Chapter 2 terms and abbreviations
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| HR | Heart Rate or Pulse
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| RR | Respiratory Rate
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| BP | Blood Pressure
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| T | Temperature
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| Ht | Height
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| Wt | Weight
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| BMI | Body Mass Index
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| SOAP | Subjective, Objective, Assessment, Plan
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| Discharge | to send home or fluid coming out of a part of the body
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| Prophylaxis | Preventative Treatment
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| acute | started recently; short term illness
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| chronic | Long term or ongoing illness
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| abrupt | all of a suddent
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| exacerbation | It's getting worse
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| febrile | fever
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| afebrile | does not have fever
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| malaise | not feeling well
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| progressive | increases more and more each day
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| symptom (sx) | how a patient says they feel
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| Noncontributory | not related to a specific problem
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| lethargic | a decrease in level of consciousness; feeling of no energy
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| genetic/hereditary | it runs in the family
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| Alert | Able to answer questions; responsive
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| Oriented x3 | Aware of who they are, where they are and the current time/day
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| Marked | Something stands out (such as on an x-ray or MRI)
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| Unremarkable | Normal results or no findings on images
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| Auscultation | "to listen" (ex. listening with stethoscope)
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| Percussion | to hit something and listen to resulting sound or feel for vibration
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| Palpation | "to feel" (ex. Doctor may feel abdomen to see if tenderness occurs.)
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| Impression | a.k.a. "assessment"
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| Diagnosis (Dx) | What the health care provider had decided is wrong with the patient.
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| Differential Diagnosis (DDx) | Based on symptoms and test results, more than diagnosis is possible;
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| Benign | safe or not cancerous
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| Malignant | Danger or it is Cancer
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| Degeneration | It's getting worse
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| Remission | Most often used to discuss cancer. It does not mean the cancer has been completely cured, but not currently having symptoms
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| Idiopathic | No known specific cause of illness
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| Localized | In a particular part of the body
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| Systemic/Generalized | Over most or all of the body
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| Prognosis | The changes for things getting better or worse.
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| Occult | means "hidden"
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| Lesion | Diseased tissue
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| Recurrent | to have again
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| Sequela | a problem resulting from a disease of injury
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| Pathogen | the organism that caused the illness
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| morbidity | the risk for being sick
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| Mortality | the risk for dying
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| etiology | the cause of the disease or pathogen
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| Disposition | what happened to the patient at the end of the visit (used mostly in ER visits)
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| Palliative | Treating the symptoms, but not a cure. (Making the patent comfortable.)
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| Sterile | Germ free conditions
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| Chief Complaint (CC) | Main reason for patient's visit. Goes under Subjective section; also describes how the patients says they feel. See also HPI
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| History of Present Illness (HPI) | Same as "Chief Complaint"
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| Review of Systems (ROS) | A review of the individual body systems to determine if any are related to the main problem.
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| Past medical history (PMHx) | Anything the patient has previously been diagnosed with or treated for.
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| Past Surgical history | Any previous surgeries are documented here.
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| Family history (FHx) | Usually contains information about immediate family members; documents significant illnesses that could run in the patient's family.
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| Social history | A record of history of smoking, drinking, drug abuse, or sexual practices that could impact health
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| Tx | Treatment
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| Rx | Prescription
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| H & P | History and Physical
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| Hx | History
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| NKDA | No Known Drug Allergies
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| NKA | No Known Allergies (food or drug)
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| PE | Physical Exam
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| Pt | Patient
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| y/o | years old
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| PCP | Primary Care Provider
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| f/u | follow up
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| SOB | Shortness of Breath
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| HEENT | Head, eyes, ears, nose, and throat
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| CV | Cardiovascular
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| RRR | Regular Rate Rhythm
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| NOS | Not otherwise specified
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| NEC | Not elsewhere classified
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| PO | By mouth
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| NPO | Nothing by mouth
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| IM | Intramuscular
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| IV | Intravenous
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| PICC | Peripherally inserted central catheter
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| Sig | Instructions short for signa; "label"
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| BID | Twice daily
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| TID | Three times daily
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| QD | daily or each day
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| QID | Four times daily
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| QHS | at night or at bedtime
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| AC | before meals
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| PC | after meals
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| prn | as needed
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| Sub q | Subcutaneous
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