Valuable practice for USMLE Step 2 CS and to assess your neuro exam
One patient encounter of 30 minutes with 20 minutes for the written note
Arrive on time, appropriately dressed. Establish rapport with the patient, and conduct yourself professionally. This exam is partly designed to test your inter-personal skills and professional demeanor.
Bring your equipment. You will be provided a clipboard and piece of paper. There will be a door note with the patient’s name, age, gender, reason for visiting the doctor, and vital signs.
As a guide, you might spent about 12-18 minutes on history, 8-12 minutes on the physical, and 3-5 minutes on counseling the patient.
Note should be structured just like a typical clinic note. Use headings and full sentences in a narrative format. Do not use bullet points. Record (1) your history, including the HPI, PMH, ROS, SH, and FH, (2) your physical exam, (3) up to 3 localizations, (4) up to 5 differential diagnoses in order of likelihood, and (5) up to 5 immediate plans for further diagnostic work-up and management.
You will return for a brief counseling encounter with additional information and test results. This follow-up encounter will assess your ability to communicate, educate, listen, demonstrate respect for the patient’s feelings, and put forth a plan.
Interpersonal pleasantries count, so be sure to knock, introduce yourself, shake hands, wash hands, provide an overview of the visit, and give clear instructions while maintaining comfort.
Focus on the chief complaint listed on the door, but don’t neglect medications, risk factors, potential family history. Do not get bogged-down in ROS.
Keep moving along on the physical exam. Don’t take 5 minutes for sensory exam. If the patient says something is reduced or numb, take it at face value. They are not trying to trick you. The whole exam should take about 6-8 minutes, the history 10-15 minutes, 2-3 minutes for opening and closing.
Do a complete screening neuro exam. Just as if you are seeing a new patient in clinic. Do not dwell on cognition or language unless the history suggests the need.
Be sure to give a closing statement about what you think may be going on, and what you are going to do next. Closure counts.
Again, for the post-encounter, it is probably best to try to write a mini-H&P and not a bulleted outline. If you list out meds, SH, FH, then you will not miss anything.
Write-out your exam, just as in clinic. If you don’t write it, you didn’t do it. Be specific and detailed, meaning do not write CN 2-12 intact. You should abbreviate: A+O, conversant. Vision 20/20 OU, VFFTC, Fundi nl, PERRL, EOMI, Face = with nl sensation, hearing intact, tongue/palate straight, shoulders =. Strength 5/5, nl tone, nl FFM/toe tapping. F-N and HKS nl. Sensation intact to pin and vibration, Romberg absent. Reflexes symmetric, down toes. Stance, gait, tandem, hopping nl.
Do not panic if the diagnosis is not obvious. Just think through the case and construct a reasonable differential.
For the post-encounter, do not explain the situation using technical terms, listen and encourage the patient to expand on their feelings, give them your undivided attention as you speak/listen, validate their feelings, and emphasize your commitment to provide the best care.