| Term | Definition |
|---|
| H & P | History and Physical |
| Hx | History |
| CC | Chief Complaint |
| c/o | complains of |
| HPI (PI) | History of Present Illness (Present Illness) |
| Sx | Symptom |
| PMH (PH) | Past Medical History (Past History) |
| UCHD | usual childhood diseases |
| NKA | no known allergies |
| NKDA | no known drug allergies |
| FH | family history |
| SH | Social History |
| OH | Occupational History |
| ROS (SR) | Review of Symptoms (Systems Review) |
| PE (Px) | Physical Examination |
| HEENT | head, eyes, ears, nose, throat |
| NAD | no acute distress, no appreciable disease |
| PERRLA | pupils equal, round, and reactive to light and accomodation |
| WNL | within normal limits |
| Dx | Diagnosis |
| IMP | impression |
| A | assessment |
| R/O | Rule out |
| P | Plan or recommendation or disposition |
| CCU | coronary (cardiac) care unit |
| ECU | emergency care unit |
| ER | Emergency Room |
| ICU | Intensive care unit |
| IP | inpatient (registered bed patient) |
| OP | outpatient |
| OR | operating room |
| PACU | postanesthetic care unit |
| PAR | postanesthetic recovery |
| post-op/postop | postoperative (after surgery) |
| pre-op/ preop | preoperative (before surgery) |
| RTC | return to clinic |
| RTO | return to office |
| BRP | bathroom privileges |
| CP | chest pain |
| DC, D/C | discharge, discontinue |
| ETOH | ethyl alcohol |
| pt | patient |
| RRR | regular rate and rhythm |
| SOB | shortness of breath |
| Tr | Treatment |
| Tx | Treatment or traction |
| VS | vital signs |
| T (vital sign) | temperature |
| P (vital sign) | pulse |
| R (vital sign) | respiration |
| BP (vital sign) | blood pressure |
| Ht (vital sign) | height |
| Wt (vital sign) | weight |
| WDWN | well-developed and well-nourished |
| y.o. | year old |
| # | number or pound (#2-number 2 or 150#-150lbs) |
| acute | sharp, having intense, often severe symptoms and a short course |
| chronic | a condition developing slowly and persisting over time |
| benign | mild or noncancerous |
| malignant | harmful or cancerous |
| degeneration | gradual deterioration of normal cells and body functions |
| degenerative disease | any disease in which there is deterioration of structure or function of tissue |
| diagnosis | determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results), (dia=through, gnosis=knowing) |
| etiology | cause of a disease (etio=cause) |
| exacerbation | increase in severity of a disease with aggravation of symptoms (ex=out, acerbo=harsh) |
| remission | a period in which symptoms and signs stop or abate |
| febrile | relating to a fever (elevated temperature) |
| gross | large, visible to the naked eye |
| idiopathic | a condition occurring without a clearly identified cause (idio=one's own) |
| localized | limited to a definite area or part |
| systemic | relating to the whole body rather than only a part |
| malaise | a feeling of unwellness, often the first indication of illness |
| marked | significant |
| equivocal | vague, questionable |
| morbidity | sick, a state of disease |
| morbidity rate | the number of cases of a disease in a given year, the ratio of sick to well individuals in a given population |
| mortality | the state of being subject to death |
| prognosis | foreknowledge, prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease |
| progressive | the advance of a condition as signs and symptoms increase in severity |
| prophylaxis | a process or measure that prevents disease (pro=before, phylassein=to guard) |
| recurrent | to occur again, describes a return of symptoms and signs after a period of quiescence (rest or inactivity) |
| sequela | a disorder or condition after, and usually resulting from, a previous disease or injury |
| sign | a mark, objective evidence of disease that can be seen or verified by an examiner |
| symptom | occurence, subjective evidence of disease that is perceived by the patient and often noted in his or her own words |
| syndrome | a running together, combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease |
| noncontributory | not involved in bringing on the condition or result |
| unremakable | not significant or worthy of noting |
| cc | cubic centimeter |
| cm | centimeter |
| g or gm | gram |
| kg | kilogram |
| L | liter |
| mg | milligram |
| ml, mL | milliliter |
| mm | millimeter |
| cu mm | cubic millimeter |
| fl oz | fluid ounce |
| gr | grain |
| gt | drop (gutta-drop) |
| gtt | drops |
| dr | dram (1/8 ounce) |
| oz | ounce |
| lb or # | pound |
| qt | quart |
| tab | tablet |
| cap | capsule |
| suppos | suppository |
| fluid | route-inhalation |
| parenteral | route-by injection |
| ID | intradermal-within the skin |
| IM | intramuscular-within the muscle |
| IV | intravenous-within the vein |
| Sub-Q, SC, SQ | subcutaneous-under the skin |
| topical | surface of the skin |
| transdermal | absorption of a drug through unbroken skin |
Combine with other sets
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