Understand this well please. This is  not the style you practice in the Step 2 CS but it is the basis of the summary you will create.

How is a case presented? It is quite like other countries but  since I have worked in 4 countries, I am going to outline this here for the Step 2 CS.

The Chief Complaint (CC):
One sentence that covers the main reason(s) for the visit.  (Sometimes I ask the patient who has multiple complaints - "What is the problem that you want sorted out most importantly" - or "If I could help you with only one thing today, what is that complaint?"

"Mr. Jones is a 45 yo white male with dizziness for 4 days."

This can also be written as

"Mr. Jones - 45 yo WM C/C Dizziness X 4D"

History of Present Illness (HPI):
The HPI should provide enough information without being too inclusive.

For instance, in a case with dizziness, one is concerned about heart, ear, cerebellum and vestibular nerve mechanism. Important negatives/positives  would address chest pan, SOB, nausea, vomiting, diaphoresis, tinnitus, hearing loss, ear discharge, nasal stuffiness, recent viral illnesses, drugs that decrease BP or those that cause vestibular side effects like NSAIDs, Gait disturbance, falls, head injury, stroke history.

Standard features like time frames of worsening, severity, alleviating and provoking factors, diurnal variation, positional variation, etc must be there.

Important facts that impact the thought process towards or away from different differential diagnoses should be included.

For instance, in a patient who is having a GI bleed, history of Warfarin/NSAIDs is important.

Occasionally a patient may have two unrelated problems on the same visit and both may be important. In such cases present each with its own HPI.

For the Step2 CS purposes, there is no reason not to do so.

Past Medical History (PMH):
List the past history. Important PMH to include depends on the current scenario. For a man with dizziness a negative to be recorded would be stroke/diabetes/MI/Meniere's ds etc.

Do list all positives and then either in the same or separate heading, put past surgical history.

"T & A" is tonsillectomy & adenoidectomy
"Appy" is appendectomy, "Lap chole" is laparoscopic cholecystectomy etc.

Past Surgical History (PSH):
All past surgeries should be listed with the approximate date.

Medications (MEDS):
List current medications, dosages and frequency. Knowing reasons for meds are helpful. Do not forget to ask about OTC/"Herbs" and specifically ask young women about contraception as most forget about BCP/patches/shots.

Allergies/Reactions (All/RXNs):
Note the medications with the type of reaction.

Social History:
This is a broad category which includes:

• Occupation, type of work & exposures.
• Smoking (pack years - meaning for a person who smokes t packs of cigarettes for the past 5 years, he has a 10 pack year history ( i.e. 2 packs x 5 years = 10 pack years)
• Alcohol (quantity, frequency & duration - if excessive, then go into greater detail like time of starting in the course of a day -  eye opener drink etc)
• Illicit drug usage (IDU) like Pot/cocaine/heroin etc. Last usage and frequency.
• Marital Status: Single/single with partner living together/married/divorced/separated/widowed etc.
• Kids and their wellbeing (this may appear in family history)
• Sexual History:
• Other....e.g. pets, hobbies, travel

Family History:
Cancer, MI, DM, HTN, CVA problems related to present illness. Parents and children - A&W means alive and well.

Obstetrical History (where appropriate):

Review of Systems (ROS): Some of this is done in the HPI as one teases out important complaints related to the current illness. It is good to have a standard list in mind anyway.

General: Fever, chills, loss of appetite, weight loss/gain

HENT: Headaches, Blurred vision, Ear pain/Discharge, hearing loss, Nasal stuffiness, throat pain, painful swallowing, etc

Neck: Neck pain, swelling/glands etc

Chest/heart:  Cough, pain, SOB, palpitations, dizziness, etc

Abdomen; Nausea/vomiting, abdo pain, diarrhea, bleeding, swelling

GU: nocturia, dysuria, frequency, narrowed stream of urine, hematuria

Neuro: weakness, choking, walking, numbness

Psych: depressed, anxious, concentration, etc

Skin: rashes, ulcers, concerning lesions

Endocrine: Temperature intolerance, abnormal hair growth/pigmentation

Physical Exam: Always wash your hands or put on gloves before beginning the physical examination.
Generally begins  the patient's appearance.  Looks well, slightly unwell, moderately or severely unwell. In distress or not - In NAD (no acute distress)
Vital Signs: T, P, BP, RR (already given in the test.
HEENT: Includes head, eyes, ears, nose, throat, oro-pharynx, thyroid.
Lymph Nodes: Cervical preedominantly
Lungs/chest wall: do not unnecessarily leave uncovered.
Heart:
Carotids: you may examine this before or after the heart
Abdomen: Be gentle,  do not unnecessarily leave uncovered.
Rectum:
Genitalia/Pelvic: This cannot be done in the CS but can be included in your written plan if you think it is important. It goes in the INVESTIGATIONS section.
Extremities, Including Pulses:
Neurologic:

• AAOx3 (Alert, awake and oriented to time, place and person)
• Higher function/Mental Status
• Cranial Nerves
• Motor Strength
• Sensation (light touch, pin prick, vibration and position)
• Reflexes, Babinski
• Cerebellar Function, Gait

Affect:

Assessment and Plan:

For the Step 2 CS, it has to incorporate 2 things: Differential diagnoses and Investigations. 5 of each.

If your own style incorporates the above, you need not change it. You may instead improvise/modify the above to suit your own style.

SAMPLE WRITE UP: You must practice with your format. Check it repeatedly to see how you can improve it. Once you have done so,