam: Auscultation, Palpation, Percussion, Check for CVA tenderness.

Differential Diagnosis for Hematuria:

Nephrolithiasis Bladder cancer Coagulation disorder BPH Prostate Cancer Polycystic kidney disease Renal Cell Carcinoma Glomerulonephritis IgA nephropathy Pyelonephritis UTI

Diagnostic Work up for Hematuria:

Genital exam Rectal exam (check for BPH or Prostate cancer) Urinalysis CBC, PT/PTT Urine Culture Urine cytology Kidney ultrasound BUN/Cr PSA, IVP Cystoscopy CT abdomen / pelvis

Step 2 C.S. Made Easy - Compiled by Dr. Varshil Mehta 9

HOARSENESS

PHYSICAL EXAMINATION for Hoarseness mnemonic

HEENT: Inspect conjunctivae, mouth, throat, lymph nodes and thyroid gland Pulmonary exam: Auscultation Cardiovascular exam: Auscultation Abdominal exam: Auscultation, palpation Extremities: Inspection, DTRs

DIFFERENTIAL DIAGNOSIS for Hoarseness mnemonic

Laryngitis Laryngeal cancer Vocal cord polyps/Nodules Hypothyroidism Mitral valve stenosis

DIAGNOSTIC WORKUP for Hoarseness mnemonic

CBC TSH Cardiac Echocardiogram Laryngoscopy CT scan of chest and neck

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INSOMNIA

Physical Examination for Insomnia (Sleeping Problem):

HEENT exam: Thyroid, Lymphadenopathy CV exam: Auscultation Pulmonary exam: Auscultation Abdominal exam: Auscultation Extremities: Check for tremor on outstretched fingertips & edema Skin: Inspection for dryness Neurologic: DTRs, Brisk reflexes

Differential Diagnosis for Insomnia (Sleeping Problem):

Anxiety Caffeine-induced insomnia Hyperthyroidism Insomnia related to depression Advanced Sleep phase disorder Delayed sleep phase syndrome Adjustment insomnia Illicit drug abuse Obstructive sleep apnea

Diagnostic Work up for Insomnia (Sleeping Problem):

TSH, Free T4 CBC Urine drug test Polysomnography ECG

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JAUNDICE

PHYSICAL EXAMINATION for Jaundice

HEENT: Inspect sclera, Under tongue Cardio vascular & Pulmonary: Auscultation Abdominal exam: Inspection, Auscultation, Palpation, Murphy’s sign, Percussion Extremities: Check for Asterixis, Edema Skin exam: Spider nevi, Cutaneous telangiectasia, Palmar erythema,

DIFFERENTIAL DIAGNOSIS for Jaundice

Viral Hepatitis Acetaminophen (Tylenol) toxicity Alcoholic hepatitis Primary biliary cirrhosis Ascending cholangitis Cholecystitis Pancreatic cancer

DIAGNOSTIC WORKUP for Jaundice

AST/ALT, Bilirubin, Alkaline phosphatase CBC Viral hepatitis serology Abdominal Ultrasound Abdominal CT ERCP

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KNEE PAIN

PHYSICAL EXAMINATION for Knee Pain

Mouth: Inspection (Look for ulcers to rule out SLE) Musculoskeletal exam: Inspection, Palpation, ROM of both knees. Examine other joints (Wrist,

shoulder, elbow, hands, fingers, hip) Hair & Skin exam: Inspection Cardiovascular exam: Auscultation Pulmonary exam: Auscultation Abdominal exam: Inspection, Auscultation, Palpation, Percussion

DIFFERENTIAL DIAGNOSIS for Knee Pain

Gout Pseudogout Systemic lupus erythematosus (SLE) Rheumatoid arthritis Gonococcal arthritis Septic arthritis Osteoarthritis

DIAGNOSTIC WORKUP for Knee Pain Mnemonic

Pelvic examination Cervical culture Knee aspiration & Synovial fluid analysis XR of knees CBC ANA, Anti-dsDNA, Rheumatoid factor Blood culture

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MUSCULOSKELETAL PAIN

PHYSICAL EXAMINATION for Musculoskeletal Pain Mnemonic

1) Shoulder Pain: Head and neck exam: Checked for bruises, neck movements and signs of head trauma Exam of the arms: Compared both arms in terms of strength, range of motion (shoulder, elbow, wrist),

sensation, DTRs, pulses

2) Lower back pain: Back exam:Inspection, palpation, range of motion Extremities: Inspection, palpation of peripheral pulses, hip exam Neuro exam: Motor, DTRs, Babinski sign, Gait (including toe and heel walking), passive straight leg

raising, sensory exa 3) Calf Pain:

Extremities: Inspection, palpation; checked for Homans’ sign Joint exam: Inspection, palpation, range of motion (knee, ankle, hip joint on both sides) Neuro exam: Sensory and motor reflexes (knee, ankle)

4) Heel Pain:

Extremities: Palpation of medial calcaneal tuberosity, Achilles tendon, plantar fascia, retrocalcaneal bursa. Passive range of motion and general strength of ipsilateral knee and hip. Ankle dorsifl exion and great toe extension and passive range of motion; strength testing of ankle dorsifl exion and plantarflexion

Neuro: Checked sensation to light touch for dermatomes of foot and ankle; assessed Achilles tendon reflex

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DIFFERENTIAL DIAGNOSIS for Musculoskeletal Pain Mnemonic

1) Shoulder Pain:

Shoulder dislocation Rotator cuff tear Clavicular fracture Humeral fracture Osteoporosis Elder abuse

2) Lower Back Pain:

Lumbar muscle strain Disk herniation Lumbar spinal stenosis Metastatic prostate cancer Tumor in the vertebral canal Vertebral compression fracture Multiple Myeloma Malingering Ankylosing spondylitis

3) Calf Pain:

Deep venous thrombosis Cellulitis Myositis Rupture of Baker’s cyst Hematoma Spasm due to injury or sprain

4) Heel Pain:

Plantar fasciitis Calcaneal stress fracture Achilles tendinitis Retrocalcaneal bursitis Tarsal tunnel syndrome Foreign body Ankle sprain

DIAGNOSTIC WORKUP for Musculoskeletal Pain Mnemonic

1) Shoulder pain: XR of the shoulder and arm MRI—shoulder Bone density scan (DEXA)

2) Lower back pain:

Rectal exam XR—Lower spine MRI—Lower spine PSA CBC, calcium, BUN/Cr Serum and urine protein electrophoresis

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3) Calf pain: Doppler U/S of the lower extremities D -dimer Hypercoagulability testing CBC with differential CPK and myoglobin level CT venography MRI

4) Heel pain:

XR—right ankle Bone scan MRI

ERECTILE DYSFUNCTION

DIFFERENTIAL DIAGNOSIS for Erectile dysfunction

Drug induced erectile dysfunction (eg. Beta-blockers, SSRI’s) Hypertension induced erectile dysfunction Diabetes mellitus induced Erectile dysfunction Psychogenic Erectile dysfunction (eg. Depression) Peyronie’s disease Leriche syndrome

DIAGNOSTIC WORKUP for Erectile dysfunction

Genital examination Urinalysis, Microalbuminuria Serum glucose, HbA1c, BUN/Cr CBC Doppler ultrasound of penis Nerve conduction studies

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PSYCHOSIS

PHYSICAL EXAMINATION for Hallucinations Mnemonic

Eye examination: Inspect pupils and check for reactivity

Neurologic exam: Mini-Mental Status Exam, Cranial nerves (2-12), Motor exam, DTRs, Gait, Sensory exam

Pulmonary exam: Auscultation

Cardiovascular exam: Auscultation

Abdominal exam: Auscultation

DIFFERENTIAL DIAGNOSIS for Hallucinations Mnemonic

Drug induced psychosis

Brief psychotic disorder

Schizophreniform

Schizophrenia

Schizoaffective

DIAGNOSTIC WORK UP for Hallucinations Mnemonic

Mental status exam

Urine Toxicology

TSH

CBC

Electrolytes

Polysomnography

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TREMORS

PHYSICAL EXAMINATION for Tremor:

NOTE: Make sure to wash your hands or wear gloves before you start physical examination. Make sure to ask permission before you start each physical exam. Make sure to use proper draping (don’t forget to tie back patient’s gown). Make sure to explain the physical examination in layman’s term to your patient. Do NOT repeat painful maneuvers.

Neurologic exam: Mini-Mental Status Exam, Cranial nerves (2-12), Muscle strength exam, Sensory

exam, DTRs, Cerebellar, Gait.

CV exam: Auscultation

Pulmonary exam: Auscultation

DIFFERENTIAL DIAGNOSIS for Tremor:

Parkinson’s disease (resting tremor)

Essential tremor (postural tremor ―tremor on outstretched arms‖, action tremor)

Physiologic tremor (postural tremor, action tremor) [eg, anxiety, caffeine, hypoglycemia…]

Hyperthyroidism (fine tremor + classic signs of hyperthyroidism)

Drug induced tremor [eg, Beta-agonist, nicotine, lithium, metoclopramide…]

Wilson’s disease (resting tremor, similar to Parkinson’s tremor)

Midbrain lesion

DIAGNOSTIC WORK UP for Tremor:

CBC

TSH and Free T4

Heavy metal screens (eg, Arsenic or Mercury)

Brain MRI

Slit lamp for Kayser-Fleischer ring,

Serum Ceruloplasmin,

AST/ALT, Liver biopsy (Wilson’s disease work up)

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FORGETFULLNESS

PHYSICAL EXAMINATION for Forgetfulness Mnemonic:

NOTE: Make sure to wash your hands or wear gloves before you start physical examination. Make sure to ask for permission before you start each physical exam. Make sure to use proper draping (don’t forget to tie back patient’s gown). Make sure to explain each physical examination in layman’s term to your patient. Do NOT repeat painful maneuvers.

Eye exam: Inspect pupils, Funduscopic exam.

Neck exam: Carotid Auscultation.

Neuro exam: Mini-Mental Status Exam, CN (2-12), Motor, Sensory, Gait, DTRs, Romberg sign.

DIFFERENTIAL DIAGNOSIS for Forgetfulness Mnemonic:

Alzheimer’s disease

Vascular ―Multi-infarct‖ dementia

Pseudodementia (Dementia due to depression)

Hypothyroidism

Vitamin B12 deficiency

Subdural Hematoma

Step 2 C.S. Made Easy - Compiled by Dr. Varshil Mehta 19

DIAGNOSTIC WORK UP for Forgetfulness Mnemonic:

CBC

Electrolytes, Calcium, Glucose, BUN/Cr

Serum B12, TSH, PRP

CT of head

MRI of brain

EEG

COUNSELING for Forgetfulness Mnemonic

If patient does not remember the name of his/her medication, ask for the list of the medication. Patient should

have a Paper with the list of medications.

I would like to ask your permission to speak to your family and ask them a few questions.

I would like you and your family to meet with our social worker to assess home safety and supervision.

SMOKING CESSATION COUNSELLING

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OB/GY CASE

PHYSICAL EXAMINATION for OBGYN History Mnemonic

Pulmonary exam: Auscultation

Cardiovascular exam: Auscultation

Abdominal exam: Auscultation, palpation, percussion

DIFFERENTIAL DIAGNOSIS for OBGYN History Mnemonic

All females in reproductive age

Pregnancy

Amenorrhea

Dysmenorrhea (Endometriosis)

Domestic violence

Depression

Infertility

Sexually transmitted disease

Females who are going through menopause

Dyspareunia

DIAGNOSTIC WORKUP for OBGYN History Mnemonic

Pelvic examination, Rectal examination

Urine Beta-hCG

Cervical culture

KOH prep, Wet mount, Vaginal pH,

TSH

Pelvic ultrasound

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Child with Noisy Breathing (Stridor):

Differential Diagnosis for Child with Noisy Breathing (Stridor):

Foreign body aspiration

Croups

Laryngitis

Epiglottitis

Retropharyngeal bascess

Angioedema

Peritonsillar abscess

Diagnostic Work up for Child with Noisy Breathing (Stridor):

ABG (Arterial Blood Gases)

Chest X-ray

Neck X-ray

CBC

Direct laryngoscopy

Bronchoscopy

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CHILD WITH DIABETES MELLITUS

DIFFERENTIAL DIAGNOSIS:

Type 1 Diabetes Mellitus

Type 2 Diabetes Mellitus

Cushing’s syndrome [Cushing’s syndrome Mnemonic]

DIAGNOSTIC WORKUP for Child with Diabetes Mellitus mnemonic

Basic metabolic panel

HbA1c

Urinalysis/Microalbuminuria

Insulin and C-peptide level

Islet cell antibodies

24 hour urine cortisol

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COUGH

Do NOT forget to

Offer Cup of Water or a Tissue if the patient is coughing

If patient is holding a tissue make sure to ask her to show it to you to see if there is any blood.

Ask if tried quit smoking in past, if not educate.

Physical Examination for Cough:

HEENT: Inspect Mouth, Throat, Lymph nodes

Cardiovascular exam: Auscultation

Pulmonary exam: Auscultation, Palpation, Percussion, Tactile fremitus

Abdominal exam: Auscultation, Palpation

Differential Diagnosis for Cough:

Tuberculosis

Lung Cancer (with chronic history of smoking)

Lung abscess

Atypical pneumonia

Typical pneumonia

COPD exacerbation

Wegener granulomatosis

Diagnostic Work up for Cough:

PPD, Sputum gram stain, Acid Fast smear, CXR, CHEST CT

Bronchoscopy, Lung biopsy

CBC, Blood Culture, C-ANCA

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DEPRESSION

PHYSICAL EXAMINATION for Depression mnemonic

HEENT

Cardiovascular exam

Pulmonary exam

Neuro exam

DIFFERENTIAL DIAGNOSIS for Depression mnemonic

Major depressive disorder

Adjustment disorder

Pseudodementia (Confusion/memory loss)

Domestic violence (Abuse)

Normal Bereavement

Schizoaffective disorder

Dysthymic disorder

Cyclothymic disorder

Bipolar type 1

Bipolar type 2

Fatigue

Weight loss

Weight gain (atypical depression)

Sleeping problem (Sleepiness/Insomnia)

Erectile dysfunction

Dyspareunia (pain during sex)

Diabetes Mellitus

Step 2 C.S. Made Easy - Compiled by Dr. Varshil Mehta 25

Tremor

Amenorrhea

Cancer

DIAGNOSTIC WORK UP for Depression mnemonic

Physical Exam

Mental Status Exam

Complete Blood Count (CBC)

Urine Drug test

TSH

HbA1c

Pelvic exam/Genital exam

CT of the head

DOMESTIC ABUSE

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DIZZINESS

PHYSICAL EXAMINATION for Dizziness Mnemonic

HEENT: Inspect for Nystagmus, Rinne & Weber test, Whisper test, Otoscopy, Funduscopic exam, Mouth &

Throat.

Cardiovascular: Auscultation

Pulmonary: Auscultation

Neuro: Cranial nerves (2-12), Sensation, Motor, DTRs, Gait, Romberg test, Dix-Hallpike Maneuver.

DIFFERENTIAL DIAGNOSIS for Dizziness Mnemonic

Ask the patient whether they experienced Vertigo ―sensation of room spinning‖ or Lightheadedness.

Ménière disease (Vertigo, Tinnitus, Hearing loss)

Orthostatic hypotension due to dehydration (Diarrhea, Vomiting or Diuretic use. ―Presents with

lightheadedness not vertigo)

Benign paroxysmal positional vertigo (Dizziness on changing position and Nystagmus)

Labyrinthitis (Recent URI, Hearing loss, Vertigo)

Vestibular neuronitis (Recent URI, NO hearing loss)

DIAGNOSTIC WORK UP for Dizziness Mnemonic

Dix-Hallpike Maneuver

VDRL/RPR (to r/o syphilis associated with Ménière disease)

Tilt table test

Audiometry

MRI of brain,

Brain stem auditory evoked potentials

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DIABETES F/U

PHYSICAL EXAMINATION for Diabetes Follow Up mnemonic

Eye examination: Funduscopic exam

Neck exam: Carotid auscultation

Cardiovascular exam: Palpation, auscultation

Pulmonary exam: Auscultation

Abdominal exam: Auscultation, palpation, percussion

Extremities: Inspect feet for infection or ulcers, Check peripheral pulses

Neurologic exam: Motor, Sensation, DTRs, Babinski Reflex

DIFFERENTIAL DIANGOSIS ―DDx‖ for Diabetes Follow Up mnemonic

In this case the DDx depends on the patient’s HPI and whether he/she has any other complains other than

the request for refill prescription. For example if the patient is complaining of ―Chest pain‖ then you must do

DDx for Chest pain, or if the patient is having problem with erection then you must do differential diagnosis

for Erectile dysfunction and…

DIAGNOSTIC WORK UP for Diabetes Follow Up mnemonic

Genital Exam (If patient complains of Erectile dysfunction -> Mnemonic)

Serum Glucose

HbA1c

Urinalysis

Urine Microalbumin (to check Kidney function)

BUN/Cr (to check Kidney function)

CBC

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COUNSELING for Diabetes Follow Up mnemonic

Diabetes Mellitus & Hypertension Counseling –> MEDOWS

Medication (Regularity/Compliance)

Exercise (For obese/secondary life style)

Diet modification (Less Salty & Fatty food)

Ophthalmoscopic exam (EVERY Year ―annually‖)

Weight management

Sugar check up daily

Step 2 C.S. Made Easy - Compiled by Dr. Varshil Mehta 29

ACKNOWLEDGEMENT SPECIAL THANKS TO MEDICAL-INSTITUTION.COM AND OUR READERS WHO HELPED US WITH

MNEMONICS

DR. VARSHIL MEHTA HAS COMPILED ALL THE INFORMATION FROM THE ABOVE MENTIONED

SITE AND PRESENTED IN A SIMPLE WAY.

HE HOLDS NO RESPONSIBILITY FOR ANY ERRORS OR WRONG INFORMATION. HE HAS NOT

WRITTEN ANYTHING OF HIS OWN, EVERYTHING IS FROM THE ABOVE MENTIONED SITE.

FULL CREDITS TO MEDICAL-INSTITUTION.COM.

ALL THE BEST FOR YOUR EXAMS.