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211 Cards in this Set
- Front
- Back
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-
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negative; deceased (especially if in parentheses)
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+
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positive; living (especially if in parentheses)
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4Q
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four quadrants
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A
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assessment; Achilles
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AAA
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abdominal aortic aneurysm; acute anxiety attack
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ABD
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abdomen; abdominal
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ABG
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arterial blood gases
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ACEI
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angiotensin-converting enzyme inhibitor
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ACS
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acute coronary syndrome
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ADM
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admission
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ADR
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adverse drug reaction
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AFIB
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atrial fibrillation
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AFVSS
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afebrile, vital signs stable
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AIDS
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acquired immunodeficiency
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All
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allergy; allergies
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AMA
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against medical advice
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AMI
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acute myocardial infarction
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AO; A&O; A/O
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alert(awake) & oriented
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AO3; A&O x3
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alert (awake) & oriented to person, place and time
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AO4; A&O x4
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alert (awake) & oriented to person, place,time and object
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AOB
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alcohol on breath(board)
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A/P
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assessment and plan
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APAP
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acetaminophen
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APGAR
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appearance, pulde, grimace, activity, and respiration
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ARB
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angiotensin II recepter blocker
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ARF
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acute tenal failure
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ARI
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acute renal insufficiency
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ARS
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adult respiratory syndrome
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ASA
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aspirin
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B
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biceps
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BB
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beta blocker
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BF
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black female
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BG
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blood glucose
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BH
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behavioral health
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BHU
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Behavioral health unit
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biPAP
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bi-level(biphasic) positive airway pressure
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BL; B/L
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bilateral
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BM
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black male
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BP
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blood pressure
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BPH
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benign prostate hyperplasia
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BPM
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beats per minute
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BR
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brahioradialis
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BRP
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bathroom privileges
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BS
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breath sounds; bowel sounds
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BVM
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bag-valve-mash
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c (w/ line over it)
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with
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C
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centigrade; celsius; carotid [pulse]
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CA
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cancer
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CABG
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coronary artery bypass graft
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CAD
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coronary artery disease
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CAO
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conscious, alert & oriented
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CC
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chief complaint (often small case)
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CCB
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calcium channel blocker
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C/C/E
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clubbing-cyanosis-edema
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CHF
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congestive heart failure
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CF
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caucasian female
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CM
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caucasiam male
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CN
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cranial nerve(s)
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CNS
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central nervouse system
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C/O
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complains of
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COPD
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chronic obstructive pulmonary disease
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CRI
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chronic renal insufficiency
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CTA
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clear to auscultation
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CTABL
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clear to auscultation bilaterally
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CV
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cardiovascular
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CVA
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cerebral vascular accident
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DC; D&C
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discharge; discontinue(d); deceased
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D&C
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dilation and curettage
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DM
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diabetes
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DNR
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do not resuscitate (revive)
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DOB
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date of birth
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DOE
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dyspnea on exertion
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DP
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doraslis pedis [pulse]
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DT
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delirium tremens
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DTR
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deep tendon reflexes
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DVT
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deep vein thrombosis
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Dx
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diagnosis
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EAC
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extermal auditory canal
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ED
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emergency dept
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EENT
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eyes, ears, nose, throat
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EMS
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emergency medical sevices
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EOM
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extraocular muscles
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EOMI
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extraocular muscles intact
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ER
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emergency room
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EtOH
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ethanol; ethyl alcohol
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F
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father; fahrenheit
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FDLMP
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first day of last menstrual period
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FDLNMP
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first day of last normal menstraul period
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FEM
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femoral [pulse]; female
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FH; FHx
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family history
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GI
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gastrointestinal
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GMF
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general medical floor
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GU
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genitourinary
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HA
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headache
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HH; HOH
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hard of hearing
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HIV
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human immunodeficiency virus
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HF
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heart failure
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H/O
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history of
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H&P; H/P
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history and physical
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HPI
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history of present illness
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HRT
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hormone replacement threapy
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HTN
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hypertension
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Hx
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history of
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ICU
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intensive care unit
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IM
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intramuscular; internal medicine
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IO; I/O
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ins and outs
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IPPA
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inspection, palpation, percussion, auscultation
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JVD
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jugular vein distension
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L
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left (often circled)
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LAT
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lateral
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LE
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lower extremity
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LLE
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left lower extremity
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LLQ
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left lower quadrant
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LOC
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loss of conciousness; level of conciousness
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LPN
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licensed practical nurse
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LTC
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long term care
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LUQ
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left upper quadrant
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L&W
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living & well
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M
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mother; male
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MAR
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medication administration record
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MDR
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multi drug resistant
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MDRO
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multi drug resistant organism
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Meds
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medications
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MedHx
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Medication history
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MH; MHx
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medical history
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MI
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myocardial infarction
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M/R/G
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murmurs/rubs/gallups
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MS
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musculoskeletal; multple sclerosis; medical student
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N
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negative (usually circled)
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NAD
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no apparent (acute) distress
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ND
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non-distended
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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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NP
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nurse practioner
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NPO
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nothing by mouth
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NT
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non-tender
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NT/ND
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non-tender, non-distended
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N/V
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nausea and vomiting
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N/V/D
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nausea, vomitin, and diarrhea
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O
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objective
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OA
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osteoarthritis
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OC
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oral contracpetive
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OM
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osteopathic manipulation
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OMT
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osteopathic manipulation technique
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OR
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operating room
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OT
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occupational therapy; occupational therapist
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OTC
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over the counter
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p (with line over it)
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after
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P
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after; pulse; plan; patellar; positive (especially if circled)
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PACU
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post-anesthesia care unit
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PCP
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primary care physician
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PE
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physical exam; pulmonary embolism
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PEARL
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pupils equal & reactive to light
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PEARLA
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pupils equal and reactive to light and accomodation
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PH; PHx
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past history
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PI
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present illness (injury)
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PMH
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past medical history
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PMI
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point of maximum impulse
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PN
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progress note
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POA
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power of attorney
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POMR
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problem oriented medical record
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POP
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popliteal [pulse]
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POS
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positive; position
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PROG
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prognosis
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PT
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physical therapy; physical therapist; posterior tibialis [pulse]; patient(especially if small case)
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PTA
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prior to admission
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PVC
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premature ventricular contraction; pulmonary venous congestion
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PVD
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peripheral vascular disease
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Px
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prognosis
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R
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respiration(s); radial [pulse]; right (especially if circled)
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RA
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rheumatoid arthritis
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RAN
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resident's admission note
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RLE
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right lower extremity
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RLQ
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right lower quadrant
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RN
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registered nurse
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ROM
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range of motion
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ROS
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review of systems
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RP
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radial pulse
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RR
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regular rate; respiration rate
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RRH
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regular rate & rhythm
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RT
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respiratory therapy; respiration therapist; right
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RUQ
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right upper quadrant
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Rx
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pharmacy; pharmacist; prescription; medication; therapy; treatment
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RXN
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reaction
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s (with line over it)
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without
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S
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without; subjective
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SBO
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small bowel obstruction
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SH; SHx
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social history
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SNF
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skilled nursing facility
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SOB
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shortness of breath
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S/P
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status post
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S/S
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signs & symptoms
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STD
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sexually transmitted disease
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Sx
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symptoms
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T
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temperature; triceps
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T&A
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tonsillectomy and adenoidectomy
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TAH
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total abdominal hysterectomy
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TB
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tuberculosis
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TIA
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tranient ischemic attack
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TM
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tympanic membrane
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Tx
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treatment; therapy
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UE
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upper extremity
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UTI
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urinary tract infection
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VS
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vital signs
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WD
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well developed
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WF
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white female
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WM
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white male
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WN
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well nourished
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W/O
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without
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W/R/R
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wheezing/rales/rhonchi;wheezes/rhonchi/rales
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Y/O
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year old
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