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MT Abb History etc.

MT Abbr. History Exams Office Diagnostiv

TermDefinition
H & P history & physical
Hx history
HPI history present illness
PH past history
FH family history
PI present illness
ROS review of systems
W white
y/o year old
DOB date of birth
L&W living & well
A&W alive & well
Pt patient
LMP last menstrual period
ADL Activities of daily living
N/A not applicable
PE physical examination
WNL within normal limits
WD well developed
WN well nourished
CC chief complaint
S/S signs & symptoms
C/O complains of
R/O rule out
Imp impression
Dx diagnosis
R/T related to
Etiol etiology
Rx/Tx treatment, prescription, therapy
sig. let it be labeled
D/C discontinue
ht height
wt weight
OV office visit
NS no show
DKA did not keep appt.
AMA against medical advice
F/U follow up
VO verbal order
TO telephone order
X-ray x-ray
CAT computerized axial tomography
CT computerized tomography
MRI Magnetic resonance imaging
Procto proctoscopic examination
TUR TURP transurethral resection or transurethral resection of the prostate
Cysto cystoscopy
IVP intravenous pyelogram
IV intravenous
KUB kidneys, ureters & bladder (test)
UA urinalysis
Lap laparoscopy
Bx biopsy
VS or V/S vital signs
T temperature
p.o. per mouth (per oral)
R rectally or respirations
AX axillary
Tym tympanic
P pulse
BP blood pressure
AKA above knee amputation
AODA alcohol & other drug abuse
Ca cancer
DOA dead on arrival
DT's delirium tremors
Fx fracture
N&V nausea & vomiting
OD overdose
FUO fever unknown origin
UTI urinary tract infection
MVA motor vehicle accident
TKA total knee arthroplasty
THA total hip arthroplasty
FBS fasting blood sugar
Created by: 100001916589047
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