Right this down on your sheet before knocking!!!!

PAM HUGS FOS SO DATA WADE

P - past medical history
A - allergies (drugs, food)
M medications (including over the counter and herbal meds)
H hospitalizations, past surgical history
U - urinary problems
G - GIT problems
S - sleep problems
again ask a transition question for FOS SO DATA :
NOW I WOULD LIKE TO ASK YOU ABOUT SOME PERSONAL QUESTIONS WHICH WILL
HELP ME ASCERTAIN YOUR MEDICAL ISSUES, WHATEVER YOU WILL TELL ME WILL BE
KEPT CONFIDENTIAL. IS THAT OKAY?
F - family health history
O - ob/gyn issues / history
S - sexual history, STD
S smoking, do you smoke?
O occupation, what do you do? Is your work stressful? (I used to ask this during handwashing)
D drugs, do you take any recreational drugs?
A alcohol, do you drink alcohol? How much?
T - travel history, have you traveled recently/trauma?
A - anything else, do you have ANY other thing to tell me before I start your physical? ( I saved this for LAST)
W weight changes?
A Appetite? (hows your appetite?)
D Diet? (what is your diet like? what do you eat?)
E exercise (do you exercise?)
_________________________
When you start questioning first talk to them about their chief complaint, then say you would like to ask few
questions on their health history.. and use PAM HUGS FOS SO DATA WADE
Also this was MONEY for complaints of PAIN write it down always

LIQOR AAA

Pain when? during eating, drinking, is it burning, previous episodes

L location
I intensity (tell me on a scale of 1 10)
Q quality (is it sharp or is it dull, throbbing etc)
O onset, progression, frequency (when did it start, is it getting better or worse, how often does it occur)
R radiation (does it radiate to the front back, up or down)
A associated symptoms
A alleviating factors (anything makes it feel better? laying on one side etc.)
A aggravating factors (anything makes it worse?)

First Sight...
Knock 3 times with confidence, a smile, walk in and say,
"Good morning Mr. Smith, I am Dr. Ahmad and am here to see you today as your physician."
Shake hands with the patient, look around the room and say
"Is everything in the room alright for you ?"
SP says yes - Then you say
"Let me make you a little more comfortable".....and while saying so,
drape the patients legs up to his belly (applies to a sitting or a reclining SP) .
Then,
or..

"So Mr. Smith, how may I help you today?"

"Mr. Smith, it seems you have come in today for a racing heart - could you tell me more about it?"
( Chief complain is already stated on the door before you enter !)

After the patient tells you the chief complaints and stops, first express sympathy - say,
"Oh I am sorry to hear that, I shall try my best to help you. Hope you dont mind if I make a few
notes as you speak"
This makes you free to write or pretend to write as you try to recall what to ask - actually a good time to write
your mnemonics !! If the setting is appropriate - you may sit on a stool and bend forwards as if listening - I did
so because it created a feeling of showing humility and friendliness.
After finishing off with data collection, i.e. "PAM HUGS", before you move on to "FOSS", it is good to say,
"Mr. Smith, the way clinical medicine works, there could be some clues hidden in a few personal
questions I need to ask you - is that OK with you ? "
and then move on to FOSS.
If you think you have finished or can't recollect what else needs to be asked, do give the patient a final chance
by saying
" Is there anything else you want to tell me ?"
then move on to washing hands and examination. Warning : Dont ever express explicitly that you have
concluded your questioning, because you might remember something during physical examination and it is ok
to ask then !

Transitioning to a hand wash:

There have been quite a few concerns about how to handle a change from history mode to a hand wash
mode ...A sample transcript :
You =
"I shall now need to perform a quick general examination and then look at your heart - is that fine ?"
SP = "Sure, doctor"
You = "Arrite ! Before we begin Mr. Smith , excuse me for a moment here to wash my hands" (smile)
I had reserved the time to wash my hands to enquire about occupation and say "thats interesting, my uncle used
to do something similar" or something like that.
Transitioning to a Physical exam:
Before you begin physical examination say
"I will now need to perform a quick general examination and then we shall have a look at your chest [or
abdomen - wutever the chief complaint is]"
and do keep talking during each thing your examine - like "lets start with your eyes, could you look up for me"
while examining pallor.
By the way , a good mnemonic of quickly completing general examination is "PICKLE" - Pallor, icterus,
Cyanosis, Clubbing, Koilonychia, Lymphadenopathy and Edema Feet" along with Jugular veins, carotid bruit if
a CVS case.
At the end of the entire general + systemic examination, summarise :
"Based on what you told me and your physical exam, there are certain diagnostic possibilities like
1._____, 2. ________ or 3. _______ and others.
But to be more certain, let us order a few tests - like blood tests, chest x-ray , an EKG , and then discuss
further management. "

The last minutes...

While concluding, keep this 4-stage pattern in mind to cover everything and to be courteous:
a. First, Counsel !!!
For example - for a case of diabetes, it is good to say a few words on foot care ! if the patient smokes or drinks
alcohol - say
"are you aware of the harmful effects of smoking / alcohol ? Have you ever considered quitting - if you
wish to , we have a good support team that is willing to help you quit the habit" thats it
dont get personal about it .
b. Then say " Have you understood everything we have discussed today ?"
c. Then "Are there any special concerns you have ?"
d. Finally " Thankyou very much Mr. Smith . I shall leave my contact information with my nurse - feel free to
contact me anytime if you have any questions"

A Trick, in case Time falls short...

If you have to leave, dont make it abrupt and embarrasing.
Rather it is good to pretend looking at your beeper and say
"Oh ! Mr. Smith, We have an emergency and I have to leave - I will see you as soon as I get free"
and leave with a smile.

Sad, Depressed:
" I know this is a very tough time in your life, but I assure you that we can deal with this
much better together. I really want to understand your problems and help you as a
friend and a physician. You said you were perfectly happy and healthy 3 months ago could you try and tell me what exactly happened 3 months ago that started this ?"
What if SP goes "I want to Die Doctor!"
Hmmm...Again lets modify our formula a bit - "I know this is a very tough time in your
life, but I also know that running away from problems is not the answer. I really want to
understand your problems and help you get your strength back, because I know it is
possible. We can deal with this together."

Smoking : "Mrs. Ray, as a concerned physician, I must ask if you are aware of the badeffects of smoking on your health... Have you ever tried quitting ? coz' it will save you a
lot of health and money in the long run. I understand that old habits die hard and all
people experience difficulty in giving it up due to stressful symptoms. But you can use
Nicotine patches or Gum to help reduce those withdrawal symptoms and we even have a
professional team to help you deal with it better. Feel free to contact me anytime if you
decide to quit. "
Alcoholism / Alcoholic Patients:
"As a concerned physician, Mrs. Dodge, I must caution you about the ill-effects of
alcohol consumption. Alcohol has tons of calories but lacks nutrients. Besides altering
judgement, excess consumption raises your risk of high blood pressure, strokes,
vehicular accidents, and is known to cause Liver Cirrhosis, Inflammation of the pancreas,
brain and heart damage along with birth defects if consumed during pregnancy.
- Limit intake to one drink per day ( for women) or two per day (for men).
- Eating food while drinking will slow alcohol absorption.
- Avoid drinking before or when driving, or whenever it puts you or others at risk.
We have a professional support group who would be eager to help you overcome your
habit, if you wish to give up but find it tough to do it by yourself."
Diabetes: After you are done with explaining investigations - "So Mr. Jim - we will begin
your treatment once I have evaluated your lab results. I want you to know that besides
drugs, there are other simple but important measures to keep yourself healthy and
reduce complications. 1. Follow regular exercise and diet instructions that will be
provided to you 2. Diabetic patients are vulnerable to injury-induced ulcers on the foot,
so make a habit of using soft footwear whenever you walk - indoors or outdoors. 3. Be
regular in blood-sugar monitoring so that dose adjustments can be done on time. Now
was that too bad ?" (smile)
Hypertension Counseling: "Mr. Demiris, for a majority of patients, we cannot detect a
cause for High Blood Pressure and is well controlled with exercise, diet changes and
drugs, if needed. However, there may be some patients with treatable causes - we shall
do a few tests soon to see if we can detect those in you."
Enuresis (Bed wetting) Counseling : "Mrs. Cole, kids with bedwetting usually
undergo natural healing with age, but this problem needs tenderness. Punishing your
child could worsen it - a much better technique would be to rather reinforce positive
behaviour by praising and rewarding him if he stays dry while sleeping. I would advise
you to monitor your child's drinking habits before going to bed and encourage the child
to go to bathroom before going to bed. We also need to do some tests to rule out other
conditions."

HIV Counseling:"The biggest danger in HIV may not be the HIV itself - rather other
diseases that can occur more easily due to reduced body resistance. This means that
your body must be fortified in advance against such disease with vaccines. Secondly,
even the mildest suspicion of an infection must be tackled aggresively. Thus, periodic
examinations and followups are important. We have a professional support group here
which will help you with strengthening you emotionally and tackle other social issues
with you."
Safe-Sex Counseling points:
1. Multiple sexual partners and unprotected sex put you at risk of Sexually transmitted
diseases like HIV, gonorrohea and increase the risk of Cervical Cancer, unwanted
pregnancies and complications from abortions.
2. Don't have more than one sex partner at a time. The safest sex is with one partner
who has sex only with you.
3. Watch for symptoms of STDs, such as unusual discharge, sores, redness, or growths
in your and your partner's genital area, or pain while urinating.
4. Use contraceptive methods to protect yourself - u can consult your family physician
for specific methods that will work best for you.
5. Add counseling about PAP smear depending on the Patients age !
6. Be responsible - Avoid sexual contact if u have symptoms of an infection. If you or
your partner has herpes, avoid sexual contact when a blister is present and use
condoms at all other times.
Lab-Result (Trichomonas): Lets go over some relevant points in this case 1. Both the SP and her partner needs treatment.
2. While on Metronidazole therapy - alcohol is to be avoided, since that will cause
nausea and vomitting (Disulfiram like reaction)
3. Abstinence from sexual intercourse until therapy is complete 4. If lady has multiple
sexual partners - counsel on protection, risk of other STDs like HIV & risk of cervical
cancer (need for PAP smears).
5. Ask her if she has had a pregnancy test recently and when - if not done, ask her to
consider having that done. (and mention that on your PN as an Investigation)
Counseling for Heel Pain:
1. Use soft-heeled or soft-padded footware
2. Refrain from long standing positions or long walking activities
3. Do see us again if the prescribed pain medications do not work

Counseling a Non-Compliant Seizure Patient who wants to drive:

1. Ask him what he knows about his disease and how often does he get seizures
2. When did he last have a seizure
3. Importance of compliance for seizure control ...
4. Explain that most states in USA allow issuing non-commercial licenses to seizure
patients based on the length of the "SFI" = Seizure Free Interval ..and can range from 3
to 12 months..whereas for commercial driving license, 10 years or so are required and
that too while NOT taking anti-epilepsy drugs..
5. Tell him why driving is dangerous not only to him but also to others on the road in
event of a seizure

Look for these 'Acting' Hints and Tips from the SPs
These are soft signs that SPs might display. Showing that that u noticed it says oceans about your observation
powers ! and courteous behaviour ! I looked for these the moment I entered the room and introduced myself.
1. Yawning SP : Ask - "You look tired Mr. Smith, did you sleep well ?" This could unearth a duodenal ulcer that
kept the patient awake at night ! Ofcourse other possibilities exist.
2. Shivering SP: Could mean fever or also could mean the room is too cold .right ? so first do ask the SP if the
room temperature too cold for him/her. Surely shows u as very courteous and sensitive to the patient - if he / she
says yes, say " Ok, I will have the nurse fix the temperature very soon". Or could it mean hypothyroidism :-)
3. Sweating SP : It is important is to remind yourself that this case could be a case of bleeding with hypotension
like Bleeding varices , hematemesis, etc.

Question: Doctor will I die ?

Possible Answer: Mrs. Ray, it must be very tough for you, but we must wait for all the investigation
results to comment on that. Lets hope for the best (Smile), I will keep you informed.
Question: I am in pain ! Please give me a pain killer !
Possible Answer: I know it is not easy to bear the pain, but without unless we know what we are dealing
with, it will be tough to decide the right pain-killer. As soon as we are done with a quick examination, I will
have my nurse treat your pain. Is that fine Mr. Harrison?
Question: Doctor, do you think I have a fracture ??
Possible Answer: It is a possibility, but we must wait for your X-ray to arrive.
Question: Is this cancer !!!!!!!!
Possible Answer: Mrs. Hicks, I understand your apprehension, but we need to wait for investigations. I
will keep you informed.

Snellen's Chart, Visual Acuity and Step 2 CS ?

So should you perform the Snellen's chart reading on the CS ? Don't bother about it
on the CS ... merely mention that as an Investigation on the Patient Note (PN). But
yeah guys - do the Finger counting test instead.
This is how : Ask the SP to look striaght ahead and then hold your fingers in front of the
SP at approximately 3 feet from his/her eyes. Request the SP to count them for you.
Now, in real life situations, if the patient cannot count them - it means you gotta
perform the next level of testing - that is moving finger test for motion detection. But on
the Step 2 CS , since the SPs have normal vision, you wouldn't need to go that far.
On the patient note, mention "visual acuity done by Finger Counting at 3 Feet". And of
course mention Snellen's chart testing for visual acuity on the Patient Note, [ repeating
that in case your eyes missed that on the first line ;-) ]
Q. On what cases would you bother testing visual Acuity ?
A. Cases with Visual Problems, cases where visual complications can occur, like DM, HT
AND in cases where you will be checking out Cranial nerves !

First things first- When to do an MMSE ? In cases of non-focal-deficit CNS Cases like
memory Loss / dementia, Delirium / Confusion, Delusions / Schizophrenia.
Would you do it for every CNS Case?Not really - use priority + time judgement. If
patient has a symptoms suggestive of Focal Neurological Lesion/s - Its more important
to do a complete CNS exam + gait and then think about MMSE.
Before you begin the MMSE, use a statement like this,
"Mr. Watson, I will now ask you simple questions to test your memory and thinking, shall
we begin ?"
ORIENTATION
1. Which state or city are u in ?
2. What's your name OR Do you know who I am ?
3. Can you guess what time it is now ?
REGISTRATION
Mention three objects slowly and clearly - ask the patient to repeat once u are done.
(e.g. Pen, Watch, Ball)
ATTENTION AND CALCULATION
1. Ask patient to say "WORLD" backwords
2. Ask patient to count back from 7
RECALL
Ask the patient to repeat again those 3 words u told him before (To not forget these
yourself in the heat of the exam, practice with three standard words ready)
LANGUAGE
Show him ur pen - ask him wut color is it
COMMAND FOLLOWING
On a piece of paper, draw intersecting pentagons, each side about one inch and ask him
to copy it exactly as it is. To score correctly, all ten angles must be present AND two
must intersect. Tremor and rotation are ignored.

Female Chest Examination ??

Many exam takers have questions about modesty concerns while examining the chest of a female patient. Here
are the facts you should know so that you don't get your SP angry and embarass yourself !
1. It is perfectly OK to expose the Bra in a female SP - - BUT politely inform the patient before proceeding to
untie the gown knot present behind her neck. So, you go : "I will need to untie your gown & expose your chest
to listen to your heart / lungs properly- hope it is fine with you".
2. Never Never NEVER remove or even attempt to remove or even go underneath the Bra - it is enough to
auscultate around it or maybe a little area over it at the borders.
3. After you are done with examination, you inform the SP and say "You can now tie it back - thankyou"

Ophthalmoscope...
Well bad news and good news ...
Bad News - Yes you do need to use the Ophthalmoscope....
Good News - Only required if the patient gives a history of Hypertension, Diabetes, Visual Complaints and any
condition where you would expect increased Intra-cranial tension.
Very Good News - You only need to 'pretend' that you are using it , but you got to pretend in a technically
correct fashion.
Switch it on ..ask the patient to gaze across the room and inform her/him that you will shining a small light into
her/his eye to have a closer look. Then holding the instrument in front of, say, your right eye, shine the light on
the patients right eye....
What I am trying to stress here is that if it is your left eye, then shine on the patient's left eye - basically the eye
diagonally opposite to yours. When you right the Patient Note outside the room, just make a mention that u did
it !
Q. How do you write Opthalmoscopy findings on the Patient Note ?
A. 'No Abnormalities Detected on Ophthalmoscopy' - or you could be more explicit like the reader mentioned in
the comments below : "ophthalmoscopic examination : No retinal exudates, A-V malformations, or
hemorrhage."

Were you planning to measure BP?

Don't need to - Yeah ! you heard me - you don't need to measure it on the Step 2 CS All measurements provided on the door are to be assumed to be officially recent and
accurate.
However, you need to tackle it on your Patient Note :
1. Do mention the exact Blood Pressure measurements provided to you on the door
2. If the case warrants checking Orthostatic Blood Pressures and other pressure
measurement tests - definitely mention that as a diagnostic workup on the Patient Note,
don't have to do it inside the room
3. Even in a suspected case of Aortic Dissection, mention BP measurement in both arms
as an Investigation on ur PN ...
Hmmmm...having said this - I might consider actually measuring the SP's B.P. in these
cases - if time permits ...
a. Pre-Employment check-up
b. Hypertension Follow-up

Measuring JVP
After ur general examination...i.e. 'PICKLE'
1. Recline the patient at 45 degress..
2. "Before we look at the heart, I need to see if I can see any
pulsations on your neck - could you please look to your left Mr. Smith ...Thank you"
3. Shine a light on the neck so that light falls almost at 180 degrees on the surface - Of course u woudn't see any
pulsations on the Step 2 CS test (No need to get your own pen-light to the exam, use the light from the
Otoscope hung on wall of the SP room !)
4. After u are done , then proceed to auscultate for carotid bruit..

Yo Listen up yall ! This is 'bout

Auscultation...
Many of us always have doubts about how far should we go about auscultation on the
Step 2 CS - especially if the case is not about Cardiac conditions or Respiratory
condition. Do we auscultate in other cases at all ?
Let's keep a simple rule:
Ausculate the usual complete details in a CVS and RS case - in ALL OTHER cases, with
the SP in a sitting position , quickly listen to the four heart valve areas and then listen to
the breath sounds at the lung bases on the front of the chest in a sitting position (should
cost you about 30-45 seconds). So with the SP sitting we go, "Lets quickly listen to your
heart - would you mind holding your breath for 5 seconds". And then "That was great,
lets listen to what your lungs have to say - could you take in a deep breath Mr.
Knoxville" ........... and you are done :-)
Notable Reminders:
1. Ofcourse for a GI case - you will be auscultating for bowel sounds
2. In a CVS and stroke case - in addition you need to auscultate for Carotid Bruit !
3. And between all the smiles and dialogues and acting ...remember to warm up the
diaphragm before use !
4. Do not auscultate over the gown - go under the gown if you have not exposed the
area already
5. One excellent and valuable tip from Jay Raj, MD, which he employed to good effect
on the Step 2 CS! These are his words :
"I did do one thing which I have not seen any one telling on all these USMLE forums or USMLE
books and that was cleaning the stethoscope with an Etoh swab (Alcohol / Spirit Swab), each
time I started a physical. I always asked the SPs if they were allergic to Etoh, before using the
swab to clean. Each time I did this, I noticed an instant pleasant response on all SP faces. It was
obvious that no one was using this hygiene technique on the exam. I strongly recommend it!
Honestly all these patients in exam are being seen by all those examinees with one stethoscope
touching all 12 patients. You can try imagining if you would like if it yourself if it is cleand infront
of you before put on to your skin ! I believe it helped me big time in passing the Step 2 CS Exam
- Since it is heavily dependent on how you perform with SP's"

Patient refuses to answer questions about his/her sexual history?

"Dear Mrs. Bush, I understand the sensitive nature of this question, but be assured that
this will not go out of this room. The way clinical medicine works, there may be
important clues hidden in this kind of information and I want to do my best to help you.
So shall we try answering these questions again ?"
If this ever happens - it will most likely to happen in a case of depression!

STICKY SITUATION B
Patient moving with extreme pain on the bed the moment you enter the room !
1. Introduce Yourself with appropriate soberness
2. Say "I am sorry that you are in so much pain - I shall go through some quick questions and physical
examination - as soon as I am done, I shall promptly have my nurse give you something for your pain. I only
ask you to bear with me for a few minutes - Is that ok Mr. Clinton?"
3. Drape the SP
4. Start

General Rules for PN :

a. Practice , practice , practice writin' patiently within 9 minutes
b. Broken English is fine , like Google keywords ! Grammar can take a back seat
c. Have a protocol like the one mentioned below to manage time well !
d. Use only standard abbreviations permissible on the PN - Read more about this below
e. D/Ds don't have to be 5 in number ! You could write even 2 or 3 but its EXTREMELY
IMPORTANT that you arrange them in the order of relevance / possibility to the SP that
you saw !
f. Some people tend to mention therapy in the Management - NEVER do that , you are
only supposed to write Investigations on the USMLE Step 2 CS Exam.
My Protocol for completing a PN on time :
1.
2.
3.
4.

D/D and Management first

Then Chief Complaints and their description
Significant Negative History
Systemic Examination

This ensures that the Higher grade-earning points are done within time.
5. In the time left, finish off PAM HUGS FOSS and General Examination (Always copy
vitals from the door please - even if you got different readings !)
Q. Do we mention about counseling on the PN - like DM , HT, etc. ?
A. No ! Counseling only inside the room with the SP :-) The Patient Note is only for
D/Ds, Findings, History and Investigations - No Interventions !

ASKING ABOUT SEXUAL HISTORY

Check out this logical pattern that I learned during a lecture I attended during my observership sessions - which
means this should not only help you for the CS , but also when you get into a residency :-)
Q 1. "Mr. John, Are you Sexually Active ?"
Q 2. "How Many Partners are you active with ?"
Q 3. "Are your partners male or female or both ?" [Unless the SP says wife or husband in question 2]
Q 4. "Do you use protection during intercourse ?"
Q 5. If yes in Q. 4 "What kind of protection do you use?"
Q 6. Ask about anal intercourse in male homosexuals

THE "GET UP AND GO" TEST

This test is to used as a measure of balance in elderly patients. I would rather that this test were called "Get up,
go and Get back" Test ..you will see why.
How is the Test Done ?
Have the patient sit in a straight-backed chair and ask him/her to:
1. Get up from a chair to standing position
2. Walk forward feet in a straight line
3. Turn back around & walk back to the chair
4. Sit down again
Interpreting the test:
You can either score it by the timing (Less than 20 seconds for the whole procedure is normal , More than 30
seconds indicates gait/balance problems) Or you can score it on a grading system like:
0 - patient does not use arm-rests to get up
1 - uses arm-rest in one attempt
3 - needs multiple attempts
4 - cant get up without assistance
all this Besides noting gait stability while walking
On the USMLE Step 2 CS, I would rather recommend either doing the easy timed method OR simply noting
what you observed during the test - like difficutly in getting up , unsteady gait and needed assistance to sit back
down..etc.

Handling a Lab-Result Explanation Case ?

This presents an amusing paradox - on most cases on the CS, we are worried about finishing on time,
whereas the main concern on this one is how to expand all you can talk to fit those 15 minutes ! This
somehow reminds me of my daytime sleep ;-) it seems to effortless expand and fill-up all the space it gets
;-)
But tell you what, lets have a protocol to tackle any kind of Lab-Result Explanation cases. Here's one for,
say, a Trichomonas lab result:
1.
2.
3.
4.
4.
5.

Reveal the lab findings to the SP and explain the diagnosis in layman terms
Tell the SP it's nothing too serious and explain how trichomonas is contracted
Get History about Vaginal Discharge, then Sexual + Menstrual history
History pertaining to other STDs (rash, genital lesions, lymph-nodes, etc.)
Ask her if she has any new complaints and tell her you would like to repeat a general physical exam
Ask her if she has any specific questions and if she knows how to avoid Trichomonas in future

6. Counseling should cover the following :

a. Explain that both the SP and her partner would treatment.
b. Tell her that if she will put on Metronidazole therapy - alcohol is to be avoided, since that will cause
nausea and vomitting (Disulfiram like reaction)
c. Abstinence from sexual intercourse until therapy is complete
d. Counsel on protection, risk of other STDs like HIV & risk of cervical cancer (need for PAP smears) .
e. Ask her if she has had a pregnancy test recently and when - if not done, ask her to consider having that
done. (and mention that on your PN as an Investigation)
f. If not pregnant, advise about birth-control methods.
I guess this particular case is more about SEP and CIS component !
On the PN - merely include general exam in the Physical Exam section - the rest of the PN will be like any
other case.

Sore Throat Case ? No Probs !!!

SORE THROAT WAS BAD !
S- wallowing food is painful ?
O- rigin, Duration, Progress
R- unny Nose
E - ar Problems ?
T- emp ? / Chills ?
H- eadache
R- espi. Sympt - Cough, SOB, Chest pain
O- ccupation ?
A- spiration + Abdominal Symp.- Nausea, Vommiting, Pain (esp in LUQ)
T- iredness(Fatigue), Touch with ill people (ill contacts - boyfriend, girl friend)
W- t. loss ?
A- ppetite Change / Alcohol ?
S- moking Sleep changes ? Sexual History
B - owel Habbit
A - nything else do you wanna tell me ???
D - rugs ( illegal IV drugs ?)
As if this weren't not good enough, we have a another cool one for investigations ! :-)
THROAT
T - hroat Culture
H - IV antibody and viral titer
R - apid streptococcal antigen
O - mOnospot test
A - nit EBV Antibody
T - routine Tests - CBC, Pripheral smear.

Shoulder examination ?
Let us look at examination for a case of Shoulder Pain (People you gotta supplement this with your standard
notes). Assuming that you have already washed, wiped and warmed your hands...
1. Expose both the shoulders - and examine as if you are comparing both shoulders for swelling, deformity.
Especially look out for painted bruises - cause those suggest elderly abuse (besides a fall) and implies you got to
address that part while counselling.
2. Next, say this to ur SP = "Let us examine your shoulder gently to locate the origin of pain - is that ok ? Let
me know immediately if it hurts anytime"
3. Palpate affected shoulder for tenderness and look out for any sign of wincing on the SP's face. Should there
be any wincing/moaning, say "sorry that hurt" and never repeat at that site.
4. Ask the patient to perform shoulder motions to check for his/her range of motion - A more effective way to do
it is ask the SP to mimic your actions-then you move your shoulder the way you want him to move - simpler
than explaining each action and wasting time eh ?
5. The above can aslo be combined with you resisting his motion and checking out strength of motion in
addition!
6. And dont forget to feel for his pulses in the affected hand and verify they are felt normally.
A Quick Mnemonic for Shoulder pain D/Ds : (Think of a deformed shoulder)

'DEFORMS'
D - Dislocation
E - Elderly Abuse
F - Fracture
O - Osteoporosis / Osteomyelitis
R - Rotator Cuff Injury
M - Myositis
S - Sac Inflammation (Bursitis) + Sprain (as suggested by a reader in the comments below)

Q. Does the Patient / SP Understand 'abduction', 'flexion' etc. of the shoulder - do we have to spend time
explaining all that to him/her ?

A. While asking the patient to perform ANY maneuver, remember that actions speak louder than words "Could you move your shoulder out like this " for abduction and then doing it yourself to indicate how is better
and faster. OR, while checking active Range of Motion (ROM) you could simply say at the start, "Mr. Allen, I
will now make various arm movements at my shoulder joint and I want you to copy my actions, to help me
understand how severe your problem is - Is that fine ? shall we begin ? "

What's with 'SPORTS' & Knee Pain ?

The Knee is a pretty common injury in Sports....So lets use the word 'SPORT' to our advantage on the Step2CS
- a pretty good mnemonic for D/Ds for Knee Pain !!!!
S - Septic arthritis
P - Pseudo-gout + Patello-femoral pain syndrome + Psoriatic arthritis
O - Osteoarthritis
R - Rheumatoid arthritis, Reactive arthritis (Rieters syndrome)
T - Tophi (Gout), Trauma (Fall, Elderly Abuse and SPORTs!)
S - Sac Inflammation (Bursitis)
Again, as I mentioned before, each of these D/Ds should help you ask specific data-collection questions:
For e.g. :
Septic Arthritis : - Ask about fever, and a warm joint feeling
Rheumatoid Arthritis - Ask about morning stiffness and other small joints...and so on.

HEEL PAIN...
Heel Pains ? Foot Pains ? Same thing ? Well almost - at least for the sake of our Mnemonic for Heel Pain ;-)
This mnemonic was generously contributed by Dr. Nikhil Gohokar, MD [ GMC - Nagpur, India]

"FOOT PAINS"
F - Fat Atrophy (age related) + Foreign Body
O - Osteomyelitis (not common)
O - Osteoporosis (not common)
T - Tarsal Tunnel Syndrome, Tendonitis (Achilles) + Tumor
P - Plantar fascitis (Most Common Cause), Periostitis (Calcaneum)
A - Apophysitis (Calcaneal), Arthitis (Reiters, Rheumatoid, Reactive)
I - Ischemia (Peripheral Vacular Disease)
N - Nerve Entrapment (Jogger's Foot)
S - Stress Fractures in Athletes and Spurs in Bone (Calcaneum)
Thus, the above mnemonic also tells us what questions to ask in the history taking, as per the Steps I mentioned
in the Art of History Taking. Applying the steps to this case ...
Step 1 - Patient tells you that his heel pains
Step 2 - you gotta drill him about the pain (LIQOR AAA)
Step 3 - Data-Collection for this case ( Ask about leg swelling, redness, fever, trauma history, footwear
preference, walking habits, long standing hours, morning stiffness, rashes, etc.)
Step 4 - Other Leg symptoms you can think of - like Numbness [Can u feel the heel ;-)], tingling, weakness, et.)
Step 5 - Complications like associated Knee Pain due to change in gait - and then move on to PAM HUGS
FOSS..
A few pointer to Clinical Exam in Heel Pain :
As in Shoulder pain, expose Both Feet !
Then check out for swelling, redness, foreign body and trauma signs in Inspection along with range of active
movements. Next palpation: first check for warmth (active inflammation) , superficial and deep palpation to
pinpoint location. Then go ahead and check peripheral pulses, sensations over both feet, passive joint
movements , power, etc...
At each stage, dont forget to compare with the normal leg..
Finally ask the Pt. to walk to futher qualify the pain
Counseling for heel pain ?
1. Use soft-heeled or soft-padded footware
2. Refrain from long standing or long walking
3. See us again if presribed pain medications do not work

I have FFFOOTTT.
F : Fasciitis / Fascia rupture
F : Fat atrophy
F : Fracture x stress
O : Osteomyelitis
O : Osteoporosis fracture
T : Tendonitis / Bursitis
T : Tarsal tunnel syndrome
T : Tumor

CHEST PAIN : A MNEMONIC

A Mnemonic to remember what else you need to ask the SP besides specifics of the pain itself i.e. LIQOR AAA.
This one is of good help for data-collection in a case of chest pain ...

"CHEST P"

C - Cough
H - Hemoptysis, HeartBurn
E - Emesis (Vomitting) & Diarrhea AND Edema over ankle
S - Shortness of Breath (SOB), Sweating, Syncope
T - Temperature (Fever), Tenderness on the chest ( chondritis - also ask for Trauma) + Tenderness of Legs
(suggestive of DVT that can predispose to Pulm. Embolism) +

P - Palpitations - "Did you feel your heart pounding or racing ?"

A Potent Mnemonic for Impotence

LIMP P3ENIS
When things don't stand ... it's time to use this outstanding mnemonic for data-collection in a case of Erectile
Dysfunction on the Step 2 CS ;-)
L-ibido changes
I-njury
M-edications (B-blockers)
P-ast / Present medical history (HTN, DM, Vascular= e.g.: Leriche Syndrome)
P-revious prostate Sx
P-erformance Anxiety
P-eyronie's Disease
E-rection at all? (Are you able to have an erection at all?)
N-octurnal erection ?
I-ncontinence
S-tress/Depression
how about this one for the diferentials?
DOC!! My Penis Doesn't Go UP
D epresion
O H (alcohol)
C laudication (Leriche Syndrome)
M edications
P resure (HBP)
D Mellitus
G onads (Hypogonadism)
U nknown etiology ED
P rostate surgery, Peyronies Dz

"VAGINAL BLEEDS"
V - Vaginal injuries
A - Adenomyosis + Abortion
G - Genital cancer
I - Infections: PID
N - Neoplasms [Maligant(endometrial CA) + benign ( fibromas)
A - Abruptio placentae
B - Bleeding disorders
L - Leiomyomas
E - Ectopic pregnancy
E - Endocrinopathies, Endometriosis
D DUB (e.g. Anovulatory Cycle)
S - Sores, Condylomas ( after trauma)
For amennorrhea,i hv another mneumonic.Pregnant AMENORRHEA
P-Pregnancy
A-Absent ovulation[anovulation]
M-Menopause
E-Eating disorders[Anorexia nervosa]
N-Nursing mother[Lactational amenorrhea]
O-Ocp's
R-Raised prolactin[Hyperprolactinemia]
R-Raised adrenal hormones
H-Hypothyroidism,Haemorrhage[PPH]
E-?
A-All A's in ur post[Anxiety,Asherman's,etc]

A Stupid Mnemonic for Amenorrhea !!!

P6 A5
i.e. PPPPP AAAAA
P- regnancy
P - rolactinemia (Prolactinoma / Hypothyroidism)
P - COD
P - ills
P - erimenopausal woman (ask for Hot flashes / Dry Vagina)
P - Post-Partum Hemorrhage (As suggested by a kind reader)
A - Anorexia Nervosa
A - novulatory cycles
A - nxiety
A - sherman's syndome
A - Adrenal Hyperfunction !

"FACE SLIPS"
Yeah...when depressed and sad , did your face not slip into your hands ? Arrite..here we
go :
F - Feelings of : Guilt, anger and worthlessness ?
A - Appetite (include diet , weight history) ?
C - Concentration levels ?
E - Energy levels in daily activities ?
S - Sleep disturbances ?
L - Libido Levels ? + Loneliness ?
I - Interests , hobbies ?
P - Psychomotor symptoms ? Pleasure Levels ?
S - Suicidal Ideation , any plans for suicide...?
So here we are armed with specific data-collection points for history.
But what if ...your SP seems bugged and does not seem to come out with why on earth
he/she is sad in the first place...so get smarter and try this :
" I know this is a very tough time in your life, but I assure you that we can deal with this
much better together. I really want to understand your problems and help you as a
friend and a physician. You said you were perfectly happy and healthy 3 months ago could you try and tell me what exactly happened 3 months ago that started this ?"
This should hit the nail right on the head ! coz, basically the SPs are trying to assess
whether you can connect with them at a emotional level or not ....logical, since they are
testing your psychiatry skills...
Sticky Situation: What if SP goes "I want to Die Doctor!"
Hmmm...Again lets modify our formula a bit - "I know this is a very tough time in your
life, but I also know that running away from problems is not the answer. I really want to
understand your problems and help you get your strength back, because I know it is
possible. We can deal with this together."
Some pep-talk like that and gently divert the SP back to your questioning :-)
In a way, if the patient puts on the "I wanna die" comment, it saves you the trouble of
ascertaining whether the patient has any suicide ideation ;-) - LOL - Am I mean or funny
? Anyways, here's a way to ask the patient about suicide ideation, as I answered to a
reader on the comments to this post.

I prefer the Two Question Series Question 1:

"Have you ever felt like you don't want to ever get up from sleep"
OR
"Have you ever had thoughts about ending your life"
Question 2:
"In the recent weeks, did you make any plans or attempts on hurting yourself or killing
yourself"
Why two questions ? - coz' asking only the first question can mean nothing - "wanna
kill myself" is something I feel & say too when really frustrated with myself, but dont
mean it, while asking only the second question could take them off-guard and put the
patient on the defensive.

Don't Let your Mind go Dark in a case of

Dark Urine
Again ...a cool Mnemonic to help you memorize the Differential Diagnosis :
"Fellow Has DARK Pee"
F-Foods like Beet, Blackberry
H- Hematuria
D - Dehydration + Drugs like Rifampin, Vit-B
A - Alkaptonuria
R - Rhabdomyolysis
K - Kernicterus ( well not really - but let the word remind u of Hyerbilirubinuria)
P - Paroxysmal Noct. Hemoglobinuria
Causes of hematuria:
HITTERS
H:Hematologic/coagulation disorders
I:Infections (cystitis)
T:Trauma
T:Tumors:RCC,bladder cancer,prostate
E:Exercise
R:Renal disorders (glomerulonephritis)
S:Stones

Blood in Stools
(Hematochezia)
Not to confuse this with Melena, which implies black tarry stools (most commonly due to a bleed within the
upper Gastrointestinal track making the blood turn black due to it's digestion to hematin).
Hematochezia is frank blood that goes down the drain - i mean the Pot :-) I used the word Drain here for a
reason : A Mnemonic !!

DRAIN gives us the D/Ds for Hematochezia :

D - Diverticulosis (Most Common Reason)
R - Rectal Bleed [Piles, Fissures]
A - Angiodysplasis + Anal Sex
I - Inflammatory Bowel Disease [UC + Crohn's], Infectious Diarrhea, Ischemic Colitis + Injury (as suggested
by a cool reader)
N Neoplasms

I dunno where to start my experience but I read for step 2 CS for almost 2 months. Wasnt regular at all as I was
also having my regular classes in my medical school....
Read UW first and then I read somewhere that digidoc studied FA so I started FA as well and found that FA is
sufficient enough to go with the exam.
also went through www.csprotocol.blogspot.com website. A very useful link indeed.
FA is DEFINITELY BETTER than UW but as my friends told me that UW is the best I did 6 to 7 readings of
UW and 2 readings of FA.
Screwed a lot of cases in the end just because I knew too much. This test is not a TEST of your proficiency in
MEDICINE...thats for sure...
15 days are MORE than enough for study and yes ...
water in the CS center is too much SOFT so try using very less amount of soap to wash hands. I took 2 minutes
to wash my hands that just made me go helpless in the end and I wasnt able to complete 7/12 patients. Tragic
isnt it? :P
anyway...
started with UW and read the basic protocol...I made my basic protocol first that starts like:
examinees.. you may begin...this is the first command...look at the door information...write down the LAST
NAME ON THE SHEET provided to you in big letters...with age
then write the abnormal vitals and then write the D/D or the specific mnemonic for the case...I also wrote
RECTAL EXAM and COUNSELLING in the end along with JCO CVA(jvp, carotid bruit, ophthalmic exam,
CVA = costovertebral angle tendernes) because I tend to forget them .... rectal exam/pelvic exam counselling I
used to do along with examining the patient...
Knock on the door...dont forget to smile and then open the door...
Good morning Mr. LAST NAME. I am Dr. FIRST NAME LAST NAME and am here to see you as your
physician today. Nice to meet you. (shake hands) dont shake hands with SPs in severe pain. Then ask ...
Is everything in the room allright for you?
and after that ... say... LET ME MAKE YOU A BIT MORE COMFORTABLE...saying this open up the
drape ...OPEN IT COMPLETELY...a friend of mine told me to open it half and I messed it up just because half
sheet doesnt cover the legs of the patient.....cover the legs in the beginning as it seems more corteous...
afterwards...if its an office case...sit down on the chair and if its an emergency case...keep standing...
start with ... THE NURSE TOLD ME THAT YOU ARE HAVING ________ (THE CC). CAN YOU PLEASE
TELL ME MORE ABOUT IT? and the patient will start telling you ...it will be only a single sentence... :P
after that ....you say...OH I AM SO SORRY TO HEAR THAT. I SHALL TRY MY BEST TO HELP YOU
(SMILE). HOPE YOU DONT MIND IF I TAKE SOME NOTES WHILE YOU SPEAK.
and then write quickly the mnemonics ...NOW ASK THE PATIENT ...ODPFAAA (onset,duration, progression,
frequency, aggravating, alleviating, precipitating,associated) factors...read bout ART OF HISTORY TAKING
from the blogspot website of digital doc...
I had basic mnemonics for every symptom...
when you finish with them...then start with
questions specific for D/D...5 or 6 in number...
after that... ask
F fever
F fatigue
A apetite
W weight changes
you dont have to ask these questions in every patient but its better to ask them..
then say..
OKAY MR. XYZ NOW I WOULD LIKE TO ASK YOU SOMETHING ABOUT YOUR HEALTH IN

GENERAL. IS THAT OKAY WITH YOU?

start with
P past medical history past surgical history
A allergies
M medications
H hospitalizations
U urinary problems
G GIT problems
S sleep problems
again ask a transition question:
NOW I WOULD LIKE TO ASK YOU ABOUT YOUR FAMILY HEALTH. OKAY?
F family health
again another transition:
NOW I WOULD LIKE TO ASK YOU ABOUT YOUR GYNECOLOGICAL AND SEXUAL HEALTH.
WHATEVER YOU WILL TELL ME WILL BE KEPT CONFIDENTIAL. IS THAT OKAY?
O obs/gyn
S sexual history
another transition:
NOW I WOULD LIKE TO ASK YOU ABOUT YOUR LIFESTYLE.OKAY?
S do you smoke?
O what do you do? Is your work stressful? (I used to ask this during handwashing)
D do you take any recreational drugs?
A do you drink alcohol?
T have you travelled recently/trauma?
A do you have ANY other thing to tell me before I start your physical?
OKAY MR. XYZ. NOW I NEED TO DO A QUICK PHYSICAL EXAM AND LOOK AT YOUR HEART. IS
THAT OKAY WITH YOU?
he will say okay
say ARRITE THEN. EXCUSE ME FOR A MOMENT HERE SO THAT I CAN WASH MY HANDS. OKAY?
go for hand washing ceremony. and wash them for REAL because they are watching you.
come back and start. OKAY NOW I NEED TO SEE YOUR EYES FIRST. CAN YOU PLEASE LOOK UP
FOR ME. and now keep on doing the running commenty while you keep on doing the physical exam. what I did
was that
I thought to auscultate lungs and heart with general physical exam. STARTED with eyes, then oral cavity, then
neck glands + thyroid, then chest, then feet (edema) and in case if calf tenderness has to be seen, I check it as
well...
NOW UNCOVER BACK AND auscultate plus CVA and spine tenderness checked...
after that...
COVERING THE PATIENT BACK... I said... THANKS FOR YOUR COOPERATION MR. XYZ. NOW I
WOULD SIT AND TALK OVER WHAT I AM CONSIDERING SO FAR. YOU TOLD ME THAT YOU

HAVE HAD THIS PROBLEM SINCE _ DAYS AND IT IS PROGRESSIVELY GETTING WORSE AND ON
PHYSICAL EXAM I WAS NOT ABLE TO FIND ANYTHING SIGNIFICANT/I WAS ABLE TO FIND THAT
YOU HAVE DECREASED BREATH SOUNDS ON LEFT SIDE etc. BASED ON THIS THERE ARE A FEW
DIAGNOSTIC POSSIBILITIES LIKE TB AND PNEUMONIA BUT THERE ARE OTHER POSSIBILITIES
AS WELL AND WHAT I AM GOIN TO DO NOW IS TO RUN A FEW TESTS LIKE BLOOD TESTS AND
CHEST X RAY ON YOU AND ONCE THE RESULTS OF THESE INVESTIGATIONS COME OUT WE
WILL SIT TOGETHER AGAIN AND DISCUSS YOUR PROBLEM IN MORE DETAIL.
I did counselling during the encounter but most of the peopel do counselling at this place. What I did was that.
e.g. if they smoked, drink alcohol and take drugs. I said after aksing all the questions about them. THE
REASON WHY I AM ASKING YOU THIS IS BECAUSE SMOKING, DRINKING EXCESS ALCOHOL
AND TAKING DRUGS PUTS YOU AT HIGHER RISK OF GETTING MANY DISEASES. SO AS YOUR
CONCERNED PHYSICIAN I MUST ADVISE YOU THAT YOU SHOULD EITHER CUT IT OR IDEALLY
QUIT IT. ARE YOU WILLING TO DO THAT? if they say YES. say EXCELLENT MR. XYZ. THERE ARE
ALSO A FEW PROFESSIONAL SUPPORT GROUPS AVAILABLE THAT WOULD BE HAPPY TO HELP
YOU. IF YOU ARE WILLING I CAN CONTACT THEM ON YOUR BEHALF OR YOU CAN CONTACT
THEM ON YOUR OWN. PLEASE LET ME KNOW IF I CAN BE OF SOME HELP TO YOU. if they say NO
then say I UNDERSTAND THAT IT IS VERY DIFFICULT TO QUIT AN OLD HABIT BUT SMOKING
DAMAGES YOUR BODY A LOT AND IT MIGHT BE ONE OF THE CAUSE OF THIS CONDITION OF
YOURS. THERE ARE A FEW PROFESSIONAL SUPPORT GROUPS ALSO AVAILABLE THAT WOULD
BE HAPPY TO HELP YOU. PLEASE LET ME KNOW IF I CAN BE OF SOME HELP TO YOU. thats it!!!!!
dont push them to quit smoking or do what you want ... :)
as some patients might say that they arent here for smoking or alcohol counselling but YOU HAVE TO
COUNSEL..
for DIABETES just use the same way:
ask for diabetic control, diet, exercise, foot care n then say
THE REASON WHY I AM ASKING YOU THIS IS BECAUSE NOT CONTROLLING DIABETES, TAKING
FATTY FOODS, NOT DOING REGULAR EXERCISE AND NOT WATCHING YOUR FOOT REGULARLY
PUTS YOU AT HIGHER RISK OF GETTING COMPLICATIONS OF DIABETES. AS YOUR CONCERNED
PHYSICIAN I MUST ADVISE YOU TO OBSERVE STRICT DIABETIC CONTROL, TAKE LESS FAT, DO
REGULAR EXERCISE AND WEEKLY OBSERVE YOUR FOOT.
same goes for Hypertension except that there is BP control and NO FOOT CARE :P in the counselling...
for SEX COUNSELLING after sexual history you can say:
THE REASON WHY I ASKED YOU THIS IS BECAUSE NOT PRACTISING SAFE SEX METHODS THAT
INCLUDE USING CONDOMS AND LIMITING YOURSELF TO ONLY SINGLE PARTENER WHO DOES
SEX WITH YOU PUTS YOU AT HIGHER RISK OF GETTING STDs, HIV AND CANCER OF THE NECK
OF YOUR WOMB. AS YOUR CONCERNED PHYSICIAN I MUST ADVISE YOU TO OBSERVE SAFE
SEX METHODS....bla bla OKAY ?
for difficult and challenging questions:
make your own protocol for answering them:
always say first...
I UNDERSTAND YOUR PROBLEM/CONCERNS/ that you want to go for hiking/you are in pain etc etc..
then in the next sentence GIVE YOUR HONEST OPINION BUT IT SHOULD BE PEP TALK. you can say.
BUT RIGHT NOW IT IS DIFFICULT FOR ME TO SAY FOR SURE AS I NEED TO RUN SOME
TESTS/INVESTIGATIONS AND ONCE THE RESULTS COME OUT I WILL BE IN A BETTER POSITION
TO TELL YOU WHAT WE ARE DEALING WITH. etc etc...
in the third sentence

use:
I WILL KEEP YOU INFORMED
IS THERE ANYTHING I CAN DO TO MAKE YOU FEEL MORE COMFORTABLE
PLEASE BEAR WITH ME I WILL VERY MUCH APPRECIATE YOUR PATIENCE....
believe me all of your challenging questions will be answered if you use this protocol :D
anyway after counselling that you can do during the history or in the end but its always to do that during the
history because most of the people forget the counselling part...
after that ask
"ARE THERE ANY SPECIAL CONCERNS YOU HAVE?"
"HAVE YOU UNDERSTOOD EVERYTHING THAT I HAVE TOLD YOU TODAY?"
"OKAY THEN MR. XYZ. I AM GLAD THAT I WAS ABLE TO WORK WITH YOU AND I ASSURE YOU
THAT I AM ALWAYS HERE TO HELP YOU. THANKS FOR YOUR COOPERATION AND IT WAS
REALLY NICE MEETING YOU. (SHAKE HANDS) BYE FOR NOW AND TAKE CARE".
that's it...
always remember time is VERY SHORT during the exam...so try to practice practice and practise plus shorten
your questions...
dont WORK TOO MUCH ON QUESTIONS.....
for timing they dont allow you to use digital watches so what I did was that I used to bring the hands of my
clock to 12:01 o clock before the encounter and that wud make my clock a stop watch :D
it really helped me but I did it in the end :(
I had a few mnemonics that I want to share:
A (Amount and frequency)
B (Blood)
C (Content, Consistency, color)
O (Odour)
can be used for
vaginal discharge: with additional questions of Itching and sores
vomiting: with additional questions of nausea
sputum: preceded by a question like is cough productive or dry?
diarrhea: with additional questions of tenesmus and fecal incontinence
constipation: with additional questions of tenesmus and fecal incontinence and pain on defecation
FOR CONCISE EXAMS. USE KAPLAN BOOK FOR STEP 2 CS. EXAMS ARE BEST WRITTEN IN
KAPLAN.
for general exam..i follwed the PICKLE and added O of opthalmoscope to it...check pedal edema now...and ask
fr it also...check pulses...take BP
now this is what i did personally for,, systemic exam...
--i started with sp sitting untie the gown with back chest insep/percussion/tactile fremituis/ascultation....check
for spinous tenderness and CVA tenderness at the same time..

---SP still sitting..come front take the gown down ..sternal tenderness/ supraclavicular nodes axillary
nodes...PMI...all 4 heart sounds and ascultate the lungs..
--tell the SP to lie down....look for JVP..carotid pulse...go for abdomen...IAPP..
here is what you should do a night before step 2 CS
iron ur clothes in the evening and practice ur cases with tie on( u may laugh on this but it might be a bit diffcult
with trousers and tie)
sleep as ealy as u can...get up around 6...practice
1) general case
2) pedis case
3) pyshicatry case
4) absue case
5) telephone case..
6) enuresis case