Term | Definition |
abdomen, abdominal | Abd |
antibiotics | Abx |
atrial fibrillation | A fib |
acute otitis media | AOM |
assessment and plan | A/P |
acetylsalicylic Acid (Aspirin) | ASA |
twice dailing | BID |
bilateral lower extremities | Bilat LE |
bowel movement | BM |
blood pressure | BP |
with | c (with line on top) |
cancer, carcinoma | CA |
coronary artery bypass graft | CABG |
coronary artery disease | CAD |
complete blood count | CBC |
congestive heart failure | CHF |
chest pain | CP |
complains of | c/o |
chronic obstructive pulmonary disease | COPD |
chronic renal failure | CRF |
caesarean section | C-section |
cervical spine | C-spine |
computerized assisted tomography | CT or CAT |
clear to auscultation | CTA |
cardiovascular | CV |
cerebrovascular accident | CVA |
chest x-ray | CXR |
diabetes mellitus | DM |
dyspnea on extertion | DOE |
dorsalis pedis/ posterior tibialis | DP/PT (pulse) |
deep vein thrombosis | DVT |
diagnosis | Dx |
electrocardiogram | EKG/ECG |
extraocular movement intact | EOMI |
alcohol | EtOH |
family history | FHx |
follow up | F/U |
fracture | Fx |
grastroesophageal reflux disease | GERD |
gastrointestinal | GI |
gravida/para/abortion | G/P/Ab |
genitourinary | GU |
headache | HA |
head, ears, eyes, nose, throat | HEENT |
health insurance portability and accountability act | HIPAA |
hyperlipidemia | HLD |
history of present illness | HPI |
hypertension | HTN |
history | Hx |
hemoglobin and hematocrit | H&H |
incisions and drainage | I&D |
insulin dependent diabetes mellitus | IDDM |
intrauterine pregnancy | IUP |
intravenous drug absue | IVDA |
left lower extremity | LLE |
left lower quadrant | LLQ |
last normal menstrual period | LNMP |
loss of consciousness | LOC |
lumbar spine | L-spine |
left upper extremity | LUE |
left upper quadrant | LUQ |
myocardial infarction | MI |
not applicable | N/A |
no acute distress, no acute disease | NAD |
non-insulin dependent diabetes mellitus | NIDDM |
no known drug allergies | NKDA |
normal | nl/nml |
non steroidal anti-inflammatory drug | NSAID |
normal sinus rhythm | NSR |
nausea/vomiting, diarrhea | N/V/D |
oxygen saturation | O2 sat |
obstetrics and gynecology | OB/GYN |
overdose | OD |
otitis media | OM |
oropharynx | OP |
open reduction and internal fixation (orthopedic surgery) | ORIF |
primary care physician/Primary medical doctor | PCP/PMD |
physical exam/pulmonary embolism | PE |
pupils are equal, round and reactive to light | PERRL |
per Os (by mouth) | PO |
as needed | prn |
patient | pt |
prior to arrival or peritonsillar abscess | PTA |
peripheral vascular disease | PVD |
every | q |
every day | QD |
at every bedtime | QHS |
four times a day | QID |
right lower extremity | RLE |
right lower quadrant | RLQ |
range of motion | ROM |
review of system | ROS |
regular rate and rhythm | RRR |
right upper extremity | RUE |
right upper quadrant | RUQ |
prescription | Rx |
rule out | r/o |
shortness of breath | SOB |
subjective, objective, assesment, and plan | SOAP |
status post (after) | s/p |
symptoms | Sx |
S/T elevation myocardial infarction | STEMI |
tonsillectomy and adenoidectomy | T&A |
transient ischemic attack | TIA |
three times a day | TID |
tympanic membrane | TM |
treatment | Tx |
Thoracic spine | T-spine |
urinalysis | UA |
upper respiratory infection | URI |
ultrasound | US |
up to date | UTD |
urinary tract infection | UTI |
within normal limits | WNL |
years old | y/o |