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Med Term Chapter 2

TermDefinition
SOAP Subjective, objective, assessment, plan
VS vital signs
HR heart rate
RR respiratory rate
BP blood pressure
T Temperature
Ht height
Wt weight
BMI Body Mass Index
I/O input/output
Dx Diagnosis
DDx Differential diagnosis
Tx Treatment
Rx Prescription
Hx history
PMHx Past medical history
FHx family history
H&P History and physical
CC Chief complaint
HPI history of present illness
ROS review of symptoms
PE physical exam
PCP primary care provider
NKDA no known drug allergies
Pt Patient
y/o years old
h/o history of
f/u follow up
PO per os (by mouth)
IV intravenous
SC subcutaneous
CVL central venous line
IM intramuscular
PR per rectum
NPO nil per os (nothing by mouth)
BID twice daily
TID three times daily
Q every x time (Q4hour = every 4 hours)
QD each day
QHS every night
AC before food
PC after food
PRN as needed
ad lib as desired
SOB shortness of breath
HEENT head, eyes, ears, nose, throat
PERRLA pupils equal, round, reactive to light and accomodation
NOD no acute distress
CV cardiovascular
CTA clear to auscultation
WDWN well developed, well nourished
A&O alert and oriented
WNL within normal limits
NOS not otherwise specified
NEC Not elsewhere classified
RRR Regular rate and rhythm
Created by: baileyjones21
 

 



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