Mastering SOAP Note Style Questions on USMLE Step 2 CK

The USMLE Step 2 CK now includes SOAP note style vignette questions, a format that tests your ability to manage clinical scenarios efficiently. These questions require a structured approach to patient care, making it essential to master the SOAP (Subjective, Objective, Assessment, Plan) framework.

The SOAP notes presented on USMLE Step 2 CK are often long and scary if you don’t know what to expect. But, once you learn how to read the question and what to look for, they can be approached like any other question. Here’s how you can prepare for these questions and tackle them effectively on exam day.

Understanding the SOAP Note Step 2 Question Framework

Before we tackle the SOAP questions, we must first understand the SOAP note framework. The SOAP note format is a method used to document patient encounters. It stands for:

• Subjective: Patient’s past medical history, history of present illness, and symptoms
• Objective: Vitals, physical exam findings, and laboratory results
• Assessment: Differential diagnosis and clinical judgment
• Plan: Management and treatment plans

On the wards, SOAP notes are often used as a format for follow up notes or consult notes. The goal is to simplify the information that is presented (rather than a traditional note that may be presented in the HPI, PMH, PSH, SH, FH, Meds, ROS, PE, Assessment & Plan format). They can help one quickly identify the labs.

On the exam, you’ll find that the SOAP note questions are long. They often include extraneous information. Your job is to sift through the note thoroughly and quickly in order to answer the question!

Approaching the SOAP Note Style Step 2 Question

1. Start With the Question and Skim the Answer Choices

Begin by reading the last line of the vignette and the answer choices. This provides context and helps you focus on relevant information. Every once in a while the question can be so straightforward that you don’t even have to read the rest of the stem. If this is true, then answer the question and move on!

2. Quick Initial Scan

After reading the main question, do a quick scan of the SOAP note. Remember that the stems are lengthy, try to glance over the bulk of the question and glean the key information.

3. Extract Key Details

I like to look at the objective findings next. The objective findings often give you the key you need to answer the question. Look at the vitals and labs and see if that can help get you to the answer. Disregard extraneous details to save time.

4. Synthesize the Information

Lots of information presented in a new format can be overwhelming, but try to “put the story together” as you read the question. Ask yourself, “Who is this person?”, “What PMH matters?”, “What symptoms matter?” and “What labs matter?” For example, you may be able to take a lengthy 1+ page question and condense it into something like this “Pt is a 45 F with PMH of hypertension presenting with right flank pain and a fever.” This should then lead you to think about a septic kidney stone before you even get to the question!

5. Systematic Analysis

If after reading the question, skimming the SOAP note, and focusing on the objectives you still don’t know the answer, begin to review the vignette more thoroughly. This ensures you don’t miss critical information. That said, BE CAREFUL! Don’t burn too much time searching for the perfect detail to get you to the answer. If you are struggling to answer the question, then just move on.

6. Mark and Move

If a question is too challenging, mark it, make an educated guess, and move on. This strategy allows you to maximize the number of questions you answer and revisit difficult ones with remaining time.

SOAP Note Question Analysis Tips for Step 2

Know What to Expect

When you click the next button and a SOAP question pops up, don’t panic! Remember that you have prepared for this. SOAP questions are long, but they are manageable. Have a game plan for how you will approach the question:

• Don’t get lost in the details: This style of question is famous for lots and lots of details that are not needed to answer the question. For example, if the patient is a 60 year old female with left tibia fracture, her obstetric history may be irrelevant to answering the question (of course, in real life, it’s important to get the whole picture of the patient, but on the USMLE, our goal is to get to the right answer!). Make sure that you are emphasizing information that is relevant to the question asked.

• AND, don’t forget the details: While it’s important to not get lost in the details, remember that details also DO matter. This can be a tricky balancing act, but the more practice questions you do, the better you will get! As you are reading the question, keep an eye out for what key details really matter to help you get to the right answer.

Simulate Exam Conditions

Practice under timed conditions to build stamina and improve time management. This helps you get accustomed to the exam’s pace and reduces test-day anxiety. Especially when approaching these longer stemmed questions. Take a look at our Step 2 study calendar which will start you off with untimed practice questions, and transition over time to more and more timed mode practice.

Example SOAP Note Style Question and Explanation

Let’s take a look together at a SOAP note style question, and the process you could go through to answer this.

Example Step 2 SOAP Note Question

Subjective

A 45-year-old woman presents to the clinic with complaints of fatigue and joint pain. She has a past medical history of hypertension and GERD. She has a past surgical history of an appendectomy. She is a G4P3. The patient lives at home with her husband and 3 children. She reports that the pain started in her hands and wrists about two months ago and has progressively worsened. She also notes morning stiffness lasting more than an hour. She has no other significant past medical history and takes no medications.

Objective

General Appearance:

• The patient is a well-nourished, well-developed female, appearing stated age, in no apparent distress.

Vital Signs:

• BP: 120/80 mmHg
• Heart Rate: 72 beats per minute
• Respiratory Rate: 16 breaths per minute
• Temperature: 98.6°F (37°C)
• Oxygen Saturation: 98% on room air

HEENT:

• Head: Normocephalic, atraumatic.
• Eyes: PERRLA (pupils equal, round, reactive to light and accommodation), EOMI (extraocular movements intact).
• Ears: Tympanic membranes clear, no effusion.
• Nose: Nasal mucosa pink, no discharge.
• Throat: Oropharynx clear, no erythema or exudates.

Neck:

• Supple, no lymphadenopathy, no thyroid enlargement.

Cardiovascular:

• Heart sounds: Regular rate and rhythm, no murmurs, rubs, or gallops.
• Peripheral pulses: 2+ and equal bilaterally, no edema.

Respiratory:

• Breath sounds clear to auscultation bilaterally, no wheezes, rales, or rhonchi.

Gastrointestinal:

• Abdomen: Soft, non-tender, no hepatosplenomegaly, bowel sounds present.

Genitourinary:

• No CVA tenderness, no suprapubic tenderness.

Musculoskeletal:

• Inspection and Palpation: Bilateral wrists and metacarpophalangeal joints are tender and swollen.
• Range of Motion: Full range of motion in all joints, except discomfort noted in bilateral wrists and MCP joints due to tenderness.
• Strength: 5/5 strength in upper and lower extremities.
• No deformities, other joints non-tender, no erythema or warmth in other joints.

Neurological:

• Cranial Nerves: II-XII intact.
• Motor: Normal muscle bulk and tone.
• Sensory: Intact to light touch and pinprick.
• Reflexes: 2+ and symmetric.
• Coordination: No dysmetria, normal finger-to-nose and heel-to-shin tests.
• Gait: Normal.

Skin:

• Warm, dry, no rashes or lesions.

Psychiatric:

• Alert and oriented x3, normal mood and affect.

Laboratory tests show:

Complete Blood Count (CBC):

• WBC: 5.5 x 10^3/µL
• RBC: 4.7 x 10^6/µL
• Hgb: 11.5 g/dL
• Hct: 36.0%
• MCV: 85 fL 
• Platelets: 250 x 10^3/µL 

Electrolytes:

• Na: 140 mmol/L
• K: 4.0 mmol/L 
• Cl: 102 mmol/L 
• HCO3: 24 mmol/L

Other:

• Erythrocyte Sedimentation Rate (ESR): 60 mm/hr

• Rheumatoid Factor: Positive
• Anti-Cyclic Citrullinated Peptide (Anti-CCP) Antibodies: Positive 

X-ray of bilateral wrists and hands

Significant joint space narrowing is observed in the metacarpophalangeal (MCP) joints and proximal interphalangeal (PIP) joints of both hands. Marginal erosions are present, particularly in the second and third MCP joints. Correlate clinically.

Given the patient’s history and laboratory findings, what is the most likely diagnosis?

(A) Osteoarthritis
(B) Rheumatoid arthritis
(C) Systemic lupus erythematosus
(D) Fibromyalgia
(E) Gout

Approach to the question

Before we jump into the clinical knowledge required to answer this question, let’s talk strategy. Earlier we discussed an approach to the SOAP note style question. Follow the path below for the best way to approach this LONGGG question!

• When approaching this question, we read the last sentence first, and we learn that they are looking for a diagnosis. 
• We skim the answer choices, and we immediately know there is likely an MSK (and possibly autoimmune) concern.
• After jumping to the subjective information, we learn that this is a 45-year-old female with wrist and MCP pain.
• Immediately move to the objective information and skim the information provided. You can skip the normal, and notice that the patient is slightly anemic, has an elevated ESR, positive rheumatoid factor, positive anti-CCP, and joint space narrowing on x-ray with bony erosion.
• This information is enough to help me get to the answer choice, rheumatoid arthritis, without analyzing every detail of the stem.

Answer: B. Rheumatoid arthritis

Because the SOAP note questions are so unique, they require a bit more skimming than the usual USMLE-style questions. Of course, be careful not to miss any key information, but it is often not the best use of your time to thoroughly read every word of these questions. (And in other USMLE questions, make sure to thoroughly read them!!) If you realize you can get the answer without reading every word, that’s great! Go ahead and answer and move on. If you’ve gone through these steps and still think you can’t answer this question without spending 10 minutes; make an educated guess, mark it, and move on. If you have time, return to your marked questions later.

Explanations

Given the patient’s history of symmetrical joint pain, morning stiffness lasting more than an hour, positive laboratory markers (elevated ESR, positive rheumatoid factor, and anti-CCP antibodies), and x-ray with joint space narrowing and erosions, the most likely diagnosis is rheumatoid arthritis. This condition typically presents with these clinical features and lab findings, differentiating it from other potential diagnoses.

(A) Osteoarthritis typically presents with joint pain that worsens with use and does not have significant morning stiffness that lasts more than an hour or positive rheumatoid factor/anti-CCP antibodies.

(C) Systemic lupus erythematosus can present with joint pain but usually has other systemic symptoms and different antibody profiles such as a positive ANA and anti-dsDNA.

(D) Fibromyalgia presents with widespread pain without significant inflammation or positive rheumatoid factor/anti-CCP antibodies. This is key, fibromyalgia will NOT have positive markers.

(E) Gout typically presents with acute, episodic joint pain, often in the big toe, and involves elevated serum uric acid levels. There would not be positive rheumatoid factor.

Final Thoughts on Step 2 SOAP Note Style Questions

Don’t let the SOAP style notes on your USMLE Step 2 CK test throw you for a loop. Often times the answer is not that tricky, you just need to sort through the information to get to the correct answer. Remember to start with the question first, then glance at the patient, and then jump to the important objective findings. Be sure not to burn too much time on these questions as you have plenty of other questions to answer that deserve your time and attention. Do your best to get the big picture, answer it, and then move on!

By practicing with examples like this and following a structured approach, you can effectively manage SOAP note style questions on the USMLE Step 2 CK. For more personalized guidance, consider scheduling a consultation with Elite Medical Prep. Our experienced Step 2 tutors can provide tailored strategies and insights to help you excel on your exam.