-
ABX - Antibiotics
ABD - Abdomen
ADL - Activities of Daily Living
AF - Atrial Fibrillation
AI - Aortic Insufficiency
ALL - Allergies (also refers to Acute Lymphocytic Leukemia)
AMI - Acute Myocardial Infarction; also Anterior Myocardial Infarction
A&O - Alert And Oriented (often listed as A&O x3....oriented to person,
place, time)
AP - Anterior-Posterior (in reference to chest x-ray technique)
A/P - Assessment and Plan
APPY - Appendectomy
AS - Aortic Stenosis; also Anklyosing Spondylitis
AVR - Aortic Valve Replacment
AVSS - Afebrile, Vital Signs Stable
- B - Bilateral
BIB - Brought In By
BID - Twice a Day
BL CX - Blood Culture
BP - Blood Pressure
BS - Bowel Sounds; also Breath Sounds and Blood Sugar
BX - Biopsy
- CABG - Coronary Artery By-Pass Graft
CAD - Coronary Artery Disease
CARDS - Cardiology
CATH - Catheterization (usually refers to cardiac catheterization)
C - With
CC - Chief Complaint
CCE - Clubbing, Cyanosis, Edema (with reference to extremity exam)
CB - Cerebellar
C/B - Complicated By
CBC - Complete Blood Count (inludes hematocrit, white blood cells,
platelets)
Chemo - Chemotherapy
CHF - Congestive Heart Failure
Choly - Cholycystectomy
CMP - Cardiomyopathy
CN - Cranial Nerves
CNIS - Carotid Non-Invasive Study
COPD - Chronic Obtructive Pulmonary Disease
CPAP - Continuous Positive Airway Pressure
CRI - Chronic Renal Insufficiency
CT - Cat Scan; or Chest Tube
CTA - Clear To Auscultation
CVA - Cerebral Vascular Accident
CVP - Central Venous Pressure
CX - Culture
CXR - Chest X-Ray
CVL - Central Venous Line
C/W - Consistent With
- D - Diarrhea
DC - Discharge; also Discontinue
DDx - Differential Diagnosis
DIF - Differential (with reference to white blood cells)
DM - Diabetes Mellitus
DNI - Do Not Intubate
DNR - Do Not Recusitate
DTs - Delirium Tremens
DTR - Deep Tendon Reflex
DVT - Deep Venous Thrombosis
DX - Diagnosis
DDX - Differential Diagnosis
D/O - Disorder
DTR - Deep Tendon Reflexes
- E/O - Evidence Of
ECHO - Ultrasound Exam of the Heart
ECG - Electrocardiogram (also known as EKG)
EEG - Electroencephalogram
EF - Ejection Fraction (in reference to ventricular function)
EGD - Esophago-Gastro Duodenoscopy
EKG - Electrocardiogram (also known as ECG)
EMG - Electromyelogram
EOMI - Extra Occular Muscles Intact
EPS - Electro-Physiologic Study (used in diagnosis/treatment of cardiac
dysrhythmias)
ERCP - Endoscopic Retrograde Cholangio-Pancreotography
ESRD - End Stage Renal Disease
ETOH - Alcohol
ETT - Exercise Tolerance Test
EX LAP - Exploratory Laparotomy
EXT - Extremities
- FNA - Fine Needle Aspiration
FX - Fracture
- G - Guiac (followed by + or -)
GC - Gonorrhea
GERD - Gastroesophageal Reflux
GI - Gastroenterology
GMR - Gallups, Murmurs, Rubs (with reference to cardiac exam)
GS - Gram Stain
GSW - Gun Shot Wound
GU - Urology
- HCT - Hematocrit
HEENT - Head, Ears, Eyes, Nose, Throat
HEME/ONC - Hematology/Oncology
HI - Homicidal Ideation
HL - Heparin Lock (an IV catheter site)
HPI - History of Present Illness
HSM - Holo-Systolic Murmur (with reference to cardiac exam; also hepato-
splenomegaly)
HTN - Hypertension
HX - History
- ID - Infectious Diseases
IDDM - Insulin Dependent Diabetes Mellitus
I&D - Incise and Drain (with reference to an absecess)
IH - Inguinal Hernia (usually preceded by L or R)
IMI - Inferior Myocardial Infarction
IMP - Impression
IV - Intravenous
IVDU - Intravenous Drug Use
- JVD - Jugular Venous Distention
JVP - Jugular Venous Pressure
- L - Left
LAD - Left Anterior Descending (coronary artery)
LAP - Laproscopic (may also refer to laporotomy)
LBO - Large Bowel Obstruction
LCx - Left Circumflex (coronary artery)
LE - Lower Extremity (usually preceded by R or L)
LENIs - Lower Extremity Non-Invasive Studies (ultrasound used to detect
DVTs)
LMD - Local Medical Doctor
LOA - Lysis Of Adhesions
LP - Lumbar Puncture
LS - Lumbro-Sacral (usually inreference to that area of the spine)
LV FXN - Left Ventricular Function
LVH - Left Ventricular Hypertrophy
- MEDS - Medicines
MI - Myocardial Infarction
MR - Mitral Regurgitation
MRI - Magnetic Resonance Imaging
MS - Mental Status; also Mitral Stenosis and Multiple Sclerosis
MVP - Mitral Valve Prolapse
MVR - Mitral Valve Replacement
- N - Nausea
NA - Not Available
NAD - No Apparent Distress
NABS - Normal Active Bowel Sounds
NIDDM - Non-Insulin Dependent Diabetes Mellitus
NKDA - No Known Drug Allergies
NPO - Nothing By Mouth
NSR - Normal Sinus Rhythm
NUCS - Nuclear Medicine
- OB - Occult Blood (followed by '+' or
'-')
OOB - Out Of Bed
O/P - Oropharynx
O&P - Ovum and Parasistes (in reference to stool examination)
ORIF - Open Reduction with Internal Fixation (refers to repairs of certain
fractures)
ORL - Oto-Rhino Laryngology (i.e. Ear, Nose and Throat)
OSA - Obstructive Sleep Apnea
OTC - Over The Counter
- P - Pulse
P - Pending
P - After
PA - Posterior-Anterior (refers to chest x-ray technique)
PCP - Primary Care Physician (also, Pneumocystis Pneumonia)
PCM - Pacemaker
PE - Physical Exam; also Pulmonary Embolism
PERRL - Pupils Equal, Round, Reactive to Light
PFTs - Pulmonary Function Tests
PLT - Platelets
PMD - Primary Medical Doctor
PMH - Past Medical History
PMI - Point of Maximum Impact
PNA - Pneumonia
PNBX - Prostate Needle Biopsy
PRBCs - Packed Red Blood Cells
PRN - Refers to treatments which patient can receive on an "as needed"
basis
PSH - Past Surgical History
PTA - Prior To Admission (also Peritonsilar Abscess)
PTCA - Percutaneous Transluminal Coronary Angioplasty
PTSD - Post-Traumatic Stress Disorder
PTX - Pneumothorax
PUD - Peptic Ulcer Disease
PVD - Peripheral Vascular Disease
PVR - Post Void Residual
- Q - Every (refers to a time interval...eg.
if followed by 6, means "Every 6 Hours"; if followed by AM, D, W, or M =s
"Every Morning Day, Week, or Month" respectively)
QHS - Every Night
QID - Four times per day
QAC - Prior to all meals
- R - Right
R/B - Referred By
RBC - Red Blood Cell
RCA - Right Coronary Artery
Rheum - Rheumatology
R/O - Rule Out
ROS - Review Of Systems
RR - Respiratory Rate
RRR - Regular Rate and Rhythm (with reference to cardiac exam)
RX - Treatment
- S - Without
2/2 - Secondary To
SBO - Small Bowel Obstruction
SEM - Systolic Ejection Murmur (with reference to cardiac exam)
SI - Suicidal Ideation
S/P - Status Post
STD - Sexually Transmitted Disease
SX - Symptoms
- TAH - Total Abdominal Hysterectomy
THR - Total Hip Replacement
TIA - Transient Ischemic Attack
TID - Three times per day
TKR - Total Knee Replacement
TLC - Triple Lumen Catheter
TM - Tympanic Membrane
TOA - Tubo-Ovarian Abscess
TR - Tricuspid Regurgitation
TURP - Trans-Urethral Prostatectomy
TX - Transfusion
- UA - Urine Analysis (also refers to Uric
Acid)
UCX - Urine Culture
UE - Upper Extremity (usually preceded by R or L)
URI - Upper Respiratory tract Infection
US - Ultrasound
UTI - Urinary Tract Infection
- V - Vomiting
VAX - Vaccine
VF - Ventricular Fibrillation
VS - Vital Signs
VSS - Vital Signs Stable
VT - Ventricular Tachycardia
- WBC - White Blood Cells
WDWN - Well Developed, Well Nourished
- X - Except
XRT - Radiation Therapy
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