What if the patient becomes belligerent or uncooperative during the physical examination?

This is seen in the clinics everyday. Such actions test your skills as a communicator and as a decision maker. Be on the lookout for psychiatric disorders, substance abuse, spousal abuse, metabolic disorders or other medical conditions that can make a patient behave abnormally. Always maintain your composure and talk in a diplomatic manner so as not to antagonize him.

Another thing to consider is to make sure that your technique is not hurting patient. You might be bending his swollen osteoarthritic knees too much or you might be strongly tapping on an inflamed area. Informing him ahead of time what you intend to do minimizes bad encounters like these.


What are the restrictions in doing the physical exam?

No genitourinary, pelvic, rectal or breast exam for female patients. No inguinal hernia assessment and no corneal reflex exam. They all can be ordered as part of the work-up plan if you think they are relevant to your case. Checking for inguinal pulse is not a genital exam so that can be done. Lifting the breast to feel the heartbeat is not a breast exam so that can be done too but you should explain to the patient what you will be doing and why.


I feel uncomfortable examining a white, female patient in a gown. What should I do?

Dont be. Treat her as you would any other patient. Some Asian cultures harbor a Caucasian superiority complex. This perception can spill over in the clinics where they expect a Caucasian patient to be demanding or intimidating, particularly if the examining physician is a male and the Caucasian patient is a female. To some examinees, this may be your first time to see a Caucasian female patient in a hospital gown, and you may feel uncomfortable and hesitant in doing all the physical examination maneuvers. This should change if you aspire to do your residency in the states. Treat each patient with dignity and respect, regardless of their gender, and do not be intimidated.


I want to get refreshed in doing a proper physical exam. Is the Step 2 CS video enough as a review?

The tape is an overview of how the test is administered but it is far from perfect covering a thorough physical exam. If you have access to a medical school library in the U.S., you can borrow videotapes that comprehensively deal with this subject matter. If you dont, you can scan the web and look for videotapes created for nurse practitioners and physician assistants (instructional) because these tapes can be a very useful resource. If you have high-speed Internet connection, you can use the sites mentioned in this book.


What do you do if a patient comes in for a routine check-up without any complaints?

Do a thorough interview and physical exam. This can be very tricky because you only have 15 minutes to do everything. Just like an actual patient, he may not have medical complaints initially but as you go along the interview, you may unearth some hidden symptoms and you must be quick to start focusing on them. Dont forget to ask for weakness, weight changes, fever, etc. Listen to the chest and tap his abdomen. Ask for thyroid symptoms. Make quick relevant exams from head to toe. Try to inject a few psychiatric questions to rule out malingering. Such a situation like this is tough since you are going up against time. But it is certainly doable.


How do we handle pediatric cases? Are we going to get actual pediatric patients?

According to the official USMLE website, pediatric cases will be conducted over the phone. Instead of a pediatric patient in the room, expect to see a telephone. The person calling in will be a parent or a relative of a child seeking consultation for the child who is at home or too sick to come to the hospital. Obviously, in this case you cannot do a physical exam but you can put it as part of your further work-ups. The history should be expanded and more comprehensive because the entire 15 minutes will be devoted to the interview.


How about geriatric patients?

As with pediatric patients, these exams will be conducted over the phone, as mentioned in the USMLE information bulletin.


15 minutes is such a short time to do everything. Can I look at my watch every once in a while during this 15-minute period?

If you look at your watch too often during the course of the interview, patients may think you are more interested on your watch than on their condition. You should remember that they are the ones grading your performance. Some Step 2 CS online forum participants suggest placing the face of your watch towards you, so you can make quick glances at it without the patient noticing it. Make sure you follow the Step 2 CS guidelines regarding watches.


How do you handle belligerent patients?

By maintaining your cool. Thats when training and preparation come into play. You must keep your composure despite the pressure. Sometimes, even actual patients try to gauge your convincing power and your decision-making skills by intentionally being uncooperative and verbally aggressive. Use well-thought-out statements that will help persuade him to calm down. Explain that you are there to help him. Do not get irritated and if you do, dont show it. Patients can be belligerent throughout the entire process but be patient and continue on. Focus your exam on his presenting complaints. Rule out thyroid disorders, substance abuse or psychiatric problems. Some patients may calm down after you have said the right words and have struck the right chords. Expect for others to behave differently.