a.c.: Before meals. As in taking a medicine before meals.
a/g ratio: Albumin to globulin ratio.
ACL: Anterior cruciate ligament. ACL injuries are one of the most common ligament injuries to the knee. The ACL can be sprained or completely torn from trauma and/or degeneration.
Ad lib: At liberty. For example, a patient may be permitted to move out of bed freely and orders would, therefore, be for activities to be ad lib.
AFR: Acute renal failure
ADHD: Attention deficit hyperactivity disorder
ADR: Adverse drug reaction. If a patient is taking a prescription drug to treat high blood pressure disease
AIDS: Acquired immune deficiency syndrome
AKA: Above the knee amputation.
Anuric: Not producing urine. A person who is anuric is often critical and may require dialysis.
ANED: Alive no evidence of disease. The patient arrived in the ER alive with no evidence of disease.
ADH: Antidiuretic hormone
ARDS: Acute respiratory distress syndrome.
ARF: Acute renal (kidney) failure
ASCVD: Atherosclerotic cardiovascular disease. A form of heart disease.
b.i.d.: Twice daily. As in taking a medicine twice daily.
bld: Blood. Blood was visible on the patient’s scalp.
Bandemia: Slang for elevated level of band forms of white blood cells.
Bibasilar: At the bases of both lungs. For example, someone with a pneumonia in both lungs might have abnormal bibasilar breath sounds.
BKA: Below the knee amputation.
BMP: Basic metabolic panel. Electrolytes (potassium, sodium, carbon dioxide, and chloride) and creatinine and glucose.
BP: Blood pressure. Blood pressure is recorded as part of the physical examination. It is one of the "vital signs."
BPD: Borderline personality disorder. A personality disorder.
BSO: Bilateral salpingo-oophorectomy. A BSO is the removal of both of the ovaries and adjacent Fallopian tubes and often is performed as part of a total abdominal hysterectomy. Continue Reading
C&S: Culture and sensitivity, performed to detect infection.
C/O: Complaint of. The patient's expressed concern.
Ca: Cancer; carcinoma. For example, a patient who undergoing treatment for cancer should assure that they are eating and drinking enough fluids daily, both during and after treatment.
CABG. Coronary artery bypass graft. A surgery involving the heart.
CBC: Complete blood count.
CC: Chief complaint. The patient's main concern.
CDE: Complete dental (oral) evaluation.
cc: Cubic centimeters. For example, the amount of fluid removed from the body is recorded in ccs.
Chem panel: Chemistry panel. A comprehensive screening blood test that indicates the status of the liver, kidneys, and electrolytes.
CPAP: Continuous positive airway pressure. A treatment for sleep apnea.
COPD: Chronic obstructive pulmonary disease.
CT: Chemotherapy. A type of treatment therapy for cancer.
CVA: Cerebrovascular accident (Stroke).
D/C or DC: Discontinue or discharge. For example, a doctor will D/C a drug. Alternatively, the doctor might DC a patient from the hospital.
DCIS: Ductal Carcinoma In Situ. A type of breast cancer. The patient is receiving treatment for Ductal Carcinoma In Situ.
DDX: Differential diagnosis. A variety diagnostic possibilities are being considered to diagnose the type of cancer present in the patient.
DJD: Degenerative joint disease. Another term for osteoarthritis.
DM: Diabetes mellitus.
DNC, D&C, or D and C: Dilation and curettage. Widening the cervix and scrapping with a curette for the purpose of removing tissue lining the inner surface of the womb (uterus).
DNR: Do not resuscitate. This is a specific order not to revive a patient artificially if they succumb to illness. If a patient is given a DNR order, they are not resuscitated if they are near death and no code blue is called.
DOE: Dyspnea on exertion. Shortness of breath with activity.
DTR: Deep tendon reflexes. These are reflexes that the doctor tests by banging on the tendons with a rubber hammer.
DVT: Deep venous thrombosis (blood clot in large vein).
ETOH: Alcohol. ETOH intake history is often recorded as part of a patient history.
ECT: Electroconclusive therapy. A procedure used to control seizures (convulsions).
g: gram, a unit of weight. The cream is available in both 30 and 60 gram tubes.
GOMER: Slang for "get out of my emergency room."
GvHD: Graft vs. host disease. It is complicated by the syndromes of acute and chronic graft-vs-host disease (GVHD).
H&H: Hemoglobin and hematocrit. When the H & H is low, anemia is present. The H&H can be elevated in persons who have lung disease from long term smoking or from disease, such as polycythemia rubra vera.
H&P: History and physical examination.
h.s.: At bedtime. As in taking a medicine at bedtime.
H/O or h/o: History of. A past event that occurred.
HRT: Hormone replacement or hormone replacement therapy.
HTN: Hypertension. Continue Reading
I&D: Incision and drainage.
IBD: Inflammatory bowel disease. A name for two disorders of the gastrointestinal (BI) tract, Crohn’s disease and ulcerative colitis
ICD: Implantable cardioverter defibrillator
ICU: Intensive care unit. The patient was moved to the intensive care unit.
IM: Intramuscular. This is a typical notation when noting or ordering an injection (shot) given into muscle, such as with B12 for pernicious anemia.
IMP: Impression. This is the summary conclusion of the patient's condition by the healthcare professional at that particular date and time.
ITU: Intensive therapy unit
in vitro: In the laboratory
in vivo: In the body
IPF: Idiopathic pulmonary fibrosis. A type of lung disease.
IU: International units.
K: Potassium. An essential electrolyte frequently monitored regularly in intensive care.
KCL: Potassium chloride.
LCIS: Lobular Carcinoma In Situ. A type of cancer of the breast. The patient is receiving treatment for Lobular Carcinoma In Situ.
LBP: Low back pain. LBP is one of most common medical complaints.
LLQ: Left lower quadrant. Diverticulitis pain is often in the LLQ of the abdomen.
LUQ: Left upper quadrant. The spleen is located in the LUQ of the abdomen.
Lytes: Electrolytes (potassium, sodium, carbon dioxide, and chloride).
MCL: Medial collateral ligament.
M/H: Medical history
MVP: Mitral valve prolapse.
N/V: Nausea or vomiting.
Na: Sodium. An essential electrolyte frequently monitored regularly in intensive care.
NCP: Nursing care plan
npo: Nothing by mouth. For example, if a patient was about to undergo a surgical operation requiring general anesthesia, they may be required to avoid food or beverage prior to the procedure.
NSR: Normal sinus rhythm of the heart
O&P: Ova and parasites. Stool O & P is tested in the laboratory to detect parasitic infection in persons with chronic diarrhea.
O.D.: Right eye.
O.S.: Left eye.
O.U.: Both eyes.
ORIF: Open reduction and internal fixation, such as with the orthopedic repair of a hip fracture.
P: Pulse. Pulse is recorded as part of the physical examination. It is one of the "vital signs."
p.o.: By mouth. From the Latin terminology per os.
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 pain medication only when having pain and not without pain).
PCL: Posterior cruciate ligament.
PD: Progressive disease. Patients at risk of developing progressive disease of the kidneys include those with proteinuria or hematuria.
PERRLA: Pupils equal, round, and reactive to light and accommodation.
PFT: Pulmonary function test. A test to evaluate the how well the lungs are functioning.
PERRLA: Pupils equal, round, and reactive to light and accommodation.
Plt: Platelets, one of the blood forming elements along with the white and red blood cells.
PMI: Point of maximum impulse of the heart when felt during examination, as in beats against the chest.
PMS: Premenstrual syndrome
PT: Physical therapy
PTH: Parathyroid hormone
PTSD: Post-traumatic stress syndrome
PUD: Peptic ulcer disease. A type of ulcer of the stomach. Continue Reading
q.d.: Each day. As in taking a medicine daily.
q.i.d.: Four times daily. As in taking a medicine four times daily.
q2h: Every 2 hours. As in taking a medicine every 2 hours.
q3h: Every 3 hours. As in taking a medicine every 3 hours.
qAM: Each morning. As in taking a medicine each morning.
qhs: At each bedtime. As in taking a medicine each bedtime.
qod: Every other day. As in taking a medicine every other day.
qPM: Each evening. As in taking a medicine each evening.
RA: Rheumatoid arthritis. A type of joint disease.
RDS: Respiratory distress syndrome
R/O: Rule out. Doctors frequently will rule out various possible diagnoses when figuring out the correct diagnosis.
REB: Rebound, as in rebound tenderness of the abdomen when pushed in and then released.
RLQ: Right lower quadrant. The appendix is located in the RLQ of the abdomen.
ROS: Review of systems. An overall review concerns relating to the organ systems, such as the respiratory, cardiovascular, and neurologic systems.
RUQ: Right upper quadrant. The liver is located in the RUQ of the abdomen.
s/p: Status post. For example, a person who had a knee operation would be s/p a knee operation.
SAD: Season affective disorder. A type of depression that occurs during the winter months when there is little light.
SOB: Shortness of breath.
SQ: Subcutaneous. This is a typical notation when noting or ordering an injection (shot) given into the fatty tissue under the skin, such as with insulin for diabetes mellitus.
T: Temperature. Temperature is recorded as part of the physical examination. It is one of the "vital signs."
T&A: Tonsillectomy and adenoidectomy
t.i.d.: Three times daily. As in taking a medicine three times daily.
TAH: Total abdominal hysterectomy
TAH: Total abdominal hysterectomy. A type of surgery to remove a woman’s uterus, Fallopian tubes, and ovaries.
THR: Total hip replacement
TKR: Total knee replacement
TMJ: Tempomandibular joint
UA or u/a: Urinalysis. A UA is a typical part of a comprehensive physical examination.
U or u**: Unit. Mistaken as the number 0 or 4, causing a 10-fold overdose or greater (for example, 4U seen as "40" or 4u seen as "44"); mistaken as "cc" so the dose is given in volume instead of units (for example, 4u seen as 4cc).
ULN: Upper limits of normal
URI: Upper respiratory infection, such as sinusitis or the common cold
ut dict: As directed. As in taking a medicine according to the instructions that the health care professional gave in the office or in the past
UTI: Urinary tract infection
VSS: Vital signs are stable. This notation means that from the standpoint of the temperature, blood pressure, and pulse, the patient is doing well.
Wt: Weight. Body weight is often recorded as part of the physical examination.
XRT: Radiotherapy (external). A type of treatment that uses radiation. Continue Reading
YFP: yellow fluorescent protein