Section III




To discuss a therapeutic regimen with a physician you must speak his language. The terminology that will confront you in the patient care areas is different from that to which you have previously been exposed. A typical conversation you might hear at the patient's bedside would go something like, " I hear an S-2 and S-4 with no split sounds or opening snap. Since there has been no history of dyspnea and the ASO was negative, I suspect an ASD or VSD, but we will not know for sure until after the results of the cath." An admission order written by the physician might read "up ad lib, ADA diet (2000 cal), S&A, MOM 30 ml, hs, pm. Lab tests as follows: CBC, Crit., Amylase, CPK, PBI, Blood Gases, BUN, Creatinine, LDH, SGOT, SGPT and Lytes." The language of the physician is oriented toward disease, diagnostic tests and treatment. The most commonly encountered abbreviations and terminology will be helpful to you as a reference source. If you are not familiar with a term that is used, you should consult a medical dictionary or ask the physician.


Abbreviation ABE ABS ADA AF ad lib A/G AHCA AMA AK A.L.T. Amb Explanation Acute bacterial endocarditis Admitting blood sugar American Dietetic Association Acid Fast As desired Albumin-globulin ratio Agency for Healthcare Administration Against Medical Advice Above knee amputation Alanine Aminotransferase (formerly called SGPT) Ambulant Ant ANA ASCVD ASD ASHD ASO A.S.T. AV BBB BBT BE BJ BKA BM BMR BP BRP BS Anterior Antinuclear antibody arteriosclerotic vascular disease ( arteriosclerosis ) Atrial septum defect Arteriosclerotic heart disease Antistreptolysin 0 Aspartate Aminotransferase (formerly SCOT) Atrioventricular Bundle branch block or blood brain barrier Basal body temperature Barium enema Bone and joint Below knee amputation Bowel movement Basal Metabolic rate Blood pressure Bathroom privileges Breath sounds or bowel sounds III.1

DOA DOE DTR DQA DX ECG ECT EEG EENT EKG eg EMG EPS ER BSA BSP BUN BW Bx Ca Cal C and S CBC CC Ceph Floc CFT CHF CHO chr c/o CNS COLD CONG COPD CPK CSF CST CT CV CVA CVD CVP D/C D and C Derm diff DM Body surface area Bromsulphalein Blood urea nitrogen Body weight Biopsy Carcinoma Calorie Culture and sensitivity Complete blood count Chief complaint Cephalin Flocculation Complement fixation test Congestive heart failure Carbohydrate Chronic Complains of Central nervous system Chronic obstructive lung disease Congenital Chronic obstructive pulmonary disease Creatinine phosphokinase Cerebrospinal fluid Convulsive shock therapy Circulation time Cardiovascular Cerebrovascular accident Cardiovascular disease Central venous pressure Discontinue Dilation and curettage Dermatology Differential blood count Diabetes mellitus Dead on arrival Dyspnea on exertion Deep tendon reflex Division of Quality Assurance Diagnosis Electrocardiogram Electroconvulsive therapy Electroencephalogram Eye, ear, nose and throat Electrocardiogram For example Electromyography Extra pyramidal syndrome Emergency room III.2

ESR EST Ext FBS F and R FH Fld FRC FTA FUO Fx GB Gc GFR GI G-6-PD GSW GTT GU GYN H h Hb HCT HCVD Hgb H and P HPI HT HTVD Hx ICS ICU I and D I and 0 IM Imp inf int Int Med IOP IP IPPB IV IVP IVT Erythrocyte sedimentation rate Electroshock therapy Extremities Fasting blood sugar Force and rhythm of pulse Family history Fluid Functional residual capacity Fluorescent treponemal antibody Fever of undetermined origin Fracture Gallbladder Gonorrhea Glomerular filtration rate Gastrointestinal Glucose-6 phosphate dehydrogenase Gun shot wound Glucose tolerance test Genitourinary Gynecology Hypodermic Hour Hemoglobin Hematocrit Hypertensive cardiovascular disease Hemoglobin History and physical History of present illness Height Hypertensive vascular disease History Intercostal space Intensive care unit Incision and drainage Input and output Intramuscular Impression Inferior Interval Internal medicine Intraocular pressure Intraperitoneal Intermittent positive pressure breathing Intravenous Intravenous pyelogram Intravenous transfusion III.3

N NB Neg NM NG NOS NPN NPO N/S NSR NTP NTG NYD JVD K Kg KO KUB KVO lat L and A LBBB LCM LBCD LDH LE LLQ LMD LMP LOA LUQ LP LVH L and W MCH MCV Med MH MI rnm MOM MRXI MS MSE MMSE Jugular Venous distention Potassium Kilogram Keep open Kidney, ureter, bladder Keep vein open Lateral Light and accommodation (of pupils) Left bundle branch block Left costal margin Left border cardiac dullness Lactic acid dehydrogenase Lupus erythematosus Left lower quadrant Local medical doctor Last menstrual period Leave of absence Left upper quadrant Lumbar puncture Left ventricular hypertrophy Living and well Mean corpuscular hemoglobin Mean corpuscular volume Medicine Menstrual history Myocardial infarction Millimeter Milk of magnesia May repeat times one Mitral stenosis or multiple schlerosis or morphine sulfate Mental status examination Mini Mental Status Exam Normal Newborn Negative Neuromusclar Nasogastric tube Not Otherwise Specified (used as part of a diagnosis) Nonprotein nitrogen Nothing by mouth Normal saline Normal sinus rhythm Normal temperature and pressure Nitroglyercin Not yet diagnosed III.4

OOB OB OB-GYN Out of bed OR OT P p PAC P and A Para 1 PAT PBI PCV PCO


PE PM PHC PMH PI PID PO Post Op PP PPD PPT PRA Pre Op P and R PRN Prog Ps PSP Pt PT PVC qd qh qod R RA RBBB RBC Obstetrics Obstetrics and gynecology Operating room Occupational therapy Pulse After Premature atrial contraction Percussion and auscultation Having bom one child Paroxysmal atrial tachycardia Protein - bound iodine Packed Cell Volume Carbon dioxide partial pressure Physical examination Post mortem Post hospital care Past medical hospital Present illness Pelvic inflammatory disease By mouth Post operative Post partum Purified protein derivative of tuberculin Partial prothrombin time Plasma renin activity before surgery Pulse and respiration When necessary Prognosis Posterior Phenosulfonphthalein Patient Physical therapy Premature ventricular contraction Every day Every hour Every other day Right Agglutinins or right atrium Right bundle branch block Red blood cell III.5

RHD RLQ R/O ROM RPF RR ROS RV RVH RUQ Rx s S-A SBE SC SGOT SGPT SH Sig SOB s/p Sp gr SR STAT STS sup Sx T T and A TB TBW TCA's TIBC TP TPN TPR TUR TV Tx URI UTI VC VD VDH VDRL Rheumatic heart disease Right lower quadrant Rule out Range of motion exercise Renal plasma flow Recovery room Review of systems Right ventricle Right ventricular hypertrophy Right upper quadrant Treatment Without Sino-atrial Subacute bacterial endocarditis Subcutaneous Serum glutamic oxalacetic transaminase Serum glutamic pyruvic transaminase Social history Let it be labeled Shortness of breath Status Post Specific gravity Sedimentation rate At once Serologic test for syphilis Superior Symptoms Temperature tonsillectomy and adenoidectomy Tuberculosis Total body water Tricyclic antidepressants Total iron binding capacity Total protein Total parenteral nutrition Temperature, pulse and respiration Transurethral resection Trial visit Treatment Upper respiratory infection Urinary tract infection Vital capacity or vena cava Venereal disease Valvular disease of heart Venereal disease research laboratory III.6

VF vis VMA VP VS VSD WBC WNL Wt Visual field Namely Vanilmandelic acid Venous pressure Vital signs Ventricular septal defect White blood cells Within normal limits Weight III.7