| 2/2 | ”Secondary to” | |
| A/P | Assessment and Plan | |
| A+O3 | Alert and Oriented to Person, Time, and Place | Patient is awake/conscious, responsive, and able to make decisions for themselves |
| Alb | Albumin | A protein synthesized by the liver |
| All | Allergic/Immunologic | Notate whether the patient has allergies or other immune conditions |
| ALT | Alanine Aminotransferase | Liver enzyme, works on proteins, elevated when liver damaged |
| AMA | Against Medical Advice | |
| AP | Alkaline Phosphatase | Enzyme, used to diagnose liver disease |
| Appy | Appendectomy | |
| ASA | Aspirin | Decreases blood clotting |
| AST | Aspartate Aminotransferase | |
| AXR | Abdominal X-Ray | |
| B/L | Bi-Lateral | |
| RTC | Return to Clinic | |
| BB | Beta Blocker | |
| BCX | Blood Culture | |
| bilat | Bilateral | |
| BMI | Body Mass Index | |
| BMP | Basic Metabolic Panel | |
| BP | Blood Pressure | |
| BRBPR | Bright Red Blood Per rectum | |
| BS | Breath/Bowel Sounds | |
| BUN | Blood Urea Nitrogen | |
| Bx | Biopsy | |
| C/C/E | Clubbing, Cyanosis, Edema | Fingers: clubbed extremities, blueness, or swelling |
| c/o | Complains of | |
| c/w | Consistent with | |
| Ca | Total Calcium | |
| CA | Cancer | |
| CAD | Coronary Artery Disease | |
| CADRFs | Coronary Artery Disease Risk Factors | Key risk factors for coronary arterial disease (E.g. high BP, smoking, high LDL) |
| cath | Catheterization | |
| CBC | Complete Blood Counter | |
| CC | Chief Complaint | |
| Chem10 | BMP + Ca + Mg + Ph | |
| Chem20 | BMP + Mg + Ph + LFTs | |
| Cl | Chloride | |
| CMP | Comprehensive Metabolic Panel | |
| COPD | Chronic Obstructive Pulmonary Disease | |
| Cr | Creatinine | |
| Cr | Creatinine | |
| CRI | Chronic Renal Insufficiency | |
| CT | Computed tomography | Can also be cardiothoracic |
| CTA | Clear to Auscultation | Patient’s lung sounded normal when listened to with a stethoscope |
| CTX | Ceftriaxone | An antibiotic |
| CVA | Cerebrovascular Accident | |
| CXR | Chest X-Ray | |
| D/C | Discharge | |
| DB | Direct Bilurubin | Water-soluble form of bilirubin processed by the liver |
| DDx | Differential Diagnosis | |
| DES | Drug Eluting Stent | |
| DKA | Diabetic ketoacidosis | |
| DRE | Digital Rectal Exam | |
| DM | Diabetes Mellitus | |
| DM2 | Diabetes Mellitus 2 | |
| DP | Dorsalis Pedis Artery | |
| DZ | Disease! | |
| Echo | Echocardiogram | |
| ED | Emergency Department | |
| EDD | Estimated Discharge Date | |
| EF | Ejection Fraction | |
| EGD/US | Oesophagoduodunem; UltraSound. | (Duodenum is first part of SI) |
| EKG or ECG | Electrocardiogram | |
| EMS | Emergency Medical Services | |
| Endo | Endocrine | |
| ENT | Ears, Nose, Mouth, Throat | |
| EOMI | Extra Ocular Movements Intact | All six muscles controlling the eye are working well |
| ETOH | Alcohol | Ethanol |
| F/U | Follow Up | |
| FamHx | Family History | |
| FOBT | Fecal Occult Blood Test | |
| FSG | Finger Stick Glucose | |
| GI | Gastrointestinal | |
| Glu | Serum Glucose | |
| gtt | Drip | |
| H&P | History & Physical Exam | |
| HA | Headache | |
| Hb | Haemoglobin | |
| HbA1C | Hemoglobin A1C | average blood sugar over last 3 months; measurement of longterm glucose control |
| Hbg or Hb | Haemoglobin | |
| HCO3 | Bicarbonate | |
| HCT | Haematocrit | |
| HCTZ | Hydrochlorothiazide | For hypertension; diuretic |
| HD | Hospital Day | |
| HEENT | Head, Eyes, Ears, Nose, Throat | |
| HFP | Hepatic Function Panel | |
| HPI | History of Present Illness | |
| HR | Heart Rate | |
| HSM | Hepatosplenomegaly | “No HSM” → No enlargement of liver or spleen. |
| HTN | Hypertension | Blood pressure against arteries is >= 130/80 mmHg |
| Hx | History | |
| ICU | Intensive Care Unit | |
| IV | Intravenous | |
| IVDU | Intravenous Drug Use | |
| IVF | Intravenous fluids | |
| JVD | Jugular Vein Distension | Bulging of veins in neck |
| K | Potassium | |
| LAN | Lymphadenopathy | |
| LDL | Low Density Lipoprotein | Bad Cholestrol |
| LE | Lower Extremities | |
| LFT | Liver Function Test | |
| LGIB | Lower GI Bleed | |
| LLE | Left lower extremity | |
| LOMN | Letter of Medical Necessity | |
| LVH | Left Ventricular Hypertrophy | |
| M | Male | |
| m/r/g | Murmurs, Rubs, or Gallops | |
| MDI | Metered Dose Inhaler | |
| MI | Myocardial Infraction | A heart attack, no or reduced blood flow to one or more arteries of the heart |
| MICU | Medical Intensive Care Unit | |
| MSK | Musculoskeletal | |
| N | Nausea | |
| Na | Sodium | |
| NC | Non-Contributory | |
| NCAT | Normal Cephalic Atraumatic | ”The head looks normal” |
| ND | Non-distended | |
| NIFS | Non-Invasive Flow Studies | Test that measures arterial circulation |
| NKDA | No Known Drug Allergies | |
| NSCLCa | Non-small cell lung cancer | |
| NSR | Normal Sinus Rhythm | |
| NSTEMI | Non-ST-Elevation Myocardial Infarction | |
| NT | Non-tender | |
| o/n | Overnight | |
| OA | Osteoarthritis | |
| Op | Operation or Oral Pharynx | |
| Onc | Oncologist | |
| OTC | Over The Counter | |
| PA | Prior Authorization | |
| P | Pending | |
| PCN | penicillin | |
| PCTA | Percutaneous transluminal coronary angioplasty | a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle |
| PE | Physical Exam | |
| PERRLA | Pupils Equal Round & Reactive to Light & Accommodation | Pupils normal: assess brain function, look for neurological disorders |
| PET | Positron Emission Tomography | |
| PFTs | Pulmonary Functions Tests | |
| Plt | Platelets | |
| PMHx | Past Medical History | |
| PO | By Mouth | Per Os |
| PPI | Proton Pump Inhibitor | Used to treat digestive/acid related disorders |
| PRBC | Packed Red Blood Cells | Blood Transfusion |
| PSHx | Past Surgical History | |
| PT | Posterior Tibial Artery | |
| PTA | Prior to Admission | |
| PVD | Peripheral Vascular Disease | |
| QD | Once a Day | Quaque Die |
| R/O | Rule Out | |
| RCA | Right Coronary Artery | |
| Resp | Respiratory | |
| ROS | Review of Systems | |
| RA | Room Air | E.g. SpO2 93% on RA |
| RR | Respiratory Rate | |
| RRR | Regular Rate and Rhythm | |
| RUL | Right Upper Lobe | |
| RUS | Renal Ultrasound | |
| s/p | Status post | |
| S1S2 | First and Second Heart sounds | |
| SI | Suicidal Ideation | |
| SLNTG | Sublingual Nitroglycerin | |
| SOAP | Subjective, Objective, Assessment, Plan. | This is the structure that they use to exchange information. Residents → Attending. |
| SOB | Shortness of Breath | |
| SpO2 | Amount of O2 in the Blood | |
| SocHx | Social History | |
| SRS | Stereotactic Radiosurgery | |
| STEMI | ST-Elevation Myocardial Infarction | |
| SUD | Substance Abuse Disorder | |
| Swer | Social Worker | |
| T | Temperature | |
| TAH | Total Abdominal Hysterectomy | |
| TB | Total Bilurubin | ”A blood test measuring the yellow pigment produced during the normal breakdown of red blood cells, indicating liver, gallbladder, or red blood cell health” |
| Tele | Telemetry | |
| Tm | Temperature Max | |
| TOB | Tobacco | PPD is Packs Per Day |
| TP | Total Protein | Concentration of Protein in Serum |
| TPN | Total Parenteral Nutrition | A method of delivering all essential nutrients—including proteins, carbohydrates, fats, vitamins, and minerals—directly into a person’s bloodstream via an intravenous (IV) catheter, bypassing the digestive system entirely |
| Trop | Troponin | Enzyme released when there is muscle damage / tissue damage in the heart |
| TSH | Thyroid Stimulating Hormone | |
| Tx | Transfer | |
| UA | Urinalysis | |
| Ucx | Urine Culture | |
| US | Ultrasound | |
| USOH | Usual State of Health | Normal health: good physical, mental, and social well-being |
| UTI | Urinary Tract Infection | |
| V | Vomiting | |
| VATS | Video-Assisted thoracoscopic surgery | |
| VSS | Vital Signs Stable | Temp, BP, Pulse, RR are stable |
| WBC | White Blood Cells | |
| WBRT | Whole brain radiation therapy | |
| wnl | Within normal limits | E.g. “CBC wnl”, “BMP wnl”, “Coags wnl” |
| WOB | Work of Breathing | E.g. “Increased WOB” |
| WAWN | Well Appearing Well Nourished | |
| WWP | Warm and Well Perfused | |
| yo | year old | |
| lipo | Liposuction | |