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The Most Useful step 2 CS guide

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Terms and Abbreviations on STEP 2 CS

As we have a very limited time for a single case( 25 mins total ) abbreviations can really help to save time in patient note and a rough note. here is the list of terms and abbreviations used in the USMLE step 2 CS. You will find a similar paper hanging on the table out side the encounter room. where you sit down to write the Patient Note.

yo year-old
m male
f female
b black
w white
L left
R right
hx history
h/o history of
c/o complaining of
without or no
+ positive
- negative
Abd abdomen
AIDS acquired immune deficiency syndrome
AP anteroposterior
BUN blood urea nitrogen
CABG coronary artery bypass grafting
CBC complete blood count
CCU cardiac care unit
CHF congestive heart failure
cig cigarettes
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CT computed tomography
CVA cerebrovascular accident
CVP central venous pressure
CXR chest x-ray
DM diabetes mellitus
DTR deep tendon reflexes
ECG electrocardiogram
ED emergency department
EMT emergency medical technician
ENT ears, nose, and throat
EOM extraocular muscles
ETOH alcohol
Ext extremities
FH family history
GI gastrointestinal
GU genitourinary
HEENT head, eyes, ears, nose, and throat
HIV human immunodeficiency virus
HTN hypertension
IM intramuscularly
IV intravenously
JVD jugular venous distention
KUB kidney, ureter, and bladder
LMP last menstrual period
LP lumbar puncture
MI myocardial infarction
MRI magnetic resonance imaging
MVA motor vehicle accident
Neuro neurologic
NIDDM non-insulin-dependent diabetes mellitus
NKA no known allergies
NKDA no known drug allergy
NL normal/normal limits
NSR normal sinus rhythm
P pulse/heart rate
PA posteroanterior
PERLA pupils equal, react to light and accommodation
po orally
PT prothrombin time
PTT partial thromboplastin time
RBC red blood cells
SH social history
TIA transient ischemic attack
U/A urinalysis
URI upper respiratory tract infection
WBC white blood cells
WNL within normal limits

"This is not intended to be a complete list of acceptable abbreviations, but rather represents the types of common abbreviations that may be used on the patient note. There is no need to use abbreviations on the patient note; if you are in doubt about the correct abbreviation, write it out." - usmle.org (2010 hand out)

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