STEP II CS Automatic Points Guide

Every patient checklist

Knock on door before entering
Say their name using Mr. and Mrs. (NOT first names) and make
eye contact
Shake hands
Drape patient from waist down ask: Can I make you more
comfortable?
Sit down ask: Do you mind if I sit and take notes?
Ask what problem is, immediately say: Im sorry to hear that
History and relevant ROS
o Including:
ROS:
Weight changes
Appetite changes
Diet
Exercise
Stress
Sleep
Drug allergies
Past medical history
Past surgical history
Family history (if relevant)
Social history:
Occupation
Alcohol use
Tobacco
Drug use
Ask permission to do physical exam Do you mind if I examine
you?
Ensure proper draping
Use hand sanitizer and clean stethoscope with alcohol swab
Explain each exam maneuver before you do them
 Summarize HPI (in patients own words if possible), diagnostic
impression, and tests
Explain tests you will order and likely diagnosis
Ask if they have questions
Counsel on bad habits
OR
Commend on healthy lifestyle
Shake hands before leaving
Sexual history (note: can shorten below as necessary)
Warn of personal questions incoming and assure them of
confidentiality
Partners
o Do you have sex with men, women, or both?
o In the past 12 months, how many partners have you had
sex with?
o Is it possible that any of your sex partners in the past 12
months have had sex with someone else while they were
still in a sexual relationship with you?
Prevention of pregnancy
o What are you doing to prevent pregnancy?
Protection from STIs
o What do you do to protect yourself from STIs and HIV?
Practices
(preamble: To understand your risk for STIs, I need to
understand the kind of sex you have had recently.)
o Have you had vaginal sex, meaning penis-in-vagina sex?
If yes Do you use condoms: never, sometimes, or
always?
o Have you had anal sex, meaning penis-in-rectum/anus
sex?
If yes Do you use condoms: never, sometimes, or
always?
o Have you had oral sex, meaning mouth-on-
penis/vagina?
Past STI history
o Have you ever had a sexually transmitted infection?
o Have any of your partners had a sexually transmitted
infection?
Additional questions to identify HIV and viral hepatitis risk
o Have you or any of your partners ever injected drugs?
o Have you or any of your partners exchanged money or
drugs for sex?
o Is there anything else about your sexual practices that I
should know about?
Mini mental exam (an abbreviated version)
Can you state your name?
How old are you?
Where are you right now?
Repeat the 3 words Im going to tell you right now, and then Im
going to ask you to do so again a little later.
Who is the current president?
(Point at object, ask patient to name it)
Can you spell the word cat backwards?
Repeat the 3 words I asked you earlier.

CAGE
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever taken a drink first thing in the morning (Eye-
opener) to steady your nerves or get rid of a hangover?
(Report CAGE on the note section based on results, e.g. CAGE 3/4 if 3
of above questions are answered in the positive, CAGE 0/4 if all
answered in the negative, etc.)