Heart Rate
HR 60-100 bpm
Blood Pressure
BP
Respiratory Rate
RR 12-20 respirations per minute
Temperature
Temp (97-99 F or 36.1-37.2 C)
Oxygen Saturation
SaO2 (x greater than or equal to 96%)
Bradycardia and Tachycardia
When bpm is slower than 60 or greater than 100 bpm respectively
Complete Blood Count
CBC: includes WBC, Hgb, Hct, and Plt
White Blood Cells
WBC (4K-10K per mm cubed)
Platelets
Plt (150K-300K per mm cubed)
Hemoglobin
Hgb (females = 12-16 gm/dl and males = 13-18 gm/dl)
Hematocrit
Hct (females = 36-46% and males = 39-49%)
Leukopenia
When WBC levels are below 4K/mm cubed
Leukocytosis
When WBC levels are higher than 10K/mm cubed
Anemia
when either Hgb is low (F=less 12 M=less 13) or Hct is low (F=less 36% M=less 39%)
Sodium
Na 135-145 mEq/L
Potassium
K 3.5-5.0 mEq/L
Chloride
Cl 95-105 mEq/L
Calcium
Ca 8.5-10.5 gm/dl
Phosphate
Phos 2.5-4.5 gm/dl
Magnesium
Mg 1.8-3.0 gm/dl
Bicarbonate
CO2 or HCO3 22-26 mEq/L
High and Low Sodium
Hyper/Hypo-natremia
High and Low Potassium
Hyper/Hypo-kalemia
High and Low Calcium
Hyper/Hypo-calcemia
High and Low Magnesium
Hyper/Hypo-magnesemia
High and Low Phosphate
Hyper/Hypo-phosphatemia
High and Low Chlorine
Hyper/Hypo-chloremia
Blood Urea Nitrogen
BUN (5-15 gm/dl)
Serum Creatinine
SCr (.8-1.2 gm/dl)
Blood Glucose
BG (70-100 gm/dl fasting)
High and Low Glucose
Hyper/Hypo-Glycemia
Chem 8
Basic Metabolic Panel (BMP)
Chem 8 Structure
Na Cl BUN BG/GlucoseK CO2/HCO3 SCr Ca
CBC Labs Structure
Hgb WBC Plt Hct
Comprehensive Metabolic Panel
CMP (has BMP plus total protein, albumin, Alk Phos, ALT/AST, and T. bili)
Ideal Body Weight
IBW (45.5 + 2.3(height inches - 60)) female (50 + 2.3( height inches - 60)) males**in kg
Body Mass Index
BMI (kg weight/ height in meters squared)
Creatinine Clearance
CrCl (with Cockcroft-Gault Formula)(140-Age)(IBW) * if female mult by .85----------------- *ml/min (SCr)(72)
Doctor of Osteopathic Medicine
DO
Doctor of Medicine
MD
Nurse Practitioner
NP
Occupational Therapist
OT
Physician Assistant
PA
Medical Assistant
MA
Physical Therapist
PT
Registered Dietician
RD
Respiratory Therapist
RT
Registered Nurse
RN
Social Worker
SW
Adverse Drug Event/Reaction
ADE or ADR respectively
Contraindication
CI
Drug interaction
DI
Emergency Department
ED
Primary Care Provider
PCP
Within Normal Limits
WNL
Over the Counter
OTC
Chief Complaint
CC
History of Present Illness
HPI
Past Medical History
PMH
Past Surgical History
PSH
Family History
FH
Social History
SH
Ethanol/Alcohol
ETOH
IV Drug Use
IVDU
Substance Use Disorder
SUD
No Known Allergies / No Known Drug Allergies
NKA / NKDA
Review of Systems
ROS
Vital Signs
VS
Height / Weight
Ht and Wt respectively
Physical Exam
PE
Head Ears Eyes Nose Throat
HEENT
Headache
HA
Cardiovascular
CV
Chest Pain
CP
Pulm / Resp
Pulmonary and Respiratory
Shortness of Breath
SOB
Dyspnea on Exertion
DOE
Gastrointestinal
GI
Bowel Movement
BM
Bright Red Blood per Rectum
BRBPR
Nausea Vomiting Diarrhea
N/V/D
Genitourinary
GU
Musculoskeletal
MSK
Neurological
Neuro
Altered Mental Status
AMS
Loss of Consciousness
LOC
Abdominal
Abd
Extremities
Ext
BLE
bilateral lower extremity
LEE
Lower extremity edema
LUE/LLE
Left upper extremity/Left lower extremity
RUE/RLE
Right Upper Extremity/Right Lower Extremity
ROM
range of motion
WWP
warm and well perfused
A&O x 1
alert and oriented to one of the following- person- place- time
A&O x 2
alert and oriented to two things
A&O x 3
alert and oriented to person, place, and time
CN
cranial nerves
BS
bowel sounds
NTND
non-tender, non-distended
HSM
hepatosplenomegaly
TTP
tender to palpitation
RRR
Regular rate and rhythm
NSR
normal sinus rhythm
M/R/G
murmurs, rubs, gallops
CTA/CTAB
clear to auscultation/ clear to auscultation bilaterally
EOMI
extraocular eye movement intact
JVD
jugular vein distention
MMM
moist mucous membranes
NCAT
normocephalic, atraumatic
PERRLA
pupils equal round and reactive to light/ accommodation
NAD
No acute/apparent distress
WDWN
well developed, well-nourished
corrected calcium
Measured Ca + 0.8(4-serum albumin)
alb (albumin)
3.5-5.0 g/dL
alk phos
alkaline phosphatase 30-120 units/L
ALT
alanine aminotransferase 0-35 units/L
AST
aspartate aminotransferase 0-35 units/L
T. Bili
bilirubin total .3-1.0 mg/dL
high albumin
hyperalbuminemia
low albumin
hypoalbuminemia
elevated ALT/AST
transaminitis
elevated bilirubin
hyperbilirubinemia
ph
7.35-7.45
pC02
35-45 mmhg
p02
80-100 mmhg