These are the blue sheet, physical exam, diagnostic studies and differential diagnosis needed for a back pain case in the USMLE Step 2 CS exam:
BLUE SHEET BACK PAIN:
PHYSICAL EXAMINATION (Depends on the MVA, nature of the trauma and organs/systems involved):
1. HEENT:
Inspection for lesions
Pupillary reflexes (PERRLA)
2. Lungs:
Inspection of thoracic expansion and bruises
Palpation: Tactile fremitus.
Percussion: Look for tympanic or else.
Auscultation: Usually patients can move the thorax without inspiration, simulating decreased breath sounds uni or bilaterally.
3. Heart:
Inspection: for bruises or lesions
Palpation: Heaves, PMI, and chest wall tenderness
Auscultation
4. Abdomen
Inspection
Auscultation
Palpation (look for HSM, more if history of recent infectious mononucleosis)
Percussion
5. Skin:
Inspection
6. Neurologic:
Mental Status: Alert and oriented x 3 (person, place and time)
CN 2-12
Motor: Strength
Sensory
POSSIBLE DIAGNOSTIC STUDIES:
- Pelvic, rectal exam as needed
- Urine toxicology, blood alcohol level
- CXR
- CT abdomen
- CBC, blood type, and cross matching
DIFFERENTIAL DIAGNOSIS:
Lungs:
- Pneumothorax
- Tension pneumothorax
- Hemothorax
- Lung contusion
Heart:
- Cardiac tamponade
- Myocardial contusion
Chest wall:
- Rib fractures
- Flail chest
Abdomen:
- Splenic rupture
- Liver rupture
- Other organ damage
CNS:
- Epidural hematoma
- Subdural hematoma
- Skull fracture, skull base fracture (look for bilateral eye ecchymosis, CSF leak through the ears or nose, post auricular ecchymosis or Battle’s sign).
Please let me know if you have a doubt about this topic.
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I have a prob with this case and is that if a do The PE with this level of detail my 10 minutes runs out. Can you give me a tip please?
Hello Alvin,
I hope your studies are doing great. It is very difficult to finish some cases in the Step 2 CS exam. My advice with any case in which you may find difficulties with time management is to focus more on the history and counseling part taking a little less time in the physical exam (less important). Sometimes you may run out of time in a case and that is fine as long as you have been doing the most important aspects of the case. Practice this case with a study partner to improve your timing and confidence and you should do fine.
I wish you good luck in your preparation. Thanks for the comment.
Thank you doctor. What about the Pt note? What do i do if i don’t have much time because the history is very detailed or the PE is very detailed? Focus more on the history than the the PE in the Pt note as well?