medical-students

Common Medical Abbreviations and Terms

Wondering why you can’t read what the doctor wrote on your prescription? Ever see the doctor’s notes in your medical record and found peculiar abbreviations and jargon? Doctors commonly use a variety of abbreviations in order to rapidly and succinctly record information about, and give instructions to, their patients. Below is a listing of many common terms and abbreviations defined so that you can decipher those charts


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 commonligament 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.

AKA: Above the knee amputation.

Anuric: Not producing urine. A person who is anuric is often critical and may require dialysis.


b.i.d.: Twice daily. As in taking a medicine twice daily.

Bandemia: Slang for elevated level of band forms of white blood cells.

Bibasilar: At the bases of both lungs. For example, someone with apneumonia 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.”

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.


C&S: Culture and sensitivity, performed to detect infection.

C/O: Complaint of. The patient’s expressed concern.

cap: Capsule.

CBC: Complete blood count.

CC: Chief complaint. The patient’s main concern.

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.

COPD: Chronic obstructive pulmonary disease.

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.

DDX: Differential diagnosis The variety diagnostic possibilities being considered.

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.


FX: Fracture.


GOMER: Slang for “get out of my emergency room.”

gtt: Drops.


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.

HA: Headache.

HTN: Hypertension.


I&D: Incision and drainage.

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 practitioner at that particular date and time.

in vitro: In the laboratory.

in vivo: In the body.

IU: International units.


JT: Joint.


K: Potassium. An essential electrolyte frequently monitored regularly in intensive care.

KCL: Potassium chloride.


LBP: Low back pain. LBP is one of most common medical complaints.

LLQ: Left lower quadrant. Diverticulitis pain is often in the LLQ of theabdomen.

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.

mg: Milligrams.

ml: Milliliters.

MVP: Mitral valve prolapse.


N/V: Nausea or vomiting.

Na: Sodium. An essential electrolyte frequently monitored regularly in intensive care.

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.


O&P: Ova and parasites. Stool O & P is tested in the laboratory to detectparasitic 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.

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.


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.


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 organsystems, 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.

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 insulinfor 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.

tab: Tablet.

TAH: Total abdominal hysterectomy.

THR: Total hip replacement.

TKR: Total knee replacement.


UA or u/a: Urinalysis. A UA is a typical part of a comprehensive physical examination.

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 healthcare practitioner 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.

 

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