Abdomen/Abdominal
Abd
Antibiotics
Abx
Atrial Fibrillation
A fib
Acute Otitis Media (new ear infection)
AOM
Assessment and Plan
A/P
Acetylsalicylic Acid (aspirin)
ASA
Twice a Day
BID
Bilateral Lower Extremities
Bilat L E
Bowel Movement
BM
Blood Pressure
BP
With
c
Cancer, Carcinoma
CA
Coronary Artery Bypass Graft
CABG
Coronary Artery Disease
CAD
Complete Blood Count (bloodwork to look for infection or anemia)
CBC
Congestive Heart Failiure
CHF
Chest Pain
CP
Complains of
c/o
Chronic Obstructive Pulmonary Disease
COPD
Chronic Renal Failure
CRF
Caesarean Section
C-section
Cervical Spine
C-Spine
Computerized Assisted Tomography
CAT or CT
Clear to Auscultation
CTA
Cardiovascular
CV
Cerebrovascular Accident
CVA
Chest X-Ray
CXR
Diabetes Mellitus
DM
Dyspnea on Exertion
DOE
Dorsalis Pedis / Posterior Tibialis
DP / PT (pulse)
Deep Vein Thrombosis
DVT
Diagnosis
Dx
Electrocardiogram
ECG/EKG
Extraocular Movements Intact
EOMI
Alcohol
EtOH
Family History
FHx
Follow Up
F/U
Fracture
Fx
Gastroesophageal Reflux Disease
GERD
Gastrointestinal
GI
Gravida/Para/Abortion
G/P/Ab
Genitourinary
GU
Headache
HA
Head, Ears, Eyes, Nose, Throat
HEENT
Health Insurance Portability and Accountability Act
HIPAA
Hyperlipidemia
HLD
History of Present Illness
HPI
Hypertension (high blood pressure)
HTN
History
Hx
Hemoglobin and Hematocrit
H & H
Incision and Drainage
I&D
Insulin Dependent Diabetes Mellitus
IDDM
Intrauterine Pregnancy
IUP
Intravenous Drug Abuse
IVDA
Left Lower Extremity
LLE
Left Lower Quadrant
LLQ
Last Normal Menstrual Period
LNMP
Loss of Consciousness
LOC
Lumbar Spine
L-spine
Left Upper Extremity
LUE
Left Upper Quadrant
LUQ
Myocardial Infarction
MI
Not Applicable
N/A
No Acute Distress, No Acute Disease
NAD
Non-insulin Dependent Diabetes Mellitus
NIDDM
No Known Drug Allergies
NKDA
Normal
nl/nml
Non Steroidal Anti-Inflammatory Drug
NSAID
Normal Sinus Rhythm
NSR
Nausea/Vomiting/Diarrhea
N/V/D
Oxygen Saturation
O2 Sat
Obstetrics and gynecology
OB/GYN
Overdose
OD
Otitis Media (inner ear infection)
OM
Oropharynx
OP
Open Reduction and Internal Fixation
ORIF
Primary Care Physician/Primary Medical Doctor
PCP/PMD
Physical exam/Pulmonary Embolism
PE
Pupils are Equal, Round, and Reactive, to Light
PERRL
Per Os (by mouth)
PO
As Needed
prn
Patient
Pt
Prior to Arrival -or- Peritonsillar Abscess
PTA
Peripheral Vascular Disease
PVD
Every
q
Every Day
QD
At Every Bedtime
QHS
Four Times a Day
QID
Right Lower Extremity
RLE
Right Lower Quadrant
RLQ
Range of Motion
ROM
Review of System
ROS
Regular rate and rhythm (normal heart sounds)
RRR
Right Upper Extremity
RUE
Right Upper Quadrant
RUQ
Prescription
Rx
Rule Out
r/o
Shortness of Breath
SOB
Subjective, Objective, Assessment, and Plan
SOAP
Status Post (after)
s/p
Symptoms
Sx
S/T Elevation Myocardial Infarction
STEMI
Tonsillectomy and Adenoidectomy (tonsils and adenoids removal surgery)
T & A
Transient Ischemic Attack
TIA
Three Times a Day
TID
Tympanic Membrane (ear drum)
TM
Treatment
Tx
Thoracic Spine
T-spine
Urinalysis
UA
Upper Respiratory Infection
URI
Ultrasound
US
Up to Date
UTD
Urinary Tract Infection
UTI
Within Normal Limits (normal, not of concern)
WNL
Year(s) Old
y/o