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160 Cards in this Set
- Front
- Back
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H & P
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HISTORY AND PHYSICAL
documentation on patient history and physical examination findings |
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Hx
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HISTORY
record of subjective information regarding the patient's medical history, includuing past injuries, illnesses, operations, defects, and habits |
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subjective information
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information obtained from patients including hiss or her personal perceptions
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CC
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Chief complaint
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c/o
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complains of
patients\'s description of what brought them to the hospital or Dr. office offten documented in the patients own words indicated with quotes |
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HPI
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history of present illness
applification of the CC recording details of the duration and severity of the condition |
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Sx
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Symptom
subjective evidence from patient that indicates an abnormality |
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PMH (PH )
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past medical history
a record of information about the patient's past illnesses starting with childhood including surgical operations, injuries, physical defects, medications, and allergies |
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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
state of health of the immediate family members |
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A & W
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alive and well
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L & W
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living and well
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SH
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social history
a record of the patient's recreational interrests, hobbies and use of tobacco and drugs including alcohol |
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OH
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occupational history
a record of work habits that may involve work related risks |
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ROS ( SR )
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review of systems
a documetation of the patient's response to questions organized by a head to toe review of the functions of all body systems |
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PE ( Px )
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physical examination
documentation of the physical examination of a patient. including notations of (+) and (-) objective findings |
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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, reactive to light, and accommodations
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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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assessment
identification of a disease or condition after evaluation of the patient's Hx, Sx, signs, and results of lab test and Dx procedures |
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R/O
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rule out
use to indicate a differential diagnosis |
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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 ( a registered bed patient )
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OP
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out patient
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OR
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operating room
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PACU
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postanesthetic care unit
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post-op/ postop
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postoperative
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PAR
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postanesthetic recovery
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pre-op/ preop
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preoperative
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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 privileges
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CP
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chest pain
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DC
D/C |
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
traction |
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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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acute
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sharp
having intense and 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
noncancerous |
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malignant
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harmful
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 and 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
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etiology
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cause of a disease
etio = cause |
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exacerbation
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increase in severity of a disease with aggravation of symptoms
acerbo = harsh |
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remission
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a period in which symptoms and signs stop or abate
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febrile
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relating to a fever
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gross
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large visible to the naked eye
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idiopathic
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a condition occuring without a cleary identified cause
idio = one's own |
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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 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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morbility rate
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the # of cases of a disease in a given year;
the ratio of sick to well individuals in a given population |
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mortality
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the sate of being subject to death
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mortality rate
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death rate
ratio of total # of deaths to total # in a given population |
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prognosis
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foreknowledge
prediction of the likey outcomes 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 the prevents disease
phylassein = 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 |
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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 a 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 percieved by the pt an 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
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noncontributory
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not involvedin 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
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cm
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centimeter
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g
gm |
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 |
millitliter
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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
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oz
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ounce
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lb
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pound
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qt
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quart
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tablet
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oral
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capsule
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sublingual buccal
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suppository
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vaginal or rectum inserted
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fluid medication
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inhalation through nose or mouth
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parenteral
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by injection within skin, muscle, vein, or under the skin
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cream lotion or ointment
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topical applied to the surface of the skin
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transdermal
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absorption of a drug through unbroken skin
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implant
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a drug reservoir imbedded in the body to provide continual infusion of a medication
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a
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before
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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
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after
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p.c.
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after meals
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prn
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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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weekl
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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 ear
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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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celsius
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F
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fahrenheit
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m
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murmur
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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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per rectum
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PV
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through vaginal
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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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prescription
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Sig
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label; instruction to the patient
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s
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without
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w.a
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while awake
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>
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greater than
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