Professional Documents
Culture Documents
B D
BBS bilateral breath sounds DAT diet as tolerated
BE barium enema DC (dc) discontinue
BG blood glucose DCCT Diabetes Control and Complication Trials
BI brain injury DEX (DXT) blood sugar
BID twice a day DIC disseminated intravascular coagulation
bilat bilateral DKA diabetic ketoacidosis
B/K below knee DNA deoxyribonucleic acid
BM bowel movement or breast milk DNR do not resuscitate
BP blood pressure DTR deep tendon reflex
BPH benign prostatic hypertrophy DVT deep vein thrombosis
BRM biologic response modifiers Dx diagnosis
BRP bathroom privileges
BS bowel sounds E
BSA body surface area EBV Epstein-Barr Virus
BSE breast self examination ECF extracellular fluid, extended care facility
BT bowel tones EENT eye, ear, nose and throat
BUN blood urea nitrogen EMC ensephalomyocarditis
EMG electromyogram
C ERCP endoscopic retrograde
C&S culture and sensitivity cholangiopancreatography
Ca calcium, cancer, carcinoma ESRD end stage renal disease
CABG coronary artery bypass graft ET endotracheal tube
CAD coronary artery disease
CAPD continuous ambulatory peritoneal dialysis F
CAT computerized tomography scan F & R force and rhythm
CBC complete blood count FA fatty acid
CBD common bile duct FBS fasting blood sugar
CBE clinical breast examination
1- ABBREVIATIONS OF MEDICAL TERMS
FD fatal dose, focal distance J
FDA Food & Drug Administration JAMA Journal of the American Medical Association
Fx fracture JVP jugular venous pressure
FUO fever of unknown origin
FVD fluid volume deficit K
K potassium
G KCl potassium chloride
GB gallbladder KI potassium iodide
GERD gastroesophageal reflux disease KUB kidney, ureter, bladder
GFR glomerular filtration rate KVO keep vein open
GGT gamma-glutamyl transferase
GI gastrointestinal L
GOT glutamic oxalic transaminase L & A light and accommodation
GU genitourinary LAD left anterior descending (artery)
GVHD graft-versus-host-disease LB large bowel
LDL low density lipoprotein
H LE lupus erythematosus
HA headache LFTs liver function tests
Hb hemoglobin LIJ left internal jugular
HCG human chorionic gonadotropin LLQ left lower quadrant
HCO3 bicarbonate LMP last menstrual period
HCT hematocrit LP lumbar puncture
HD hemodialysis LSC left subclavian
HDL high density lipoprotein LUQ left upper quadrant
HEENT head, eye, ear, nose and throat
Hgb hemoglobin M
HIV human immunodeficiency virus MAP mean arterial pressure
HRT hormone replacement therapy MAR medication administration record
HS bedtime MCL modified chest lead
Hx history MDI multiple daily vitamin
MI myocardial infarction
I MLC midline catheter
IBC iron binding capacity MM mucous membrane
IBD inflammatory bowel disease MoAbs monoclonal antibodies
IBS irritable bowel syndrome MOM Milk of Magnesia
IBW ideal body weight MRDD mental retarded/developmentally disabled
ICCE intracapsular cataract extraction MRI magnetic resonance imaging
ICF imtermediate care facility MRM modified radical mastectomy
ICP intracranial pressure MS multiple sclerosis, morphine sulfate
ICS intercostal space
ICT inflammation of connective tissue N
ICU intensive care unit Na sodium
IDM infant of diabetic mother NaCl sodium chloride
IDDM insulin dependent diabetes mellitus NED no evidence of disease
IE inspiratory exerciser NICU neonatal intensive care unit
IH infectious hepatitis NIDDM noninsulin dependent diabetes mellitus
IHD ischemic heart disease NKA no known allergies
IIP implantable insulin pump NKDA non-ketotic diabetic acidosis
IM intramuscular NKMA no known medcation allergies
IMV intermittent mandatory ventilation NPD nightly peritoneal dialysis
INR international normalization ratio NPO nothing by mouth
IPD intermittent peritoneal dialysis NSAID nonsteroidal anti-inflammatory drug
IPPB intermittent positive pressure breathing NTD neural tube defect
ITP immune thrombocytopenic purpura NV nausea & vomiting
IV intravenous NYD not yet diagnosed
IVF in vitro fertilization
IVP intravenous pyelography
V cap: Capsule.
VA visual acuity
VBAC vaginal birth after caeserean CBC: Complete blood count.
VF/Vfib ventricular fibrillation
VLDL very low density lipoprotein CC: Chief complaint. The patient's main concern.
VMA vanillylmandelic acid
VSD ventricular septal defect
cc: Cubic centimeters. For example, the amount of fluid
VT/Vtach ventricular tachycardia removed from the body is recorded in ccs.
VW vessel wall
Chem panel: Chemistry panel. A comprehensive
W screening blood test that indicates the status of the liver,
W/C wheelchair kidneys, and electrolytes.
WBC white blood cell
WD well developed COPD: Chronic obstructive pulmonary disease.
WHO World Health Organization
WN well nourished CVA: Cerebrovascular accident (Stroke).
WNL within normal limits
D/C or DC: Discontinue or discharge. For example, a
a.c.: Before meals. As in taking a medicine before meals. doctor will D/C a drug. Alternatively, the doctor might DC
a patient from the hospital.
a/g ratio: Albumin to globulin ratio.
DDX: Differential diagnosis The variety diagnostic
ACL: Anterior cruciate ligament. ACL injuries are one of possibilities being considered.
the most common ligament injuries to the knee. The ACL
can be sprained or completely torn from trauma and/or DM: Diabetes mellitus.
degeneration.
DNC, D&C, or D and C: Dilation and curettage. Widening
Ad lib: At liberty. For example, a patient may be the cervix and scrapping with a curette for the purpose of
permitted to move out of bed freely and orders would, removing tissue lining the inner surface of the womb
therefore, be for activities to be ad lib. (uterus).
AKA: Above the knee amputation. DNR: Do not resuscitate. This is a specific order not to
revive a patient artificially if they succumb to illness. If a
Anuric: Not producing urine. A person who is anuric is patient is given a DNR order, they are not resuscitated if
often critical and may require dialysis. they are near death and no code blue is called.
b.i.d.: Twice daily. As in taking a medicine twice daily. DOE: Dyspnea on exertion. Shortness of breath with
activity.
Bandemia: Slang for elevated level of band forms of
white blood cells. DTR: Deep tendon reflexes. These are reflexes that the
doctor tests by banging on the tendons with a rubber
hammer.
Bibasilar: At the bases of both lungs. For example,
someone with a pneumonia in both lungs might have
abnormal bibasilar breath sounds. DVT: Deep venous thrombosis (Blood clot in large vein).
BKA: Below the knee amputation. ETOH: Alcohol. ETOH intake history is often recorded as
part of a patient history.
H&H: Hemoglobin and hematocrit. When the H & H is N/V: Nausea or vomiting.
low, anemia is present. The H&H can be elevated in
persons who have lung disease from long term smoking Na: Sodium. An essential electrolyte frequently
or from disease, such as polycythemia rubra vera. monitored regularly in intensive care.
H&P: History and physical examination. npo: Nothing by mouth. For example, if a patient was
about to undergo a surgical operation requiring general
h.s.: At bedtime. As in taking a medicine at bedtime. anesthesia, they may be required to avoid food or
beverage prior to the procedure.
H/O or h/o: History of. A past event that occurred.
I&D: Incision and drainage. ACL: Anterior cruciate ligament. ACL injuries are one of
the most common ligament injuries to the knee. The ACL
IM: Intramuscular. This is a typical notation when noting can be sprained or completely torn from trauma and/or
or ordering an injection (shot) given into muscle, such as degeneration.
with B12 for pernicious anemia.
Ad lib: At liberty. For example, a patient may be
IMP: Impression. This is the summary conclusion of the permitted to move out of bed freely and orders would,
patient's condition by the healthcare practitioner at that therefore, be for activities to be ad lib.
particular date and time.
AKA: Above the knee amputation.
in vitro: In the laboratory.
Anuric: Not producing urine. A person who is anuric is
in vivo: In the body. often critical and may require dialysis.
IU: International units. b.i.d.: Twice daily. As in taking a medicine twice daily.
C/O: Complaint of. The patient's expressed concern. RLQ: Right lower quadrant. The appendix is located in
the RLQ of the abdomen.
O&P: Ova and parasites. Stool O & P is tested in the
laboratory to detect parasitic infection in persons with ROS: Review of systems. An overall review concerns
chronic diarrhea. relating to the organ systems, such as the respiratory,
cardiovascular, and neurologic systems.
ORIF: Open reduction and internal fixation, such as with
the orthopedic repair of a hip fracture. RUQ: Right upper quadrant. The liver is located in the
RUQ of the abdomen.
P: Pulse. Pulse is recorded as part of the physical
examination. It is one of the "vital signs." s/p: Status post. For example, a person who had a knee
operation would be s/p a knee operation.
p.o.: By mouth. From the Latin terminology per os.
SOB: Shortness of breath.
p.r.n.: As needed. So that it is not always done, but done
only when the situation calls for it (or example, taking a SQ: Subcutaneous. This is a typical notation when noting
pain medication only when having pain and not without or ordering an injection (shot) given into the fatty tissue
pain). under the skin, such as with insulin for diabetes mellitus.
Plt: Platelets, one of the blood forming elements along t.i.d.: Three times daily. As in taking a medicine three
with the white and red blood cells. times daily.
PMI: Point of maximum impulse of the heart when felt tab: Tablet.
during examination, as in beats against the chest.
TAH: Total abdominal hysterectomy.
q.d.: Each day. As in taking a medicine daily.
THR: Total hip replacement.
q.i.d.: Four times daily. As in taking a medicine four times
daily. TKR: Total knee replacement.
q2h: Every 2 hours. As in taking a medicine every 2 UA or u/a: Urinalysis. A UA is a typical part of a
hours. comprehensive physical examination.
q3h: Every 3 hours. As in taking a medicine every 3 URI: Upper respiratory infection, such as sinusitis or the
hours. common cold.
qAM: Each morning. As in taking a medicine each ut dict: As directed. As in taking a medicine according to
morning. the instructions that the healthcare practitioner gave in
the office or in the past.
qhs: At each bedtime. As in taking a medicine each
bedtime. UTI: Urinary tract infection.
qod: Every other day. As in taking a medicine every other VSS: Vital signs are stable. This notation means that from
day. the standpoint of the temperature, blood pressure, and
pulse, the patient is doing well.
qPM: Each evening. As in taking a medicine each evening.
Wt: Weight. Body weight is often recorded as part of the
R/O: Rule out. Doctors frequently will rule out various physical examination.
possible diagnoses when figuring out the correct
diagnosis.