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