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111 Cards in this Set

  • Front
  • Back
CC
chief complaint
OH
occupational Hx
PR
through rectum
BRP
bathroom privileges
PACU
postanesthetic care unit
PH
past medical Hx
D/C
discharge or discontinue
Sig:
label, patient instruction
ER
emergency room
ICU
intensive care unit
R/O
rule out
NPO
nothing by mouth
L&W
living and well
BP
blood pressure
AU
both ears
Sx
symptoms
VS
vital signs
ROS
review of systems
pt
patient
OD
right eye
Sub-Q
subcutaneous - under the skin
H&P
Hx and physical
TX
treatment or traction
Dx
diagnosis
HPI
Hx of present illenss
febrile
relating to fever - elevated fever
syndrome
set of symptoms characteristic of disease or condition
chronic
developing slowly, lasting
remission
period where symptoms or signs stop or abate
etiology
study of cause of a disease
malignant
cancerous
prognosis
probable outcome of a disease
Dx
name of disease based on Hx, exam, and testing
Exacerbation
increase in severity with aggravation of symptoms
localized
limited to a definite are or part
Po
route of oral medications
OR
place for surgery
Ad lib
as desired
SOAP
progress note
#
pound
p.r.n.
as needed
parenteral
by injection
pre-op
before surgery
stat
immediately
OH example
works as a secruity officer
UCHD (usual childhood diseases) example
had all commonly contracted childhood diseases
HPI example
pain in the lower back for 2 weeks, worse @ night
PE (physical exam) example
lungs: clear
heart: regular rate and rhythm
CC example
lower back pain
SH (social Hx)
quit smoking 2 years ago, drinks alcohol socially
FH (family Hx) example
father, age 88, L&W
mother, age 78, died, stroke
P (plan) example
advised to lower salt intake
A (assessment) example
Ex: tonsillitis
NKA (no known allergies)
no reaction to any previously administered drug
using ionizing radiation
computed tomography, radiology, radionuclide organ imaging
computed tomography
3D x-rays
magnetic resonance imaging (MRI)
radio waves
radiology
standard x-rays
radionuclide organ imaging
gamma rays
sonography
ultrasound waves
a (line above) (ante)
before
a.c. (ante cibum)
before meals
a.m. (ante meridiem)
before noon
b.i.d. (bis in die)
twice a day
d
day
h (hora)
hour
h.s. (hora somni)
at hour of sleep (bedtime)
noc. (noctis)
night
p (line over) (post)
after
p.c. (post cibum)
after meals
p.m. (post meridiem)
after noon
p.r.n. (pro re nata)
as needed
q (quaque)
every
q d (quaque die)
every day
q h (quaque hora)
every hour
q 2 h
every 2 hours
q.i.d. (quater in die)
four times a day
q.o.d. (quaque altera die)
every other day
STAT
immediately
t.i.d. (ter in die)
three times a day
wk
week
yr
year
AD (auris dextra)
right ear
AS (auris sinistra)
left ear
AU (aures unita)
both ears
ad lib. (ad libitum)
as desired
amt
amount
aq (aqua)
water
B (encircled)
bilateral
C
celsius, centigrade
c (line over) (cum)
with
F
Fahrenheit
m (encircled)
murmur
NPO (non per os)
nothing by mouth
OD (oculus dexter)
right eye
OS (oculus sinister)
left eye
OU (oculus unitas)
both eyes
per
by or through
p.o. (per os)
by mouth
PR (per rectum)
through rectum
PV (per vagina)
through vagina
q.n.s.
quantity not sufficient
q.s.
quantity sufficent
Rx
recipe; prescription
Sig: (signa)
label; instruction to the patient
s (line over) (sine)
without
ss (line over) (semis)
one-half
w.a.
while awake
x
times or for [e.g., x 6 (six times), x 2 d (for 2 days)]
>
greater than
<
less than