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151 Cards in this Set
- Front
- Back
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H & P
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History and Physical
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Hx
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history
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CC
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chief complaint
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c/o
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complains of
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HPI or PI
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history of present illness
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Sx
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symptom
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PMH (PH)
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Past Medical History
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UCHD
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usual childhood diseases
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NKA
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no known allergies
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NKDA
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no known drug allergies
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FH
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family history
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SH
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social history
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OH
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occupational history
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ROS
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review of systems
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PE (Px)
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Physical examination
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HEENT
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head, eyes, ears, nose, throat
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NAD
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no acute distress, no appreciable disease
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PERRLA
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pupils equal, round, and reactive to light and accommodation
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WNL
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within normal limits
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Dx
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diagnosis
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IMP
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impression
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A
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assesment
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R/O
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rule out
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P
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plan
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CCU
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coronary (cardiac) care unit
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ECU
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emergency care unit
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ER
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emergency room
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ICU
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intensive care unit
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IP
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inpatient
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OP
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outpatient
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OR
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operating room
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PACU
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post-anesthetic care unit
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PAR
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post-anesthetic recovery
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post-op
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post-operative (after surgery)
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pre-op
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pre-operative (before surgery)
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RTC
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return to clinic
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RTO
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return to office
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BRP
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bathroom privledges
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CP
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chest pain
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DC, D/C
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discharge, discontinue
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ETOH
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ethyl alcohol
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pt
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patient
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RRR
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regular rate and rhythm
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SOB
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shortness of breath
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Tr
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treatment
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Tx
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treatment
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VS
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vital signs
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T
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temperature
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P
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pulse
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R
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respiration
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BP
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blood pressure
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Ht
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height
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Wt
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weight
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WDWN
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well-developed and well-nourished
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y.o.
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year old
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#
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number or pounds
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↑
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increased
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↓
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decreased
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acute
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sharp; having intense, often severe symptoms and a short course
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chronic
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a condition developing slowly and persisting over time
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benign
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mild or noncancerous
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malignant
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harmful or cancerous
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degeneration
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gradual deterioration of normal cells and body functions
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degenerative disease
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any disease in which there is deterioration of structure or function of tissue
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diagnosis
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determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings
(dia=through, gnosis=knowing) |
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etiology
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cause of a disease
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exacerbation
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increase in severity of a disease with aggravation of symptoms
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remission
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a period in which symptoms and signs stop of abate
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febrile
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relating to a fever (elevated temperature)
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gross
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large; visible to naked eye
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idiopathic
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a condition occurring without a clearly identified cause
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localized
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limited to a definite area or part
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systemic
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relating to the whole body rather than only a part
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malaise
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a feeling of unwellness, often the first indication of illness
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marked
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significant
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equivocal
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vague, questionable
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morbidity
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sick; a state of disease
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morbidity rate
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the number of cases of a disease in a given year; the ration of sick to well individuals in a given population
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mortality
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the state of being subject to death
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mortality rate
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death rate; ratio of the total number of deaths to total number in a given population
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prognosis
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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
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progressive
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the advance of a condition as signs and symptoms increase in severity
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prophylaxis
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a process or measure that prevents disease (pro=before; phylassein=to guard)
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recurrent
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to occur again; describes a return of symptoms and signs after a period of quiescence (rest or inactivity)
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sequela
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a disorder or condition after, and usually resulting from, a previous disease or injury
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sign
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a mark; objective evidence of disease that can be seen or verified by an examiner
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symptom
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occurrence; subjective evidence of disease that is perceived by the patient and often noted in his or her own words
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syndrome
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a running together; combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease, e.g. menopausal syndrome
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noncontributory
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not involved in bringing on the condition or result
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unremarkable
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not significant or worthy of noting
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cc
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cubic centimeter (1cc=1mL)
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cm
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centimeter
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g or gm
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gram
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kg
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kilogram
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L
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liter
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mg
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milligram
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ml, mL
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milliliter
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mm
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millimeter
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cu mm
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cubic millimeter
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fl oz
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fluid ounce
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gr
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grain
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gt
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drop
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gtt
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drops
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dr
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dram (1/8 ounce)
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oz
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ounce
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lb or #
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pound (16 ounces)
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qt
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quart (32 ounces)
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a.c.
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before meals
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a.m.
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before noon
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b.i.d.
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twice a day
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d
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day
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h
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hour
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h.s.
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at hour of sleep (bedtime)
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noc.
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night
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p.c.
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after meals
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p.m.
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after noon
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p.r.n.
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as needed
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q
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every
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q d
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every day
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q h
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every hour
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q 2 h
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every 2 hours
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q.i.d.
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four times a day
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q.o.d.
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every other day
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STAT
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immediately
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t.i.d.
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three times a day
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wk
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week
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yr
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year
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AD
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right ear
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AS
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left lear
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AU
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both ears
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ad lib.
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as desired
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amt
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amount
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aq
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water
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C
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celcius, centigrade
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F
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Fahrenheit
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NPO
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nothing by mouth
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OD
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right eye
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OS
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left eye
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OU
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both eyes
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per
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by or through
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p.o.
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by mouth
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PR
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through rectum
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PV
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through vagina
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q.n.s
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quantity not sufficient
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q.s.
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quantity sufficient
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Rx
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recipe, prescription
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Sig:
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label; instruction to the patient
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w.a.
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while awake
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x
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times or for
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>
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greater than
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<
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less than
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