ABBREVIATION CATEGORY LIST Medications/Drugs ASA BZD CBZ CZP DPT aspirin benzodiazepine carbamazepine clonazepam Diphtheria

and tetanus toxoids with pertussis D/T diptheria/tetanus toxoid epi epinephrine GBP gabapentin HC hydrocortisone HCTZ hydrochlorothiazide INH Isoniazid L-DOPA levadopamine LiCo3 lithium carbonate lido lidocaine LMG lamotrigine LVT levetiracetam MMR measles/mumps /rubella MOM Milk of Magnesia NS normal saline OCBZ oxcarbazepine OPV oral polio vaccine PB Phenobarbital PCN penicillin PPD purified protein derivative PTN phenytoin TAC triamcinolone Td tetanus/diptheria toxoid TGB tiagabine TPM topiramate TT tetanus toxoid Vit vitamin when followed by a specific letter, i.e., Vit. A VPA valproic acid ZOE zinc oxide and eugenol ZSM zonisamide Administration Orders Q every QD every day QOD every other day BID twice daily TID three times daily QID four times daily QH every hour Q(x)H every (x) hours AC before meals PC after meals QAM every morning QPM every night QHS every night at bedtime QSHIFT every shift H hour HS at bedtime Disp dispense(usually medications) Elix an elixir ID intradermal IM intramuscular IV intravenous Liq liquid PO by mouth PR per rectum PRN as needed Soln solution SQ subcutaneous Supp suppository susp suspension STAT immediately;at once Tbsp tablespoon tsp teaspoon VO verbal order Measurements BP BTU C blood pressure British thermal units centigrade cc cm gm gm% gtt ht I&O IBW IOP IQ IWR kg l lb lg max mcg mEq mEq/l liter mg mg% ml mm mM neg oz P RR RRR rhythm sl sm T Tbsp TPR tsp Vol VS VSS WNL wt WTR range X times y/o yr(s) cubic centimeter centimeter gram grams per hundred milliliters of serum or blood as specified drop height intake and output ideal body weight intraocular pressure intelligence quotient ideal weight range kilogram liter pound large maximum micrograms milliequivalent milliequivalents per milligram milligrams per hundred milliliter of serum or blood milliliter or milliliters millimeter millimole negative ounce pulse respirations regular rate and slight; slightly small temperature tablespoon temperature, pulse, respiration teaspoon volume vital signs vital signs stable within normal limits weight within therapeutic times, i.e., X2 = 2 year old year(s) CSF diff eos ESR cerebrospinal fluid differential eosinophiles erythrocyte sedimentation rate FBS&2hPPfasting blood sugar and 2-hour post prandial FBS fasting blood sugar FSH follicle stimulating hormone G6PD glucose-6 phosphate dehydrogenase GC gonorrhea, gonococcus, gonococcal GFR glomerular filtration rate GGT gamma glutamyl transpeptidase GTT glucose tolerance test HBcAb type B hepatitis core antibody HBsAb type B hepatitis surface antibody HBsAG type B hepatitis surface antigen Hct hematocrit Hgb hemoglobin histo histoplasmosis HIV Human Immunodeficiency Virus hpf high powered field (used only in describing urine sediments K potassium lab laboratory LE prep lupus erythematosus cell preparation LDH lactate dehydrogenase LFT liver function tests lymphs lymphocytes MCH mean corpuscular hemoglobin MCHC mean corpuscular hemoglobin concentration MCV mean corpuscular volume Mg magnesium MIC minimum inhibitory concentration MRSA Methicillin Resistant Staph Aureus Na sodium nl normal NPN nonprotein nitrogen O2 oxygen O2 cap oxygen capacity O2Sat oxygen saturation PAP Papanicolaou's smear PBI protein bound iodine PCV packed cell volume pH hydrogen ion concentration phos phosphorus pl ct platelet count polys. polymorphonuclear neutrophiles PSA Prostate Specific Antigen PT prothrombin time PTT partial thromboplastin time RBC red blood cell retic(s) reticulocyte(s) RF rheumatoid factor Rh rhesus blood factor RPR rapid plasma reagent segs segmented neutrophils SGOT serum glutamic oxaloacetic transaminase SGPT serum glutamic pyruvic transaminase sp gr Staph Strep TB TFT Toxo Trich UA UDS VDRL Vol VPA VRE WBC specific gravity staphyloccous streptococcus tuberculosis thyroid function test toxoplasmosis trichomonas urinalysis urine drug screen venereal disease research laboratory volume valproic acid Vancomycin Resistant Enterococcus white blood count

Physical Assessment AAL abd AJ amb A&O A&P A-P AROM motion AU B/F B/M BRBPR anterior axillary line abdomen ankle jerk ambulatory alert and oriented auscultation and percussion anterioposterior active range of

Laboratory ABL level ACTH anticonvulsant blood

adrenocorticotrophic hormone acid phos acid phosphatase AFB acid fast bacilli A/G albumin globulin ratio alk phos alkaline phosphatase ALT aspartate aminotransferase alb albumin ANC absolute neutrophil count AST alanine aminotransferase Bact bacterium baso basophile bl cult blood culture bld blood BOP blood, ova, parasites BUN blood urea nitrogen Ca calcium CBC complete blood count CHO carbohydrate Cl chloride cldy cloudy col ct colony count CO2 carbon dioxide Cr creatinine Cr Cl creatinine clearance C&S culture and sensitivity

each ear black female black male bright red blood per rectum br sounds breath sounds BS bowel sounds BW birth weight C1, C2, C3, etc. cervical vertebrae CM continuous murmur CN cranial nerve CNS central nervous system C/O complaint of CVA cerebral vascular accident CXR chest x-ray D distal DBW desirable body weight DIP distal interphalangeal (joint) DNR Do Not Resuscitate D/O disorder DOB date of birth DTR deep tendon reflexes DWR desirable weight range Dx diagnosis EAC external auditory canal EENT eyes, ears, nose, and throat ENT ears, nose, and throat EOM extraocular movement or muscle EOMI EOM intact EPS extrapyramidal symptoms F female FH family history F/U follow up FROM full range of motion Fx fracture GTC generalized tonicclonic (seizures) GTube gastrointestinal tube GU genitourinary Gyn gynecology H/A headache HCP Health Care Plan HEENT ears, eyes, nose, and throat HJR hepatojugular reflux h/o history of H&P History and Physical HPI History of Present Illness

inpatient ISP individual service plan LA long acting lax laxative LBP lower back pain lg large LP lumbar puncture meds medications . etc. distribution EDC estimated date of confinement et and FB foreign body FBR full body restraint HCP Health Care Plan HOB head of bed IDT interdisciplinary team In Pt. ureter. T2. RRR laceration lateral left costal margin lower extremities left lower extremity left lower lobe – lung left lower quadrant – abdomen LLSB left lower sternal border LM land mark LMP last menstrual period LN lymph node LOC loss of consciousness LR light reflex L-S lumbosacral LSB left sternal border LUE left upper extremity LUL left upper lobe – lung LUQ left upper quadrant – abdomen LV left ventricle M male m murmur (cardiac) MAL midaxillary line MCL midclavicular line MCP metacarpophalangeal (joint) MMg mammogram MSE mental status exam MSL midsternal line MTP joint metatarsophalangeal joint NAD no acute distress NKA no known allergies NKDA no known drug allergies NSR normal sinus rhythm NSVD normal spontaneous vaginal delivery N/V nausea and vomiting N/V/D nausea. Ointment UP ureteropelvic URI upper respiratory infection US ultra-sound UTI urinary tract infection UV ultraviolet V/A visual acuity V-P ventriculoperitoneal(shunt) WD well-developed WD/WN well-developed/wellnourished W/F white female W/M white male WN well-nourished WNL within normal limits General Medicine ACM anticonvulsant medications AIDS Acquired Immune Deficiency Syndrome ALL acute lymphocytic leukemia ALS amyotrophic lateral scerosis AML acute myelogenous leukemia AODM adult onset diabetes mellitus ARDS Adult Respiratory Distress Syndrome ARF acute renal failure BE barium enema BLT borderline tracing BPH benign prostate hypertrophy CA carcinoma. etc. surgical T1. T&A tonsillectomy and adenoidectomy TAH total abdominal hysterectomy TAH & BSO total abdominal hysterectomy and bilateral salpingo oophorectomy TD tardive dyskinesia TIA transient ischemic attack T-L thoracolumbar TURP transurethral resection of prostate TVH total vaginal hysterectomy UGI upper gastrointestinal UGI w/SBFT upper gastrointestinal series with small bowel follow through URI upper respiratory infection Uro urology US ultra-sound UTI urinary tract infection UV ultraviolet VCU voiding cystourethrogram VD venereal disease VDRL venereal disease research laboratory General @ at Ab antibiotic ADL activities of daily living Adm admission Admin administration AEB as evidenced by AMA against medical advise Amt amount A-P & Lat anteroposterior and lateral AMAP as much as possible AA/T activity therapy BE barium enema BM bowel movement BM/E bowel movement with enema BMR basal metabolic rate b/o because of CAL calorie cap capsule cath catheter CC chief complaint CL clinic comp complete cont continue D&C dilation and curettage D/C discontinue DD developmental disabilities Disp dispense (usually medication) dist. and reactive to light and accommodations PH past history PIP proximal interphalangeal (joint) PMH past medical history PMI point of maximum impulse Prog prognosis PROM passive range of motion pt patient PTA prior to admission R right RCM right costal margin resp respiration RLE right lower extremity RLL right lower lobe RLQ right lower quadrant RML right middle lobe – lung R/O rule out ROM range of movement ROS review of systems RR respiratory rate regular rate and rhythm RUE right upper extremity RUL right upper lobe-lung RUQ right upper quadrant SH social history SI joint sacroiliac joint SLR straight leg raising SOB shortness of breath SOM serous otitis media S/P status-post S/Sx signs/symptoms Sx symptoms Sz seizure T temperature TM tympanic membrane trach tracheostomy UE upper extremity Ung. round. L2 etc. vomiting and diarrhea OD right eye OE otitis externa OM otitis media OS left eye OU both eyes PAL posterior axillary line PE physical examination PERL pupils equal and reactive to light PERRLA pupils equal. 1st thoracic vertebra. keep vein open left (side) 1st lumbar vertebra. cancer CT computerized axial tomography CF cystic fibrosis CHI closed head injury COPD chronic obstructive pulmonary disease CP&PD chest percussion and postural drainage CPR cardiopulmonary resuscitation CRF chronic renal failure C-Section Cesarean Derm Dermatology DI diabetes insipidus DJD degenerative joint disease DM diabetes mellitus DNR Do Not Resuscitate DOA dead on arrival DVT deep vein thrombosis ECHO ultrasound cardiogram EEG electroencephalogram EMG electromyogram EMT Emergency Medical Technician ESRD end stage renal disease fluoro fluoroscopy FS fever scan (forehead thermometer) FUO fever of undetermined origin GA general anesthesia GB gallbladder GE gastroesophageal GERD gastroesophageal reflux disease GI gastrointestinal GTube gastrointestinal tube H2O water H2O2 hydrogen peroxide HBP high blood pressure HTN hypertension HSV herpes simplex virus ICCE intracapsular cataract extraction I131 radioactive iodine IVF intravenous fluids IVP intravenous pyelogram JODM juvenile onset diabetes mellitus LAD left axis deviation LAE left atrial enlargement LAH left atrial hypertrophy LP lumbar puncture Med medicine MR mental retardation MRI Magnetic Resonance Imaging MTP minor treatment protocol MVA motor vehicle accident MVP mitral valve prolapse NeuroSurg neurosurgery Neuro Neurology NG nasogastric NOS not otherwise specified NPO nothing by mouth NSAID nonsteroidal antiinflammatory drug NSDO neurosurgery danger orders OB obstetrics OOB out of bed OM otitis media Op operation OR operating room Ortho Orthopedic O/T occupational therapy OTC over the counter P2 pulmonic second sound P-A posteroanterior path pathology PEG percutaneous gastrostomy PEJ percutaneous jejunostomy PID pelvic inflammatory disease PKU phenylketonuria PMS premenstrual syndrome PND paroxysmal nocturnal dyspnea P/T physical therapy PUD peptic ulcer disease PUD w/GOO peptic ulcer disease with gastric outlet obstruction PVD peripheral vascular disease RA rheumatoid arthritis Rx prescription. treatment S1 & S2 first and second heart sounds S3 & S4 heart sounds (physiological) Sz D/O seizure disorder SC Anemia sickle cell anemia SC Trait sickle cell trait SEM systolic ejection murmur SIADH syndrome of inappropriate antidiuretic hormone SLE systemic lupus erythematous Surg surgery. lac Lat LCM LE LLE LLL LLQ history incision and drainage intercostal space inferior vena cava knee jerk kidney.hx I&D ICS IVC KJ KUB bladder KVO L L1.

ventricular tachycardia TOF Tetralogy of Fallot VSD ventricular septal defect V Tach ventricular tachycardia WPW Syndrome WolffParkinson-White Syndrome Medicine(General) AIDS ALL ALS AML AIDS ARDS acquired immune deficiency syndrome acute lymphocytic leukemia amyotrophic lateral sclerosis acute myelogenous leukemia acquired immune deficiency syndrome adult respiratory distress syndrome acute renal failure cystic fibrosis chronic obstructive pulmonary disease chronic renal failure diabetes insipidus degenerative joint straints re regarding R/T related to S signs se side effects sed sedation SIB self injurious behavior sig: directions for use. label ss enema soapsuds enema tabs tablet (tablets) temp temporary w/ with ARF CF COPD Cardiology AED A-Fib APB ASD ASHD ASCVD automated external defrillator atrial fibrillation atrial premature beat atrial septal defect arteriosclerotic heart disease arteriosclerotic cardiovascular disease atrioventricular coronary bypass graft coronary artery A-V CABG CAD disease CHD congenital heart disease CHF congestive heart failure EKG electrocardiogram EST exercise stress test HTN hypertension LAD left axis deviation LAE left atrial enlargement LAH left atrial hypertrophy LBBB left bundle branch block LVE left ventricle enlargement LVH left ventricle hypertrophy MI myocardial infarction MVP mitral valve prolapse OHD organic heart disease PAT paroxysmal atrial tachycardia PDA patent ductus arteriostosis PI pulmonary insufficiency PVC premature ventricular contractions RAD right axis deviation RAE right atrial enlargement RAH right atrial hypertrophy RBBB right bundle branch block RHD rheumatic heart disease RV right ventricle RVE right ventricular enlargement RVH right ventricular hypertrophy SBE subacute bacterial endocarditis CRF DI DJD disease DM diabetes mellitus ESRD end-stage renal disease HRT hormone replacement therapy ITP idiopathic thrombocytopenia purpura IUD intrauterine device IUP intrauterine pregnancy JODM juvenile onset diabetes mellitus PID pelvic inflammatory disease PUD peptic ulcer disease PUD w/GOO peptic ulcer disease with gastric outlet obstruction PVD peripheral vascular disease RA rheumatoid arthritis Sz D/O seizure disorder SC Anemia sickle cell anemia SC Trait sickle cell trait SIADH inappropriate secretion of antidiuretic hormone SLE systemic lupus erythematous SOM serous otitis media VDRL venereal disease research laboratory UP ureteropelvic . night none after periodic health review afternoon by mouth after after surgery before surgery preparation for patient SEM systolic ejection murmur SVT supra .ion noc ∅. Ō p¯ PHR PM PO post post-op pre-op prep pt.

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