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PhysAssist Scribe U. 2012 - Appendix B: Medical Abbreviations

PhysAssist Scribe U. 2012 Appendix B: Medical Abbreviations NOTE: TOLD WHAT THE ABBREVIATION STANDS FOR, WRITE OUT ABBREVIATION WITH CORRECT CASE & PUNCTUATION
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AFib
Atrial Fibrillation
AAA
Abdominal aortic aneurysm
AB
Abortion
abd
Abdomen, Abdominal
ABG
Arterial Blood Gas
abx
Antibiotic
AMA
Against Medical Advice
AMI
Acute Myocardial Infarction
AMS
Altered mental status
approx
Approximately
appt
Appointment
appy
Appendectomy
ASA
Acetylsalicylic Acid (Aspirin)
Auto/Ped
automobile vs. pedestrian
A&O x3
Alert & Oriented x3 (person, place, time)
BBS
Bilateral Breath Sounds
BCP
Birth Control Pill
bilat
Bilateral
BLE
Bilateral lower extremities
BM
Bowel movement
BP
Blood Pressure
BS
Bowel sounds, breath sounds
BSG
Blood Sugar Glucose
BUE
Bilateral upper extremities
CABG
Coronary Arterial Bypass Graft
CAD
Coronary Artery Disease
cath
Catheter, catheterization
CBC
Complete Blood Count
CHF
Congestive Heart Failure
CHI
Closed Head Injury
chole
Cholecystectomy
CMT
Cervical Motion Tenderness
CNS
Central Nervous System
c/o
Complains of
CO2
Carbon Dioxide
COPD
Chronic Obstructive Pulmonary Disease
CP
Chest Pain
CPAP
Continuous Positive Airway Pressure
CPR
Cardiopulmonary Resuscitation
C&S
Culture & Sensitivity
CSF
Cerebrospinal Fluid
CTA
Clear to Auscultation, CT Angiogram
CV
Cardiovascular
CVA
Cerebrovascular Accident
CVAT
Costovertebral angle tenderness
CXR
Chest X-Ray
C-Collar
Cervical collar
C-Spine
Cervical spine
C-Section
Cesarean section
d/c
Discontinue
DIP
Distal Interphalangeal (joint)
DJD
Degenerative Joint Disease
DKA
Diabetic Ketoacidosis
DM
Diabetes mellitus
DNR
Do not resuscitate
DTR
Deep tendon reflex
DVT
Deep vein thrombosis
Dx, dx
Diagnosis
EKG (ECG)
Electrocardiogram
EOMI
Extra ocular movements intact
epi
Epinephrine
EtOH
Ethyl Alcohol (consumption, dependency)
ETT
Endotracheal Tube
FB
Foreign body FHT
FHT
Fetal heart tone
FROM
Full Range of Motion
FTN
Finger-to-nose (coordination test)
Fx
Fracture
F/U
Follow Up
GB
Gallbladder
GCS
Glasgow Coma Scale
GERD
Gastro Esophageal Reflux Disease
GSW
Gunshot wound
HA
Headache
Hgb
Hemoglobin
HCT
Hematocrit
HTN
Hypertension
h/o
History of
HR
Heart rate
Hx
History
Hyst
Hysterectomy
IBS
Irritable bowel syndrome
ICD
Implantable cardioverter- defibrillator
ICE
Ice, compression, elevation
ICH
Intracranial hemorrhage
ICP
Intracranial pressure
IM
Intramuscular
IUP
Intrauterine pregnancy
IV
Intravenous
IVPB
Intravenous piggyback
I&D
Incision and Drainage
JVD
Jugular venous distension
KUB
Kidneys, ureters, bladder (X-ray)
L
Left
lac
Laceration
LBBB
Left bundle branch block
LFT
Liver function test
LLQ
Left Lower Quadrant
LMP
Last Menstrual Period
LNMP
Last Normal Menstrual Period
LOC
Loss of Consciousness
LP
Lumbar Puncture
L-spine
Lumbar spine
LUQ
Left Upper Quadrant
LVH
Left Ventricular Hypertrophy
MAEW
Moves all extremities well
med, meds
Medication; Medications
MI
Myocardial Infarction
MIP
Metacarpointerphalangeal (joint)
MVC
Motor Vehicle Collision
NAD
No Acute Distress
NCAT
Normocephalic, atraumatic
NG
Nasogastric
NH
Nursing Home
NKA
No known allergies
NKDA
No known drug allergies
nl
Normal
NPO
Nothing per os (by mouth)
NRB
Nonrebreather (oxygen mask)
NSR
Normal Sinus Rhythm
NTG
Nitroglycerin
N/V
Nausea and vomiting
N/V/D
Nausea, Vomiting, Diarrhea
NVID
NeuroVascularly Intact Distally
NS
Normal Saline
O2
Oxygen
obs
Observe
OD
Overdose
Ortho
Orthopedic; orthopedics
PA & Lat
Posteroanterior and lateral (x-rays)
palp
Palpation
PCN
Penicillin
PCP
Primary Care Physician
PE
Pulmonary embolism
PERRLA
Pupils equal, round and reactive to light and accommodation
PID
Pelvic Inflammatory Disease
PIP
Proximal interphalangeal (joint)
post-op
Post operative
PPD
Packs per day (cigarettes)
preg
Pregnancy, pregnant
PRN
As needed
Pt
Patient
PTA
Prior to Arrival
PTX
Pneumothorax
PUD
Peptic Ulcer Disease
PVC
Premature ventricular contractions
PVD
Peripheral Vascular Disease
q
Each, Every
q.d.
Every day
q.h.
Every hour
q.h.s.
At Bedtime, every night
R
Right
RA
Room Air
RA
Rheumatoid Arthritis
RBBB
Right Bundle Branch Block
RBC
Red blood cells
resp
Respiration, respiratory
RICE
Rest, ice, compression, elevation
RLQ
Right Lower Quadrant
R/O
Rule out
ROM
Range of Motion
RR
Respiratory rate
RRR
Regular rate and rhythm
RUQ
Right Upper Quadrant (of Abdomen)
Rx
Prescription
SBO
Small bowel obstruction
scope
Arthroscopy, Endoscopy
script
Prescription
SEM
Systolic Ejection Murmur
SI
Sacroiliac (joint)
SLR
Straight-leg raise
SOB
Shortness of Breath
sono
Sonogram
s/p
Status Post
SP
Suprapubic
SR
Sinus Rhythm
STAT, stat
At once, immediately
STD
Sexually transmitted disease
strep
Streptococcus
SVT
Supraventricular tachycardia
Sx
Symptoms
tachy
Tachycardia
TIA
Transient Ischemic Attack
TM
Tympanic Membrane
trach
Tracheotomy, tracheostomy
T-spine
Thoracic spine
TTP
Tender to palpation
Tx
Treatment
UA
Urinalysis
UDS
Urine Drug Screen
URI
Upper Respiratory Infection
US
Ultrasound
UTD
Up to date
UTI
Urinary Tract Infection
V-Fib
Ventricular fibrillation
VS
Vital Signs
VSS
Vital Signs Stable
V-Tach
Ventricular tachycardia
WBC
White Blood Count
W/D
Warm and Dry
WDWN
Well-developed, well- nourished
WNL
Within Normal Limits
YTD
Year to date