Irfanmir 15 Minutes Conversation Notes (Usmle Step 2cs)

KICK THE BOARDS
USMLE STEP 2 CS
15 MINUTES CONVERSATION NOTES
Prepared by
Dr. Irfan Mir
KICK THE BOARDS. USMLE STEP 2 CS.
IRFANMIR 15 MINUTES CONVERSATION NOTES
Knock the door. > (First do Identification by saying) Mr John Smith ?
( > = wait for an ans then go for next Q )
Hello Mr Smith My name is Dr Mir, your attending physician, How may I help You today ?
here Pt will tell you CC;
> Say; sorry to hear that. (show sympathy and concern in your posture)
O (onset) ------------ How long you are having this problem ? > Plz tell me more about it ? > How did it start ?
L (location) -------- Could you plz point it with one finger where exactly do u feel it ?
D (duration) -------- How long does it last ?
F (frequency) ------- How frequent it occurs? (Constant vs. Intermittent)
P (progression) ---- Is it Progressive ? (getting Better or Worst or Same)
Q (quality) ---------- Can u describe the pain how is it like ?
I (intensity) --------- On the scale of 1/10 where 10 is the worst how do you grade your pain ?
R (radiation) ------- Does it travel to some other part of the body ?
All/Exa F ------------ What makes it better ? > What makes it worst ?
(Must sympathize at this point by saying) That must be very agonizing & distressful for you, > How do you feel abt ur condition ?
(must sympathize here again by saying) I understand that must be very unpleasant experience for you.
Are your Sxs causing any interference in ADL ? (Must do Counseling such as offering education and nursing help)
Where exactly do you need help (such as bathing/ cooking/ med/ grocery/ managing accounts/ coming out of bed etc)
I need to ask you some Qs about your health in general, is that OK ? (This ROS takes < 2 mins or even less if u practices more)
(Go like that. Do u have fever, (wait for ans) chill (wait for ans), any sweating (wait for ans), dryness (carry on with the list below).
(Do not say whole sentence again and again, just one Sx or organ is enough, as explained in above line)
Asso Sxs ------- Fever/ chill/, sweating/ dryness, N/V, HA, Vision problem, Hearing problem, unusual smell,
dizziness/ Loss of balance/ pass out / Involunteer muscle movement. Difficulty swallowing,
Change in voice/ heart burn, Appetite /wt change, mass/lump any where in body, Rash/ skin Discoloration,
SOB/ Palpitation, Nipple discharge, abd discomfort, bowel problem, urinary problem,
Past similar sxs. Recent illness/ travel/ trauma/ bug bite/ new pet. Muscle pain, Bone /joint pain.
Mood (sad happy), energy, Recent incident / accident in life, Impact of illness in life. Sleep.
Denial ------- (What ever Pt denies while asking Associated Sxs write down under "denies" in ur pt notes)
(On blue sheet write down only + ve findings; do not write - ve findings on blue sheet otherwise u will never be able to close the case)
I need to ask you some Qs abut your obstetric & gynecologic health, is that ok ?
(Ask all following Qs if Case demands it, otherwise asking only 1st Q of each of the following line is enough)
Obgyn -- When did you have ur first menstruation? > Was it reg? > How long was the cycle ? > How was the flow (low/med/heavy)
When was ur First day of LMP ? How long is the cycle now ? > How was the flow ? > Any cramps ? > # of tampons ?
Any intermittent bleeding ? > Any vaginal discharge ? > Pain During Sexual relationship ?
How many kids do you have ? > With natural delivery or C section ? > Any complication during pregnancy or after ?
Any Abortions ? > How many ? > In which trimester ? > Did you any received D&C ?
When did you have ur last Mammogram ? > and Pap smear ? how was the results ? (must do counseling for both if - ve)
Is there any bleeding problem in family or relatives ? (ask this Q in pt with menorrhagia. very imp)
Medi/ All -- Are you taking any medication ? > Any herbal products ? > Do you have any allergies ?
PMH --- Do u have any other health issues (co morbidities)? > Have you ever been hospitalized for any reason ? > Any Accidents ?
FH ----- Tell me about the health of ur parents ? (If parents are deceased say sorry to hear that & ask what was the cause of death)
Is there any health problem in Family or relatives such as mental illness > Cancer > bleeding problem ?
SH ----- What do you do for living ? > any stress at job ?
(must ask support system) Is ur family supportive ? > Any problem there? > How about friends (r they supportive)?
Are you married ? > any problem there ? > How many Childrens ? > Any problem there ?
Do you drink Alcohol (EtOH) ? > what do you drink ? > How much ? > How Often ?
COPY RIGHTED MATERIAL
Must ask CAGE? (must do counseling if + ve. See examples in counselling section)
C = have u ever felt the need of CUT down on ur drinking?
A= have u ever felt ANNOYED by criticism of ur drinking?
G = Have u ever had GUILTY feeling about ur drinking?
E = Have u ever had to drink first in morning as an EYE opener? (to get rid of hang over)
Do you smoke ? > How many PPD ? > From how many yrs ? (must do counseling if + ve)
Do you use any illicit drugs ? > What kind ? > How do you use it ? (must do counseling if + ve)
Do you use caffeinated drink or energy shots ? (must do counseling if + ve)
How is ur diet (healthy or fast food) ? > Do you exercise (type?) (must do counselling for healthy food / fiber/ exercise)
* I need to ask you some Qs about your sexual heath & practices is that Ok ? > Here I also wants to reassure you that every thing we
talk here will be confidential by all mean, is that Ok ? (must say that to express ur sense of pts confidentiality)
SxH --------- Are you sexually active ? > with whom ? (ask how many boyfriends did u have in past 1 yr sp if pt is unmarried ?)
How is your sexual interest (libido) ?
do you use contraception ? > Which method ?
Have you ever been diagnosed with STD ?
Have you every been tested for HIV ? (do counseling in needed)
Phy Exam -- Now I need to perform a physical exam (PE) on you for which I have to untie your gown, Is that OK ?
Ill try my best to minimize any discomfort or pain associated with PE. OK? (Must Drape the pt before u examine)
(while wearing gloves must say) Here I also like to assure u that u r in good hands & I will do my level best to help u ?
Explain every step as u perform exam (just like running commentary and keep doing it, do not stop at any time)
(upon finishing the examination must say) Thanks for letting me examine u. (Phys Exam should not exceeds 3 min)
CLOSING --- (Must reserve 4 - 5 mins for closing)
Mr. Smith you said that you are having so & so problem + brief imp Sxs is that correct (wait for ans); OK
Well Mr. Brown at this point according to the information that u have provided me & physical examination findings my impression
is that you are most likely having so & so problem (explain all terms) but very same Sxs can also be caused by some other potential
reasons (explain two other causes). In order to get to the right dx I am indicating some routine test such as (tell few of the following)
CBC ---- which is blood count and chemistry.
Preg test -- to make sure that in case ur pregnant unknowingly, than we r avoiding medications that can cause harms to baby.
U/A & Culture --- to rule out any infection / kidney problem.
Sputum culture ---- In which we find the bacterial type.
Fecal Occult Blood test ---- Which shows presence of blood in stool
As well as I want you to have some procedures such as
ECG --- which is a Graphic cardiac reading that gives information about hearts health.
Echocardiography --- which is the heart sonography
Stress test --- they will put u on treadmill with different stress level to evaluate ur hearts health.
Ultrasound (USG) --- which use sound waves to take pictures inside your body.
Xrays / CT scan / MRI --- which is modern way to take images of the inside of your body.
Endoscopy --- which is modern way to take pictures by mean of camera.
Joint Aspiration ---- which is achieved by needle insertion and drawing out the fluid for examination. OR FNA
Snellens Chart (visual acuity)
Audiometry / Tympanometry
PFT / Spirometry
ABG / Pulse Oximetry
Renal Functional test
Pelvic exam, Rectal exam. etc
As soon as test results come in I would like to sit with you to discuss all the tx option available.
Is there any thing you feel we need to discuss that we havent talked about ?
Do you have any Q ? (this is one of the possibility, for that concern I have indicated a test to make sure we r not missing any thing).
Is that Answer ur Q? > Do you have any other Q ?
If you remember any Q later please feel free to call my office I will be glad to answer you.
And for the time being until results are available I will recommend that keep taking ur Medication, multivitamin and avoid
aggressive exercise/ stress related activities that could effect ur current condition.
At Last Must do Counseling here. (Must explain preliminary immpression, use few medical term but explains in easy language)
Beside that I also have some imp concerns regarding ur health which I like to talk. > than do counseling/ explain.
I also like you to understand that we are here to support and comfort you in every possible manner.
Ok Mr. Brown I am looking forward to see you again, Take care and good bye. shake hand.
(DONE GOOD LUCK)
If you have no time left, before leaving the room just say you will do rest later today.
It is very very important that u show compassion / concern in ur words and gesture. (be dramatic but wisely)
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HOW TO SYMPATHIZE : I understand that must be very agonizing and distressful experience for you.
I understand some time things are very tormenting & distressful.
I understand some times things are very unpleasant & heart breaking or annoying/ frustrating / irritating.
COUNSELLING --------- "R.E.V.I.C.E". (can be done in any order partly through out encounter or at last)
* Reassurance (I would like to assure you that ur in good hands & I will do my level best to help u)
* Expectations (How do u feel about your health / if needed ask what do you think it is)
* Validating Response (Your reaction is ok I would had the same response if I were on your place)
* Information sharing (Explain all possible dx and future procedure. Do Awareness / prevention)
* Concerns (Do you have any concern regarding your health / Do you have any Qs)
* Empathic (I know how upsetting this is to you.)
Examples of "R.E.V.I.C.E":
Well Mr. Smith according to info that u have provided me I think Don has some Infectious process going on (explain it)
At this point I cannot Rule out any other possibilities / complication. There fore Mr. Doug I would like you to bring Don to the hospital as
soon as possible, so I can perform a physical exam and order some Routine test to rule out any potential problem.
Do you have any transportation problem? --- OK for that I like to forward you to talk to our Social service personnel so they can arrange
you a ride to hospital. They also deal with financial concerns in case if you have one.
In the mean time I would ask you to keep watchful eye on the kid, if he develops any sign of deterioration such as
Change in skin color, difficulty breathing, Non responsive state, Absence of movement, than plz call 911 immediately.
Age could play a role in sexual dysfunction but there are also many other reversible possibilities, hormonal imbalance is one of them.
For that reason I am indicating some tests and procedure to make sure that we are not missing any cause.
I understand that you are anxious and perhaps scared of surgery most ppl feel nervousness when they hear that. At this point I can not
exclude the possibility of surgery and I would advice you to wait for the results, as soon as the results come in I would like to sit with you
to discuss all the concerns and TX option available.
I understand it is very awkward and uncomfortable revealing your medical condition to others. In order to protect u & your love ones, u
must inform her so we can run a test on her too, to rule out infectivity & provide future TX/ prevention.
Job problem: I am more concern about your health at this point and if you want I can write a letter to your employer to explain how imp
it is for you to see specialist and for that reason your absence in office.
I understand that you are in difficult & painful situation but I just want to ask you few quick Qs and relevant physical exam, so I can
better understand ur condition and get right medication for you.
Let me drape u to make u more comfortable.
I will be glad to write a letter for u but first I have to ask u some Qs and do physical examination for the better understanding of ur
problem. Is that OK?
MAMMOGRAM/ PAP SMEAR: Ms Jane it is highly recommended to have a mammogram. Mammogram is a modified xrays that give
images of inside breast which help us detectin-g any potential problem. Is that ok?
PELVIC EXAM : Later today I will perform Pelvic exam which include Observation & Palpation to look for any abnormality. Also sample
taking for Pap Smear (explain pap smear), is that OK? It is highly recommended
Ms Jane, In Pap Smear we take some samples of inside vagina which we call cervix than those samples are further evaluated under
microscope to see whether there is any potential problem.
ALCOHOL/ SMOKES: Ms Jane I am also concerned about your smoking habit. There are several options available that make quitting
which include patches and medication, Remember quit smoking will improves your health; it even reverses some problems if done in
time. Have u ever think quitting smokes? > Please give yourself a thought and in next meeting I will talk in more detail about it. Ok?
Ms Jane I also feel that u must think about quitting Etoh; There are several options available that help quitting which include, Alcohol
anonymous program, Support group & also by medication. Remember quitting alcohol improve ur health, it even reverses some
problems if done in time. Have u ever think quitting alcohol? > Plz give yourself a thought & in next meeting I will talk in more detail
about it. Ok?
BARRIER CONTRACEPTIVES: Ms Carla I highly recommend barrier contraceptives such as Male or female condoms, which not only
gives protection against possible transmission of Potential life threatening Infectious disease such as Aids, Hepatitis and syphilis but also
prevent pregnancy 99% of the time.
HRT: It is important to measure your Hormones, it detects chemical disturbance if there is any and also help us measuring the dose of
HRT. Remember HRT will help us prevents osteoporosis (thinning of bones), mood swing, Hot flashes. Etc
WT BEARING EXERCISE: Ms Jane I recommend you to have some light wt bearing exercise which help strengthen the bones and also
help slow down the process of Osteoporosis (thinning of bones).
I would also recommend you to take Ca++ supplement and Multivitamins. Which help rebuilding bones.
RECTAL EXAM: Later today I will perform a Rectal exam, which include finger insertion inside rectum to feel any potential abnormality
such as size of prostate/ Cancer. Is that OK? (if u have time u can add by saying thisprocedure is little uncomfortable but not painful)
ORTHOSTATICS: Later today I will also perform your orthostatic BP (explain it) and other exam.
OBESITY: I am concern about ur wt, it seems to me higher for your age and height. Have u ever been on diet?
well Mr Smith I would like u to seriously consider abt having diet for wt loss because over wt can cause serious condition such as Heart/
vascular problem, sleeping problem, breathing problems, Fatigue, Bone pain, even tumors.
Please give yourself a serious thought and in next meeting I will talk in more detail about it. Ok?
PHYSICAL ABUSE: Ms Smith I am concern about your security at home, I like you to talk with your family/ friends and inform them
about your situation and concern. I also want you to plan some exit strategy in case you feel imminent threat to your safety. In addition I
will leave my Tel # in case u need it, feel free to call me immediately.
Remember no one has right to hurt you physically/ mentally. Would u like to meet our social worker to help u in this?
DIET FOOD/ HEALTHY FOOD: Mr Smith I think your diet is the one of the cause of your Sxs, I like you to consider seriously about Diet
change, such as eating healthy food / vegetable/ and food rich in fiber etc. This will help you resolve many things specially the
constipation that you have.
Mr Smith I Think you must think about diet that is low in cholesterol and salt, this will help you controlling lots of your core issues such
as high cholesterol/ obesity/ vascular problems etc.
EXERCISE: Mr Smith I also like u to have reg exercise which will improve ur health in terms of mobility/ better circulation/ mood etc
TRAVEL: Mr Smith did you get your vaccination completed before you travel. > Which ones ?
Mr Smith I want you to have some vaccination and prophylaxis before you travel, such as HBV/ Pneumonia/ YFV etc and
also Antimalarial prophylaxis. OK ?
DO I HAVE CANCER: Well Mr Smith this is one of the possibility and since you have + ve family Hx, I will make sure that I am indicating
all the necessary tests to rule out this potential cause. OK? Is that answered your Q ?
WILL I LOSE MY UTERUS: Well Ms Carla, Even though chances are too low for this possibility, I will make sure that I will indicate all the
necessary test and procedures to rule out your concern, Ok ? Is that ans your Q ? (later do counseling for procedure that you will
indicate)
Talkative pt: Sorry Mrs. Brown I understand how imp those issue are for you but I am more concern about your current health situation;
so lets talk about your health for now.
Silent Pt: I understand u going through tough time, would you like to share with me, I am here to help you (little pause) together we can
do it. (Offer napkin waits for 2 or 3 seconds and ask what make u feel this way)
I understand this must have been very difficult time for you. Please tell me more about it.
I understand you feel sad would you like to tell me about it.
RECOGNIZING RESPONSES TO THE SP :
1- Mr. Smith: I see youre coughing, May I give you water or napkin?
2- Mr. Smith: I see a lesion on your face, what is that? how that happen?
3- Mr. Smith: I see youre holding your chest, are you in pain? Is there any thing I can do comfort u?
4- Mr. Smith: I see your hand is shaking, how long u have this condition?
5- Mr. Smith I noticed that ur speaking in very low voice, Is there any reason for this?
6- Mr. Smith I noticed that ur eyes are closed, Is that light is bothering u? Ask further about it. May I dim the lights?
7- Mr. Smith I noticed u r little flaccid, is there any reason for it? Are u feeling any weakness?
8- Mr. Smith I noticed that ur little anxious, is there any reason for it? Do u have any concern?
9- Mr. Smith I noticed u r wearing this maxican hat, have u traveled some where recently?
10- Mr Smith I noticed that ur holding both hand b/w ur thigh, are u cold?
You should recognize and respond to any obvious acting immediately.
Remember every action of the SP is PURPOSEFUL.
Be careful with the pts that have Hearing Problems: dont ask questions while youre washing your hand because theyre not going
to be able to hear what youre talking about.
Remember to offer a glass of water in a pt that has a cough.
Remember to use Fundoscopy in : HTN, DM, and Visual complaints.
PREGNANCY : regardless of the menstrual Hx given by the pt, suspect pregnancy in a woman of childbearing age who has
unexplained weight gain.
In a back pain or musculoskeletal pain we should start the HPI with the age and the occupation of the pt.
Remember Passing out = spell = blackout = LOC = syncope
Any case of abdominal pain, remember to ask about relation of the pain with food intake.
Remember says: thank you Mr. Smith you have been very cooperative. I have tested all your CN and theyre all right.
Epigastric pain ask about: jaundice, black stools, blood on the stools, postprandial fullness (bloating), early satiety.
Trembling hands = tremor sweaty palms = sweating , shakiness = seizures
Remember in any case of LOC , ask about : Did you passed urine or stools without your knowledge?
Dark Urine: Ask did u eat any food that could cause this change in color (berries, colored candy, beets, B comp?)
Remember to ask in any case of dark stool: Have you taken any iron supplements, beets, or Pepto-Bismol ?
Remember any pt with Chest Pain : on workup , include: Cardiac Stress Test( treadmill)
Remember to ask in any case of fatigue about: bruises, rash, hair loss, cold or heat intolerance, sexual interest( sexual drive), any
change in voice( hoarseness), any support system at home( from families or friends)
Pulses: 2/4 = normal, 3/4 = full , 4/4 = bounding (aneurysm, calcification)
Depression, insomnia or fatigue, Ask: Do u have anyone who can provide support and care u need at home?
s/p = previous condition , Stat = immediately, capillary refill ,nl = < 5 secs.
IMPORTANT NOTES :
Dont raise eye brows or frown.
Avoid phrases or words like Good. A simple Thank you or Okay is often sufficient.
Patient should not feel rushed. Quietly wait for the patient to complete each answer. Dont fill in words for the patient; the answer
should be in his or her own words.
Remain connected and purposeful during physical examination
DO NOT shake hands if pt lying down in pain or shoulder pain
DO NOT say the diagnosis first thinking that you can explain it after...SP jump and say what is that?
DO NOT SAY trauma...say accident. DO NOT give your back while washing hands
DO NOT SAY ...I dont know....say I do not know YET
DO NOT ignore pt efforts to take care of his health....congratulate him
DO NOT RUSH during the first 1 or 2 minutes,....take time so SP adapt to you
DO NOT stay stand up if pt is laying down,...is better if you seat and your eyes are same level to pt.
DO NOT forget to reassure and use the word.....let me assure you....
DO NOT move the pt unnecessarily...or too much
DO NOT write the chief complain in medical terms
DO NOT forget to say....DID that answer your question...do you have another question
DO NOT forget to paraphrasing. DO NOT use leading questions/ DO NOT repeat questions.
DO NOT put the pen in your mouth......careful if u have this tendency
DO NOT sound like robot. DO NOT say ok to everything....are your parents alive? No my dad has cancer....OK
DO NOT be afraid to make the pt repeat if he said something that you could not understood
DO NOT forget about the impact of the illness in his personal life
HISTORY PEARLS
1 - Ask about thyroid symptoms in: weight changes, depression, amenorrhea
2 - Abdominal pain: ask about black or tarry stools
3 - Abuse: ask about emergency plan, if family and/or friends know about what's going on
4 - Bruise, depression: ask about abuse
5 - Chronic cough: ask about HIV, TB, ACE inhibitors use
6 - CNS case: ask about previous stroke, migraine, seizures, syphilis
7 - Dizziness: ask about tendency to fall towards left or right
8 - Depression: ask about guns and pills at home, auditory hallucinations
9 - DM: ask about vision, sensation, ED, counsel about foot care
10 - Forgetfulness: ask about ADLs (activity of daily living), social support, head trauma, depression, syphilis
11 - Jaundice: ask about urine and stools color
12 - Hearing loss: ask about exposure to loud noises
13 - If you have to say "I don't know", say "I don't know yet!"
14 - Insomnia: ask if the problem is falling asleep, staying asleep or waking from sleep; frequent movements of legs, hot flushes;
order sleep diary for 2 wks (rule out obesity/ snore / difficulty breathing)
15 - Menopause: ask about mood swings, family breast / uterine cancer history; counsel about weight bearing exercises (osteoporosis)
16 - Palpitations, insomnia: ask about caffeine intake
17 - Ob/gyn case: ask details about periods, cycles, intercourse, pap smear
18 - Rash: ask about sun exposure, ticks, mosquitoes bites
19 - Pain in hand: ask about repetitive movements, such as operating a key board
20 - Obesity: ask about joint pain, hypercholesterolemia (Rule out Insomnia/ snore/ difficulty breathing)
21 - SOB: ask about wheezing, orthopnea, PND
22 - Swelling: ask about diurnal variation
23 - Psychiatric cases: always check social support, offer social worker help
24 - Thyroid problem: ask about change in voice
25 - Trauma in elderly: ask about abuse

26 - Vomiting: ask about fever, headache, if it is projectile; if yes for any, do a fundoscopy
PE pearls
1 - Any bleeding: order orthostatics
2 - DM: fundoscopy, test sensation and vibration, pulses, auscultate carotids, examine feet
3 - Dizziness: order orthostatics
4 - COPD: check sinus, do a complete cardiologic exam
5 - Confusion, forgetfulness: auscultate carotids, MMSE, fundoscopy
6 - Insomnia: check thyroid, DTRs
7 - Lower back pain: straight leg raising test, lumbosacral range of motion, gait, order rectal exam including "saddle area" sensory
exam, DTRs in legs
8 - Palpitations: check thyroid, extremities tremor, DTRs
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HISTORY TAKING : Start with OLDFPQIR (OLD Fat Patient Querulous In Room)
PAIN :
O 1. When did it start ? (after this always ask, Please tell me more about it? / How did it start?)
L 2. Where exactly the pain is can you show me with one finger?
D 3. How long does it last?
F 4. How frequent pain appears (how frequent it comes and go)
P 5. Is it progressive? (or getting better/ same)
Q 6 . What is the pain like? How does pain feel like ?
I 7. On the scale of 1 to 10 where 10 is worst pain of ur life, how do u grade ur pain?
R 8. Does pain travel to other part of ur body?
All /Exa: what do u do to make it better. What makes it worst?
9. How do u feel about it?
>>> Ask how do pt feel abt it & than must Sympathize here <<<
10. Does those Sxs effecting ur ADL?
>>>>>>>>>> Must sympathize again <<<<<<<<<<
NAUSEA:
1. Is there any other Sx u feel?
2. Do u feel nauseated? (do feel sick to ur stomach)
VOMIT:
1. Did u vomit or throw up?
2. How many times?
3. what color was vomit? Was there any blood in it? (what were the contents?)
4. Is it possible u can tell me the quantity
>>>>>>>>> must sympathize here <<<<<<<<<<
Does those Sxs effecting ur ADL?
>>>>>>>>> Must sympathize here <<<<<<<<<<
COUGH:
1. How long ur having the cough? (after this always ask, please tell me more about it > How did it start?)
2. How often do you cough?
3. Does any thing come up when u cough? (such as phlegm or is it dry > Is it positional?)
4. What color is it? Did you notice any blood in it?
4. Can you estimate the amount of phlegm? For eg 1 tea spoon or table spoon or a cup full?
5. Is it progressive ?
6. Do u feel any problem in breathing?
7. What makes you feel better? What makes it worst?
>>>>>>>>> Must sympathize again <<<<<<<<<
>>>>>>>>> Must sympathize here <<<<<<<<<<
HEADACHE:
1. First Make sure pt is comfortable ask for if pt wants light to be dimmed / water / or cold (need to be cover)
2. When did ur HA start? (after this always ask please tell me more about it > what cause it to start?)
3. How does ur HA feel like? (sharp, dull, pulsating, pounding, pressure like)
>>>> Must sympathize here <<<<
3. Have u ever had similar Sxs before? (or How long ur having HA?)
4. How long does it last?
5. How often u get them?
6. Can you tell me where exactly the pain is? (Is it always like that or prefer half side/ Rt side etc)
7. Do u feel any thing else during the course of HA? > Before it or after it?
8. Is it time specific? (such as certain time of the day or week)
9. Does it occur in certain situation / environment? (such as at work place, during exercise)
10. Does it wake u up during the night?
11. What do u do to make it better. What makes it worst?
>>>>>> must sympathize here <<<<<
12. Did u notice any other Sxs with HA?
13. Did u notice any Vision change, Numbness/weakness, Nausea/ vomit, Stiff Neck, Involunteer muscle movement.
>>>>>> Must sympathize again <<<<<
FEVER:
1. Do u have fever or chill? > How often do u gets it? > How high does it goes?
2. Do u experience any night sweats?
3. What do u do to relieve it? (any medication if yes which one and how often)
SOB:
1. How long ur having this? (plz tell me more about it > How did it start?)
3. In which phase ur having the breathing problem? Like when u breath in or out?
4. Do u hear any thing with SOB? (such as wheezing, crackling sound or any thing else)
5. How many steps u can climb before get short of breath?
6. How many Block on ground level u can walk before u get SOB?
7. Is there any thing come up when ur SOB? (if yes what is it, what is look like, color / rule out GERD)
8. Does it occur at any specific time? Does It wake u up during night time? (If yes How many pillows u use)
9. What do u do to make u feel better? What makes it worst?
>>>>>>>>> Must sympathize here <<<<<<<<
10. Did u noticed any swelling around ur ankles?
11. (Must ask) How do u feel about it?
>>>>>>>> Must sympathize again <<<<<<<<
BOWEL Sxs: (must mention/ write Rectal exam > do counseling)
1. How long ur having this problem? (than ask plz tell me more about it > How did it start?)
2. How many bowel movement do u have per day?
3. What is the color of ur stool?
4. Did u notice any change in consistency of ur stool? (Whether it is hard, soft, watery) ?
4. Did u notice any change in the caliber of ur stool?
5. Did u noticed any blood or mucous? (if yes is it bright red or black)
6. Do u feel any thing else before /during defecation? (such as pain, light headedness)
7. Do u feel as though u have urge to go to the bathroom but very little or nothing comes out?
8. Do u feel u have very little time to make it to the bathroom once u have urge?
9. Have u ever lost control over ur bowel?
10. What did u eat before ur Sxs start? OR Do u think that there is any relation of ur food with ur Sxs?
11. Did u travel any where recently?
12. What makes u feel better? What makes it worst?
>>>>>>>>>>> Must sympathize here <<<<<<<<<<<<<
12. How do u feel abt ur condition /problem?
>>>>>>>>>> Must sympathize again <<<<<<<<<<<<<
URINARY Sxs: (must mention Genitourinary exam/ Rectal exam > Counseling)
1. How long ur having this condition / problem? (than say plz tell me more about it)
2. What color is ur urine ? (have u noticed any blood/ pus/white material before, during or after urination)
3. Do u have any difficulty urinating. (Do u feel that u need to strain / push in order to urinate?)
4. How u explain the stream ? (is it weak / dribbling or do u feel any obstruction while urinating)
5. How often do u urinate? (all the time or under certain stressful condition)
6. Do u feel any thing else when u urinate? (such as pain, burning sensation)
7. Does that pain travel some where to ur body?
8. Are ur Sxs more pronounced at some sp time? (such as day or night)
9. Do u feel that u havent completely emptied ur bladder after urination?
10. Do u feel as though u have urge to urinate but then very little urine comes out?
11. Do u feel as though u have very little time to make it to the bathroom once u feel urge?
12. Have u ever lost control over ur bladder?
12. Do u have any physical / mental limitation that is causing u those accidents?
12. What makes u feel better? What makes it worst?
>>>>>>>>>> Must sympathize here <<<<<<<<<<
13. How do u feel about it ?
WEIGHT: (Ask abt body image/ HIV risk factor) (In wt gain must ask smoking cessation/ depression/ body image)
1. Have u noticed any change in ur wt?
2. How many lbs?
2. Over what period of time?
3. Was wt loss intentional?
APPETITE:
1. How is ur appetite?
2. Have u noticed any change in it?
DIET:
1. What do u usually eat?
2. Is there any kind of special diet ur following. 3. Do u eat unusually late ? (ask in pt with heart burns? > how earlier before sleep?)
DIZZINESS:
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1. How long ur having this problem? (plz tell me more about it > How did it start?)
2. What do u mean with dizziness could u plz explain it?
3. Was it room spinning around u? Was it light headedness like u will pass out? Or was it complete Black out?
4. What were u doing when u experienced dizziness?
5. How long the episode last?
6. How often dizziness occur?
7. Did u loose consciousness? Did u noticed any palpitation with dizziness?
8. Did u noticed any change in ur hearing? (such as ringing, hissing or pressure)
9. Did u noticed any strange smell before it? (olfactory Hallucination)
10. Did u feel nauseated/ vomit?
11. What did u do to make u feel better? What makes it worst?
>>>>>> Must sympathize here <<<<<<<
12. Did u noticed any loss of control over Bowel or urine?
13. Did u noticed any involunteer movement of any part of body?
14. Did u noticed any sweating?
15. Did u feel any pain before it?
16. Do u have any stressful job or working environment?
17. Any recent sickness?
17. What do u think might causing it?
20. Does dizziness causing any effect on ADL?
>>>>>> Must sympathize again <<<<<<<
PALPITATION:
1. How long ur having this problem? (plz tell me more abt it > How did it start?)
2. Have u ever had those Sxs before?
3. What u were doing when palpitation occur?
4. Does it occur during any specific time or situation?
5. How often does it occur?
6. Is it progressive? Or same?
7. How do u feel when u have such episode?
>>>>>>>>>>>> Must sympathize here <<<<<<<<<<<<
8. Do u feel any other Sxs along with palpitation? (such as pain/ feeling of being doomed/ sweating/ panic etc
9. What do u do to makes it better? What makes it worst?
10. Does palpitation causing any effect on ADL?
>>>>>>>>>> Must sympathize here <<<<<<<<<<<<<<
SLEEP: (obstructive sleep apnea/ stress & caffine induced insomnia/ sleep disorder/ depression/ Primary hypersomnia)
2. How many Hrs do u sleep?
(check if pt is obese, hypo/hyperthyroid, depression / stress, drink high caffeine)
2. What do u think where exactly the problem is; falling a sleep, staying a sleep or waking up?
3. Do u snore?
4. Do u feel sleepy during the day?
5. Is it progressive?
6. How is ur energy level? (If it is low ask loss of interests/ social activity/ job/ stress/ hygiene/ suicidal thoughts etc)
7. What makes it better? What makes it worst?
>>>>>>>> Must sympathize here <<<<<<<<<<
8. How do u feel abt it? (Rule out any crying episode/ PTSD/ Anxiety/ Recent trauma/ self esteem etc)
8. Does sleeping problem cause any effect on ADL?
>>>>>>>> Must sympathize again <<<<<<<<<<
JOINT PAIN:
11
1. How long ur having joint pain? (plz tell me more abt it > How did it start?)
2. Is it any sp joints? Is it migratory?
3. Do u feel any other Sxs beside with joint pain? Is there any Rash/ redness /swelling of any of ur joint?
4. How long pain last? Is there any pain free period?
4. Are ur Sxs time specific? (such as they are more pronounced in evening or early morning when u wake up)
5. How often does it come? 6. Is it progressive ?
6. Can u explain the pain how is it feel like? (sharp/ aching/ burning/ throbbing/ electric like)
7. On scale of 1/10?
8. Does that pain travel to some other part of ur body?
9. Any recent Illness/ infection/ bug bite?
10. What makes pain go away? What makes it worst?
>>>>>>>>>> Must sympathize here <<<<<<<<<<
12. Is that pain causing any limitation in ur ADL?
13. Must ask Obgyn in female.
PSY HX:
2. How / What do u feel ? would u like to share it with me?
<<<<<<<< Must sympathize earlier >>>>>>>>
3. Why do u feel that way (sad/unhappy/anxious/confused), could u plz explain it more?
3. Have u or ur love one had experienced any traumatic event or accident? who do u think is responsible for that?
4. Do u feel comfortable right now? Is there any thing that I can do to make u feel more comfortable?
6. Tell more abt ur self and future goal? > Tell me how do u spend ur time per day?
7. Do u have any idea what might be causing it?
8. Have u noticed any change in ur sleep pattern? (ask problem in falling a sleep/ staying a sleep/ waking up/ snore?)
9. Do u enjoy the thing that u use to enjoy?
10. Is that problem effecting ur ADL (activity of daily living)? <<<<<<<< Must sympathize here >>>>>>>>
11. Do u have any memory problem? Is it interfering in ur daily activity? (name 3 objects & ask later)
12. Do u have difficulty concentrating? (test concentration by asking time/place/person)
13. How is ur energy level?
14. How do u see the future? Do u have any hope? (hopeless! Ask why is that)?
15. Do u feel guilty abt any thing?
16. Do u have any thoughts to harm ur self or others?
17. Do u have any plans for it? (If yes Would u mind telling me abt it?)
18. Do u hear or see things that other cant hear or see?
19. Do u hold any belief that other ppl find it odd? (if yes what is it)
20. Do u think that other ppl are trying to harm u?
21. Do u think that other ppl are trying to control u?
22. Did u notice any appetite change?
23. Did u notice any wt change? Was it intentional? How much?
25. What thing make u feel better? What makes it worst? (Flash back?)
26. ROS: (including recent travel, infection, past similar Sxs)
27. SH: What do u do for living? How is ur performance at job? Any problem there?
28. Do u have any financial problems?
29. Whom do u live with? > How do they react to ur condition? > Are they supportive?
30. Does any one supports u in ur family or friends? Do u have any family or friend u can talk to? (if yes than whom)
31. Do u drink EtOH? Do u consume tobacco? How many PPD? Do u use any Illicit drug/ Caffine ?
32. How is ur diet? Do u do exercise?
32. If u find self addressed envelop on side walk, what would u do? (check judgment)
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33. Would u like to meet our Social worker to help u with ur issues? <<<<<< Must sympathize again >>>>>>
34. Would u Like to join the Support group? if yes encourage pt by saying that u have made the right decision.
DEMENTIA HX:
2. How did u notice it? (if pt say my wife told me than ask what did she say)
3. Did u notice any other changes in ur health or body?
4. Ok I will tell u 3 names of an object and after 5 min I will ask u to tell me those names?
5. Tell me abt ur yesterday, how was ur day and what did u do?
6. What do u do to make it better? what makes it worst?
7. Have u ever been lost and was not able to come back home?
8. Do u still able to maintain ur Bank account / driving / doing grocery?
9. Do u need help preparing food and feeding ur self?
10. Do u need any help in ADL such as getting out of bed/ bathing/ toilet /dressing / doing laundry?
11. Do u need help taking medication on time?
12. Is there any other Sxs u feel beside that? (ask general health/ gait/ any accident that he remember etc)
12. If u find self addressed envelop on side walk, what would u do? (check judgment)
12. Let me do ROS OK? (ask all Qs from head - Toe, including recent travel/ infection/ gait/Chronic illness/ vision etc)
13. MED/ALL.
14. PMH (also any similar problem in family and relatives).
15. FH.
16. SH (Rule out Abuse/ stress. ask social activity).
17. SxH
ABUSE:
1. Can u tell me abt ur bruises on ur arm? > How did it start?
1. Are u safe at home? (Must inquire abt safety of children at home)
2. Do u feel any threat to ur personal safety else where?
3. Must inquire abt presence of fire arm at home?
4. Does anyone threat to hurt u? (correlate story with body signs and Sxs)
OBGYN:
1. How old were u when u get ur first menstruation?
2. How often do u get ur periods?
4. When was the first day of ur LMP?
5. Have u noticed any change in ur period?
6. Do u feel any discomfort during periods? (such as pain/ cramps)
7. How do u describe the flow (low/med/heavy)? > How many tampons u use daily?
9. Have u noticed any spotting between periods?
10. Have u ever been pregnant? (if yes how many times)
11. How many children do u have? (if yes ask about NSVD vs. C- Section and also ask for any complication)
12. Have u ever had any miscarriage or abortion? (if yes ask in which trimester and why)
13. Do u have any problem during intercourse? (if yes rule out fear vs. real problem)
14. Do you have any vaginal discharge? (if yes what color is it and How does it smell like)
15. Do u have any problem controlling ur bladder?
16. Finally ask Last Mammogram and Pap smear? (Ask about the result and dont forget to counsel)
17. ROS: (must ask travel Hx / past similar Sxs/ nipple discharge/ voice change/ hirsuitism etc)
18. Do u have any stress at home / work place?
19. Ask diet rule out Anorexia nervosa/ Bulemia? Also rule out Vigorous exercise/ athlete)
PED HX:
13
First ask why he or she is not able to bring the child to hosp? (for any reason counsel appropriately)
Ask what is ur relation ship with the child?
1. What is the childs name?
2. How old the child is?
3. Now ask all the Qs related to CC. (must rule out rash/ recent travel/ pet/ infection/ bug bite)
4. Than ask if she is having any trouble with caring a child? <<<<<<< sympathize and counsel here >>>>>>>>>>
ROUTINE CARE:
1. Are ur childs immunization up to date?
2. When was the last routine check of ur child? > how was that?
3. Has ur child had any serious illness beside the current problem?
4. Is ur child taking any medication?
5. Does ur child have any allergies?
6. Has ur child ever been hospitalized/ any surgeries?
7. Is there any disorder or illness runs in the parents or relative?
8. Does he go to Day care or school?
FEEDING HX:
1. Did u breast feed ur child? > for how long?
2. when he started the formula? > Is it fortified with Iron? > Is he taking Pediatric Multivitamins?
3. How is ur Childs appetite? > When did ur child start eating solid food?
PREGNANCY HX:
1. Was ur pregnancy full term? > Did u have routine check up during ur pregnancy?
3. Did u receive U/S evaluation during pregnancy? How was the result?
4. Did u have any complication during pregnancy?
5. Any complication during birth process or after it?
6. Was it normal delivery or C-section?
7. Did u use any medication during pregnancy?
8. Did u smoke or drink during pregnancy? Did u use any Illicit drugs?
9. Did ur child have any medical problem after birth?
10. When did ur child have first bowel movement?
11. Were all the milestones on time and appropriate? (such as Smile/roll over/ sit crawl/talk/walk/dress/laces/hop etc)
1. Acknowledge her efforts in care.
<<<<<<<< Sympathize and Encourage here >>>>>>>>
2. Counseling and awareness is very imp in this case.
3. Explain ur impression what could happen possibly.
4. Counsel about OTC medication if needed
TRAVEL Hx: 1. Have u traveled recently? Or Do u have travel plans? (if yes where and r u vaccinated dont forget counseling)
---------------------------------------------------------------------------------------------------------------------------------------------
Start with OLDFPQIR (OLD Fat Patient Querulous In Room)
14
O (onset) ------------ When did it start ? How long you are having pain ? (Also ask how did ur pain start? imp)
L (location) -------- Could you plz point it with one finger where exactly do u feel it ?
D (duration) -------- How long does it last ? How long does single episode last ?
F (frequency) ------- How frequent is it ? (Constant vs. Intermittent)
P (progression) ---- Is it getting Better or Worst or Same ?
Q (quality) ---------- Can u describe the pain how is it like ?
I (intensity) --------- Scale of 1/10.
R (radiation) ------- Does it travel to some other part of the body ?
All/Exa F ------------ What makes it better ? What makes it worst ? >>>> Must sympathize at this point. <<<<<<
Asso Sxs ------------- Fever/ chill/ sweating, N/V, HA, Vision problem, Hearing problem, unusual smell, dizziness/
Loss of balance/ pass out / Involunteer muscle movement. difficulty swallowing/ change in
voice/ heart burn, Appetite /wt change, any mass/lump in body, skin Discoloration / dryness,
SOB, Palpitation, Nipple discharge, abd discomfort, bowel problem, urinary problem, past
similar sxs. Recent illness/ travel/ trauma/ bug bite/ new pet. Muscle pain, Bone /joint pain.
Mood (sad happy), energy, Recent incident / accident in life, Impact of illness in life. Sleep.
Denial ---------------- (write only that is denied while asking Asso Sxs and mentioned in ur pt notes)
Obgyn --------------- Ask Menarche + Regularity + Duration + Flow + LMP
Ask Change in flow / Cramps / # of tampons.
Ask Intermittent Bleeding / Vaginal discharge / Pain on Coitus.
Ask # of Pregnancy / Abortion (if yes which trimester/ D&C?)
Ask # of Children (if yes NSVD / C - Section)
Ask Last Mammogram / Pap Smear. (if Yes how were the results) (Do counseling)
Medi/ All ------------ None / NKA
(also ask herbal/ other types)
PMH ----------------- Any other morbidities (if yes inquire from how long)
FH -------------------- Parents/ relatives (If parents are deceased say sorry to hear that and find out cause of death)
SH -------------------- Occupation. Marital status/ childrens.
Support System/ safety (Do u live with family/Alone ? Does any Friend know abt ur condition)
EtOH / Tobacco / Illicit drugs/ caffeine/ Diet / Exercise.
SxH ------------------ Before I go any further I wants to assure u that our conversation will be confidential by all mean.
Mono/ polygamous/ Sexual Orientation. Use of contraception. Hx of STDs. HIV test. ( do counseling id needed)
15
PHYSICAL EXAM NOTES:

Pt appears NAD/ polite/ cooperative, Good Eye contact. Good historian.
Mild distress, Aggressive, uncooperative, poor eye contact/ historian. OR Anxious, Eager to leave. etc
VS: WNL except ------------ .
HEENT: AT/NC. PERRLA /EOMI. No mass/ NL vascularity on Fundoscopy. Visual field intact.
No Conjunctival injection. No mass/erythema/exudate observed on ENT exam
Rennie test - ve. Weber test - ve (w/o lateralization)
MOUTH: Moist mucous mem, Good dentition, No mass/erythema/exudates observed.
NECK: Supple, No JVD/ carotid bruits, NL Thyroid in size/ consistency, No Cervical LAD.
CHEST: Normodynamic. BS CTA BL. No tenderness/ dullness on palpation. Percussion/ VTF NL BL.
No axillary/ cervically /supraclavicular LA
HEART: RRR, S1 S2 NL, No R/G/M. PMI not displaced.
ABD: BS +. Soft NT/ND/T in all 4 Q. No mass /HSM. No CVA discoloration/tenderness.
Murphy sign - ve. Or RUQ pain w/o Rebound /tenderness. Or Generalized abd pain in all4 Q on deep palpation.
Psoas sign - ve.
Obturator sign - ve.
EXT: No rash/ ulcer/ deformity/edema. Pulse 2/4 BL. DTR 2 + BL. Good hair distribution.
Motor Strength 5/5 in all muscle group. Sensation to pin prick/ soft touch intact. Gait NL.
ROM w/o tenderness and difficulty in all direction in all muscle groups; OR except -----------.
MCP/PIP joint mildly tender on palpation. No swan neck deformity /nodules /swollen tendon noted.
No effusion/ swelling/ warmth.
Varicosities present BL.
SKIN: No Rash/ edema/ clubbing/ cyanosis or erythema/ dryness. (mention if there is tattoo or surgical scar)
NEURO: CN II - XII intact. Pulse 2/4 BL. DTR 2 + BL.
Motor Strength 5/5 in all muscle group. Sensation to pin prick/ soft touch intact.
Romberg - ve. Babinski - ve. Gait NL.
Kernigs sign + ve and Brudzinski sign + ve (for meningitis)
MENTAL STATUS: Rt handed. Good Concentration (distant memories are impaired)
1. Date / year / Season / Place -- A/O X 3
2. Name three object ask to repeat than ask after 5 min -- Language, Registration 3/3 , Recall 3/3. (R/R 3/3)
3. Serial 7s -- 1/5
4. 3 step command --2/3
5. If u find self addressed envelop on side walk what would u do? (checks judgment)
6. Write a sentence
7. Copy the design..
8. Look at the sentence and do that.
LEVEL OF CONSCIOUSNESS : Alert, lethargic, stuporous
Affect -- Full Range
Blunted: patient does not display emotion; answers in a monotone may speak slowly, etc.
Labile: changes in a rapid, abrupt, excessive way
Persistent: persists unduly long-laugh too long
Mood: describe depression, dysphoric, euthymic, hypomanic
Anxiety: fearful anticipation which is not attributable to real danger (palpitation, dry mouth, swearing, trembling etc)
Apathy: total loss of emotion
MUSCULOSKELETAL EXAM:
16
SHOULDER PAIN:
Neck: Supple. NT Lat bending/ extension. Foramina compression test - ve. Distraction test - ve. No LAD.
Chest: normodynamic. No mass/ LAD in supraclavicular region.
Shoulder: No erythematic/ swelling/ dislocation observed. Active ROM NT in all direction
- Motor strength 3/5 in Rt arm and 5/5 in Lt arm. Sensation to D/S/V Intact BL. Pulse 2/4 BL. DTRs 2 + BL.
- Apleys Scratch test - ve (Rt arm reach T4 & Lt arm reach T7)
- Apprehension Relocation test - ve (also called Ant stability test and post stability test)
- Sulcus sign - ve (also called Inferior stability test). Speeds test - ve. Yergasons test - ve.
- Jobe test - ve (also called empty can test)
- Gerber lift off test - ve
- Drop arm test - ve.
- Hawkin/kennedy test - ve
- Neer test - ve (scapula stable + Rotate arm up and down)
- Cross arm test - ve.
KNEE PAIN:
- No Erythema/ swelling/ dislocation observed.
- Motor strength 4/5 in Rt knee. 5/5 in Lt knee. Sensation to D/S/V intact BL. Pulse 2/4 BL. DTRs 2 + BL.
- Tender ROM on flexion and extension.
- NT patellar Glide/ compression.
- Valgus/ Varus stress test - ve.
- McMurray test - ve.
- Ant / Post Drawer sign - ve.
- Patrick faber test - ve. - Piriliformis test - ve.
- Gait antalgic.
BACK PAIN:
- No discoloration/ swelling/ mass observed on Lumbosacral area.
- Paravertebral tenderness on palpation b/w L3 - S1 (lumbosacral area)
- NT vertebral spinous processes.
- Straight leg raising test + ve at 10 degree. Passive leg raising test + ve at 20 degree.
- Bragard sign - ve (checks Sciatic nerve root)
- Bow string test - ve (check Tibial nerve root)
- Hoover test - ve (trick test)
- Tender ROM at lower back in all direction.
- Motor strength 3/5 in Rt leg, 5/5 in Lt leg.
- Sensation to D/S/V intact BL.
- Pulse 2/4 BL. Gait antalgic / posture slightly bend forward.
HIP PAIN:
- Gaenslen test + ve (roll up good leg with chest while pt is in laterally lied & hyperextend bad leg)
- Joint stability test - ve.
- Trendelenburg sign - ve
- Flamingo test - ve.
WRIST PAIN:
17
HEENT: AT/NC. PERRLA /EOMI. No mass/ NL vascularity on Fundoscopy. Visual field intact.
NECK: Supple. NT Lat bending/ extension. Foramina compression test - ve. Distraction test - ve. No LAD
Upper Ext: No mass/ erythema/ exudate/ swelling/ dislocation observed.
NT ROM in all muscle group BL except Rt wrist tenderness on palpation.
Muscle strength 5/5 BL. Sensation to D/S/V intact BL. Pulse 2/4 BL. DTR 2+ BL.
Tinnel test + ve.
Phalen test + ve.
DVT:
- Homans sign + ve (dorsiflexion of foot > pain in calve)
- Pratts sign + ve ( squeezing of post calve > pain)
REMEMBER BE COURTEOUS, CONCERNING, EMPATHIC AND COMPASSIONATE ALL THE TIME.

YOUR GESTURE MUST REVEAL HUMBLENESS, KNOWLEDGE AND HELPING NATURE ALL THE TIME.
GIVE SMILE WHEN APPROPRIATE; BE SERIOUS WHEN ENCOUNTER REQUIRES IT.
WHEN YOU WANT PT TO LIE DOWN HELP HIM IN LYING DOWN BY SAYING LET ME HELP YOU (SP WHEN PT IS OLD).
TRY TO CREATE FRIENDLY BUT CONFIDENTIAL AND TRUSTFUL ENVIRONMENT.
IF PT IS RUDE TELL HIIM, I UNDERSTAND YOUR SITUATION AND I WILL TRY MY BEST TO HELP YOU OUT IN THIS.
I RECOMMEND GIVE AT LEAST 13 MINUTES EVEN THOUGH IF U THINK U R DONE.
Remember do not take vital signs again, take door information as its yours.
GOOD LUCK IN YOUR EXAM
18

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KICK THE BOARDS

15 MINUTES CONVERSATION NOTES

KICK THE BOARDS. USMLE STEP 2 CS.