CASE 25

DOORWAY INFORMATION

Opening Scenario
The mother of Maria Sterling, an 18-month-old female child, comes to the office complaining that her child has
a fever.

Examinee Tasks
1. Take a focused history.
2. Explain your clinical impression and workup plan to the mother.
3. Write the patient note after leaving the room.

Checklist/SP Sheet
Patient Description
The patient’s mother offers the history; the child is at home.
Notes for the SP
Show concern regarding your child’s situation.

Challenging Questions to Ask

 “Do you think that I did the right thing by coming here and telling you about my child’s fever?”
 “Is my child going to be okay?”
Sample Examinee Response
“You certainly did the right thing by coming in today. Maria may have an infection that is causing her fever, so we
need to examine her here in the office and then decide whether she needs any tests and/or treatment.”

Examinee Checklist
Building the Doctor-Patient Relationship

Entrance
 Examinee knocked on the door before entering.
 Examinee introduced self by name.
 Examinee identified his/her role or position.
 Examinee correctly used patient’s name.
 Examinee made eye contact with the SP.

Reflective Listening
PRACTICE CASES

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.
 Examinee summarized the SP’s concerns, often using the SP’s own words.

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Information Gathering
 Examinee elicited data efficiently and accurately.

✓ Question
 Patient Response
 Chief complaint My child has a fever.
 Onset Two days ago.
 Temperature I measured it, and it was 101°F on her forehead.
 Runny nose Not currently, but she did have a runny nose for a few days about a
week ago.
 Ear pulling/ear discharge Yes, she has been pulling at her right ear for 2 days.
 Cough Not currently, but she was coughing for a few days about a week ago.
 Shortness of breath No.
 Difficulty swallowing She seems to have trouble swallowing, but I’m not sure.
 Rash Yes, she has a rash on her face and chest.
 Description of the rash Tiny red dots, some slightly elevated, over the chest, back, belly, and
face. There is no rash on her arms or legs.
 Onset of rash and progression It started 2 days ago on her face and then spread to her chest, back,
and belly.
 Nausea/vomiting Yes, she had an episode of vomiting last night
 Change in bowel habits or in stool No.
color or consistency
 Change in urinary habits or in urine No.
smell or color
 Shaking (seizures) No.
 How has the child looked (lethargic, She looks tired. She is not playing with her toys today and is not
irritated, playful, etc.)? watching TV the way she usually does.
 Appetite changes She is not eating much but is able to drink milk.
 Ill contacts No.
 Day care center Yes.
 Ill contacts in day care center I don’t know.
 Vaccinations Up to date.
 Last checkup One month ago, and everything was normal.
 Birth history It was a 40-week vaginal delivery with no complications.
 Child weight, height, and language Normal.
PRACTICE CASES

development
 Eating habits Whole milk and solid food; I did not breast-feed my child.
 Sleeping habits She has not slept well for 2 days.
 Hearing problems No.

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 ✓ Question
 Patient Response
 Vision problems No.
 Current medications Tylenol.
 Past medical history Three months ago she had an ear infection that was treated
successfully with amoxicillin.
 Past surgical history None.
 Drug allergies No.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination
None.

Closure
 Examinee discussed initial diagnostic impressions.
 Examinee discussed initial management plans:
 Follow-up tests.
 Examinee asked if the SP had any other questions or concerns.

Sample Closure
Mrs. Sterling, it appears that your child is suffering from an infection that may be viral or bacterial. She may be suffering
from an ear infection or something more serious. A physical exam and some blood tests will be needed to identify the source
of infection and the type of virus or bacteria involved. Although viral infections generally clear on their own, most bacterial
infections require antibiotics; however, such infections generally respond well to treatment. Do you have any questions for me?
PRACTICE CASES

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Opening Scenario
The mother of Maria Sterling, an 18-
month-old female child, comes to the office
complaining that her child has a fever.
Examinee Tasks
1. Take a focused history.
2. Explain your clinical impression and workup plan to the mother.
3. write the patient note after leaving the room.

USMLE STEP 2 CS Patient Note

History

Physical Examination

PRACTICE CASES

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 USMLE STEP 2 CS Patient Note
Differential Diagnosis
Diagnosis #1
History Finding(s): Physical Exam Finding(s):

Diagnosis #2
History Finding(s): Physical Exam Finding(s):

Diagnosis #3
History Finding(s): Physical Exam Finding(s):

Diagnostic Workup
PRACTICE CASES

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