Helpful Information for Step 2 CS

Commonly Used Medical Abbreviations

2005-10-04T13:31:00.000-07:00

At the request of several students, we have put together a list of commonly used abbreviations. All of these should be acceptable for use on a progress note for Step 2 CS. Please add your comments if there are others you would like to have added to the list.

Abd = abdomen
AC = before meals
ACLAN = anterior cervical lymphadenopathy
AFOS = anterior fontanelle open and soft
All = allergy
ALT = alanine aminotransferase (SGPT)
ANA = anti-nuclear antibody
AP = antero-posterior
Appy = appendicitis or appendectomy
ASA = aspirin
AST = aspartane aminotransferase (SGOT)
BID = twice daily
BP = blood pressure
BRBPR = bright red blood per rectum
BS = bowel sounds
BSO = bilateral salpingo-oophorectomy
BUN = blood urea nitrogen
CAD = coronary artery disease
CBC = complete blood count
CEA = carotid endarterectomy
c/o = complains of
CHF = congestive heart failure
cig = cigarette
CKD = chronic kidney disease
CP = chest pain
Cr = creatinine
CRF = chronic renal failure
CRI = chronic renal insufficiency
C/S = caesarean section
CT = computerized tomography
CTA = clear to auscultation
CTAB = clear to auscultation bilaterally
CXR = chest x-ray
d/c = discharge
DDD = degenerative disk disease
DJD = degenerative joint disease
DM = diabetes mellitus
DNR = do not resuscitate
DNVI = distal neuro-vascular intact
DOE = dyspnea on exertion
DTR = deep tendon reflex
EGD = esophagogastroduodenoscopy (upper endoscopy)
EOMI = extra-ocular movements intact
ESR = erythrocyte sedimentation rate
EtOH = alcohol
Ext = extremity
FamHx = family history
F = female
FBS = fasting blood sugar
F/C = fevers, chills
FLP = fasting lipid panel
FTT = failure to thrive
f/u = follow-up
GERD = gastro-esophageal reflux disease
GI = gastrointestinal
GU = genitourinary
HA = headache
HbA1C = hemoglobin A1C
Hct = hematocrit
HCTZ = hydrochlorothiazide
HEENT = head, ears, eyes, nose, and throat
HJR = hepatojugular reflux
Hgb = hemoglobin
H/H = hemoglobin and hematocrit
h/o = history of
HS = bedtime
HTN = hypertension
Hx = history
IBS = irritable bowel syndrome
I/O = ins and outs
ISS = insulin sliding scale
IV = intravenous
IVF = intravenous fluid
JVD = jugular venous distention
K = potassium
L = left
Lat = lateral
LE = lower extremity
M = male
Mammo = mammogram
mg = milligram
m/g/r = murmurs, gallops, rubs
MRI = magnetic resonance imaging
MS = multiple sclerosis
MVI = multivitamin
Na = sodium
NABS = normo-active bowel sounds
NAD = no acute distress
NCAT = normo-cephalic, atraumatic
Neuro = neurologic
ND = non-distended
NGT = nasogastric tube
NKDA = no known drug allergies
NPO = nothing by mouth
NSAID = non-steroidal anti-inflammatory drug
NSVD = normal spontaneous vaginal delivery
NT = non-tender
N/V/D = nausea, vomiting, diarrhea
OA = osteoarthritis
Occ = occasional
OD = right eye
OP = oropharynx
OS = left eye
OU = both eyes
OT = occupational therapy
PA = postero-anterior
PCN = penicillin
PE = physical exam or pulmonary embolism
PERRLA = pupils equally round and reactive to light and accommodation
Plts = platelets
Pna = pneumonia
PND = paroxysmal nocturnal dyspnea
PO = orally
PPD = purified protein derivative (tuberculosis test)
PR = rectally
PRN = as needed
Pt = patient
PT = physical therapy
PTX = pneumothorax
PVD = peripheral vascular disease
QAC = before every meal
QD = daily
QHS = every night
QID = four times daily
QOD = every other day
R = right
RBS = random blood sugar
RF = rheumatoid factor
ROS = review of systems
RRR = regular rate and rhythm
SEM = systolic ejection murmur
SLE = systemic lupus erythematosus
SOB = shortness of breath
SocHx = social history
SP = standardized patient
SWOP = symptoms worsen or persist
T&A = tonsillectomy and adenoidectomy
TAH = total abdominal hysterectomy
TB = tuberculosis
TID = three times daily
TM = tympanic membrane
Tob = tobacco
TVH = total vaginal hysterectomy
UA = urinalysis
UE = upper extremity
URI = upper respiratory infection
U/S = ultrasound
UTI = urinary tract infection
UTZ = ultrasound
VS = vital signs
W = white
WBC = white blood cell count
WD = well-developed
WN = well-nourished
yo = year-old

All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.

The NURS Mnemonic

2005-10-03T13:53:00.000-07:00

Giving bad news and interacting with patients regarding emotional issues can be two of the more difficult situations that we deal with in medicine. Often, it is challenging to find the right words to say and to point the interaction in a constructive direction.

The "NURS" mnemonic can be used to help frame and guide such an encounter. This mnemonic is discussed in detail below. This type of interaction really is part of the art of medicine, but this mnemonic may be helpful for the purposes of the Step 2 CS exam.

N-ame the emotion
U-nderstand
R-espect
S-upport

N-ame the emotion. Labeling the patient's emotion can be a helpful first step in communicating effectively with the patient and being able to offer the appropriate support. You may say, "you seem upset" or "you seem sad." In doing so, you may be correct in identifying the patient's underlying emotion, or the patient may correct you. Either way, you have taken the first step in dealing with the issue at hand.

U-nderstand the patient. Do not fall into the mistake of saying, "I understand how you feel" or "I know how hard this is for you." If you do this, the patient may say, "how could you possibly understand what it's like to have a child with cancer." Instead, make it clear that you understand that the situation is difficult. Say something like "I understand how hard this must be for you" or "I understand that this situation must be very upsetting for you." In this way, you state that you understand the patient's emotional status even though you probably have never been in the same situation yourself.

R-espect the patient. Perhaps the most important part of the interaction is conveying a sense of respect to the patient. The patient needs to know that you respect the situation they are in, their emotional response to the situation, and how they are handling it. Say something like, "I respect the way you are handling this very difficult situation."

S-upport the patient. Make it clear to the patient that you are there to offer emotional support. Say something like, "is there anything more that I can do to help you get through this situation?" Alternatively, you may say, "Don't hesitate to contact me if there is anything I can do to help you."

All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.

Another Mnemonic for Pain

2005-10-03T13:48:00.000-07:00

The mnemonic "CLITORIS" can be helpful in the evaluation of a patient with pain:

C-haracter (sharp, dull, crampy, burning, etc.)
L-ocation (where is the pain located?)
I-ntensity (how bad is the pain on a 1-10 scale)
T-iming (when does the pain occur?)
O-nset (when did the pain initially begin?)
R-adiation (does the pain radiate; if so, where?)
I-rritating and alleviating factors (what makes the pain worse or better)
S-ymptoms associated with the pain (e.g., nausea, sweating, blood in the urine, etc.)

All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.

A Mnemonic for the Differential Diagnosis

2005-09-26T12:08:00.000-07:00

The mnemonic "DIRECTION" can be used in helping to create a differential diagnosis. This mnemonic divides diseases into broad categories, which can then be used to create differential diagnoses within each of these categories.

D-rugs
I-nfection
R-heumatologic
E-ndocrine
C-ardiovascular
T-rauma
I-nflammatory
O-ther
N-eoplasms

All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.

Study Partner Database

2005-09-21T08:19:00.000-07:00

A new study partner database is now available at DigitalDoc's website, www.csprotocol.blogspot.com.

This database allows you to find study partners in preparation for the USMLE Step 2 CS.

The CAGE Questionnaire

2005-09-19T12:13:00.000-07:00

Some of the cases on the USMLE Step 2 CS have a component that may relate to alcohol or drug problems. The CAGE questionnaire is a helpful, brief tool designed to screen for alcoholism. The CAGE questionnaire has been updated to also be used as a screening tool for drug abuse, in which case it is called the CAGE-AID.

Before beginning a CAGE questionnaire, ask the patient two questions:
1. Do you drink alcohol?
2. Have you ever experimented with drugs?

If the answer to either of these questions is "yes," then a CAGE questionnaire should be considered. Below, the parts of the questions in parentheses is the part used to screen for drug abuse.

The mnemonic "CAGE" stands for the following:
C-ut down
A-nnoyed
G-uilty
E-ye opener

The cage questionnaire is as follows:

Have you every felt you should cut down on your drinking (or drug use)?

Have people every annoyed you by criticizing your drinking (or drug use)?

Have you ever felt bad or guilty about your drinking (or drug use)?

Have you ever had an eye-opener to steady your nerves or get in the morning or get rid of a hangover? (An eye-opener is a drink or drug use in the morning).

An affirmative answer to one of the questions indicates a possible alcohol or drug problem.
An affirmative answer to two of the questions indicates a probable alcohol or drug problem.
An affirmative answer to three or more of the questions confirms alcoholism or drug abuse.

All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.

Helpful Mnemonics for Step 2 CS

2005-09-15T12:08:00.000-07:00

We have been asked quite a few questions about helpful mnemonics for Step 2 CS. We have compiled several of them here. If you find them helpful, consider jotting them down on a sheet of paper as you enter the standardized patient exam room so that you can use them while remaining calm. Here they are:

PAM HUGS FOSS (a mnemonic for past medical history)

P-revious history of smilar symptoms
A-llergies (medications, foods, over-the-counters, etc.)
M-edications (mediations the patient may be taking, including non-prescription meds)

H-ospitalization (previous hospitalizations for any illnesses or surgeries)
U-rinary changes (frequency, urgency, dysuria, hematuria, foul-smelling urine)
G-astrointestinal symptoms (nausea, vomiting, bowel habit changes, melena, etc.)
S-leep pattern (insomnia, early waking)

F-amily history (any illnesses in the family, particulary first-degree relatives)
O-b/Gyn history (last menstrual period, pregnancies, miscarriages, abortions, length of periods)
S-exual habits (STDs, male/female preference)
S-ocial history (smoking, alcohol, drugs, occupation)

LIQOR AAA (useful for asking about pain)

L-ocation of the symptom (abdomen, back, leg)
I-intesity (use a scale from 1-10)
Q-uality of the symptom (sharp, dull, crampy, burning)
O-nset of the symptoms (when did it start, what precipitated the pain?)
R-adiation of the pain (radiation to the back, arm, groin, etc.)
A-ssociated symptoms (nausea, dysuria, chest pain, shortness of breath)
A-lleviating factors (leaning forward, lying still, using a hot pack)
A-ggravating factors (moving, eating, physical effort)

PQRST (also helpful for asking about pain)

P-osition
Q-uality (sharp, dull, crampy, burning)
R-adiation (radiation of the pain to the back, arm, groin, etc.)
S-everity (use a scale from 1-10)
T-timing (worse with meals, bowel movements, time of day, etc.)

SODAS (useful for obtaining a detailed social history)

S-moking (cigarettes, marijuana, how much, how many years)
O-ccupation (what does the patient do for a living?)
D-rugs (what drug, how do they use it, any IV drug use?)
A-lcohol (whaty type of alcohol, how often, how much, consider doing a CAGE questionnaire)
S-exual history (number of partners, protection, STDs, pregancies, etc.)

All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.

Better than the MMSE

2005-09-12T14:30:00.000-07:00

Some of the cases on the USMLE Step 2 CS require the test-taker to perform an evaluation of a patient's cognitive function. On some of the message boards, we have seen students asking about the mini mental status examination (MMSE). Our opinion is that there is a better alternative to the MMSE for the purposes of both this test as well as real-world clinical applications.

The MMSE is a multiple part test with a maximum score of 30. The MMSE can be cumbersome to administer, takes a fair amount of time (especially when the patient actually has some cognitive dysfunction), and usually requires that you have the test template in hand in order to administer the test. A newer test known as the Mini-Cog is a better test to use for the Step 2 CS, as well as for most primary care settings.

The Mini-Cog is a 3 minute instrument used to screen for cognitive impairment (most often dementia) in older adults. In several different studies, the Mini-Cog was as effective or more effective than the MMSE and other established screening tests. The Mini-Cog is able to screen for both memory and executive function.

In the Mini-Cog, the patient is told three items (such as apple, table, and penny) and is requested to repeat back and remember those three items. The patient is then asked to draw a clock face with all of the numbers, and then draw in the hands of the clock to indicate a certain time, such as 10:50. After the patient has drawn the clock face, he or she is asked to repeat back the three items that were previously stated.

That's it! The beauty of this test is its simplicity and quickness.

The test is scored as follows:
Recall of 0 items indicates dementia.
Recall of 1-2 items with an abnormal clock face indicates dementia.
Recall of 1-2 items with a normal clock face indicates no dementia.
Recall of all 3 items indicates no dementia.

Essentially, the clock face only comes into play when only 1 or 2 items are recalled. If zero items or 3 items are recalled, the diagnosis is clear-cut.

All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.

2005-09-08T19:57:00.000-07:00

An Approach to the Patient Encounter

This post is intended to provide you with a general approach to the patient encounter. Keep in mind that each case and each patient will be different. However, with a general template in mind, you may find that interacting with the standardized patients is less anxiety-provoking.

We encourage you to keep in mind how you were taught to interact with patients during medical school. Those numerous patient interactions will provide you with a framework with which to work during this examination. If you have uncertainties about your comfort with the standardized patient, if you did not get enough patient interactions during medical school, or if you are unfamiliar with the American medical system, this post should provide you with valuable information. In addition, the cases in our book are designed to mimic the cases on the USMLE Step 2 CS, so working through the cases and repeating the cases should only enhance your comfort with the standardized patient.

Before entering the room with the standardized patient, knock confidently on the door and walk in with a smile while making eye contact. Offer your hand to shake and introduce yourself, "Hello, I'm Student-doctor Smith. How may I help you today."

After the introduction, sit down and face the patient. You may consider asking the patient if he or she is comfortable sitting where they are. Then tell the patient that you will be taking a few notes during the encounter. "If you don't mind, I'm going to take a few notes as we speak to help me provide you with the best care possible." Some people would argue that you should ask permission to take notes, but in real-world medicine, the physician does not ask for permission to take notes, so we don't feel that you need to ask if this is okay.

While taking a few brief notes, be sure to maintain eye contact and give the patient the impression that you are listening. Nod your head as the patient speaks, respond to the patient's questions, and repeat back important points. "So, your back pain began only after you twisted the wrong way and you've had the pain for three days." This emphasizes the point that you are listening, improves the accuracy of your history, and allows the patient to correct you if you have missed anything.

During the history-taking portion of the encounter, focus on the patient's main complaint and ask questions that relate to the complaint. Ask about duration, intensity, exacerbating and alleviating factors, and other associated symptoms. In a future post, we will discuss this part of the history in more detail.

When asking questions related to the social history, you may wish to frame the questions. For example, you may say "I have a few personal questions to ask you that will help me understand your concerns a bit better and will allow me to take better care of you." You may then proceed to ask questions relating to alcohol use, smoking, drug use, or sexuality. Likewise, you may wish to frame the family history with a similar introduction.

Before examining the patient, be sure to wash your hands! While washing the hands, you may wish to ask a few additional questions or even make casual (but not too casual or friendly) conversation with the patient.

As you examine the patient, explain what you are doing, why you are doing it, and what your findings are. When needed, give the patient specific instructions. For example, "I am going to listen to your heart to determine if you have any murmurs." You may then instruct the patient to sit forward or lie down as you listen to the heart. Then, you might say, "Your heart sounds very normal."

When examining the patient, be sure to drape the patient in a professional and courteous manner. When examining the abdomen, the groin should be draped, covering it as much as possible. Sensitive issues regarding the examination of the patient will be discussed in a future post.

When you have finished with your examination, return to your seat and quickly collect your thoughts. At this point, you should summarize the visit for the patient to check for accuracy and to make sure the patient understands. This also allows the patient to add any additional details as necessary. At this point, you should also tell the patient your plan of care. You may tell the patient, "I think that your back pain is caused primarily by muscle spasm. However, I would like to rule out other causes such as arthritis or infection, so I am going to order an x-ray and some blood work."

At this point, remember that you may also need to counsel the patient. If there are issues such as cigarette use, drug use, or excessive alcohol intake, this should be discussed with the patient.

Ask the patient if he or she understands everything that you have discussed. If they ask questions, try to answer them as well as you can without making anything up. If you are unsure of the answer, tell them "I will have to look that up and get back to you with an answer." You may even say, "I'm not sure. I'll discuss that question with my attending physician and get back to you." After determining that the patient understands what you have said, ask the patient if he or she has any additional questions that you can answer.

Finally, tell that patient that it was a pleasure meeting him or her, shake hands, and leave the room.

All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.

2005-09-08T19:32:00.000-07:00

This blog is written by the authors of Case-Based Simulation and Review for the USMLE Step 2 CS. Our goal is to provide you with additional information regarding the exam and the ideal approach to the standardized patients.

Our book provides interactive cases which can be simulated in a small group setting, which provides an experience that mirrors that of the actual test. Each case provides background information about the standardized patient as well as scoring sheets for the case. Each case is followed by a thorough discussion of the topic.

This blog will provide details about the best ways to interact with the standardized patients and how to deal with difficult situations.

We wish you the best in studying for this exam. Please provide us with comments or email us if you have any questions or topics that you would like to have discussed.