...
GEN: General
No Acute Distress.
NAD
Awake, Alert, Oriented to person/place/time.
AAOx3
Well Developed Well Nourished
WDWN
...
HEENT: Head Ears Eyes Nose Throat
Normocephalic atraumatic
NCAT
Mucous Membranes Moist
MMM
ExtraOcular Muscles Intact
EOMI
Pupils Equally Round Reactive to Light and Accommodation
PERRLA
Bilaterally
b/l
...
NECK: Neck region
Jugular Venous Distention
JVD
Lymphadenopathy
LAD
...
CV: Cardiovascular
Regular Rate and Rhythm
RRR
murmurs/rubs/gallops
m/r/g
Point of Maximal Intensity
PMI non-displaced/non-distended
Hepatojugular Reflux
HJR
Capillary Refill less than 2 seconds
CR <2sec
...
LUNGS: Lung system
Clear To Auscultation BiLaterally
CTABL
rales/rhonchi/wheezes
r/r/w
normal
nl
...
ABD: Abdomen
Positive bowel sounds in all four quadrants.
+BSx4
Non-Distended/Non-Tender
ND/NT
Hepatosplenomegaly
HSM
cyanosis/clubbing/edema
c/c/e
...
PELVIC: Pelvic region
Cervical Motion Tenderness
CMT
Vaginal Bleeding
VB
...
RECTAL: Rectal region
Bright Red Blood Per Rectum
BRBPR
...
MSK: Musculoskeletal System
Full Range of Motion
FROM
...
--Additional Common Medical Abbreviations--
Chief Complaint
CC
History of Present Illness
HPI
Review of Systems
ROS
Past Medical History
PMH
No Known Drug Allergies
NKDA
Chest Pain
CP
Shortness of Breath
SOB
Dyspnea On Exertion
DOE
Paroxysmal Nocturnal Dyspnea
PND
Jugular Venous Distention
JVD
Lower Extremity edema
LE edema
Normal Sinus Rhythm
NSR (cardiac)
Left Ventricular Hypertrophy
LVH (cardiac)
Left Atrial Enlargement
LAE (cardiac)
Right Atrial Enlargement
RAE (cardiac)
Right Axis Deviation
RAD (cardiac)
Left Axis Deviation OR Left Anterior Descending (artery)
LAD (cardiac)
Mini-Mental State Exam
MMSE
No Tobacco/Alcohol/(IV) Drugs
No T/A/D
Contractions
Ctx
Fracture (or function)
Fx
Per Vagina
P.V.
Per Rectum
P.R.
Spontaneous Bacterial Peritonitis OR Systolic Blood Pressure
SBP
Heart Rate
HR
Deep Tendon Reflexes
DTR
Acute Renal Failure
ARF
Chronic Renal Insufficiency
CRI
Chronic Renal Failure
CRF
Fluids, Electrolytes, Nutrition /Gastroenterology
FEN/GI
Nausea/Vomiting/Diarrhea
N/V/D
Subcutaneous
S.Q.
Percutaneous Transluminal Coronary Angioplasty
PTCA
Percutaneous Intervention (cardiac)
PCI
Coronary Artery Disease
CAD
Implantable Cardioverter Defibrillator
ICD
Coronary Artery Bypass Graft
CABG ("Cabbage")
Fetal Movement
FM
Last Menstrual Period
LMP
Normal Spontaneous Vaginal Delivery
NSVD
Preterm Premature Rupture of Membranes
PPROM
Premature Rupture of Membranes
PROM
Low Transverse Cesarean Section
LTCS
Estimated Blood Loss
EBL
Fetal Heart Tones
FHT
Total Abdominal Hysterectomy with Bilateral
Salpingo-oophorectomy
TAH/BSO
Bilateral Tubal Ligation
BTL
Preterm Labor
PTL
Cerebrovascular accident
CVA
Transient Ischemic Attack
TIA
Weight
Wt
Headache
HA
Hard Of Hearing
HOH
Palpitations
Palp
Peripheral Vascular Disease
PVD
Degenerative Joint Disease
DJD
Acute gastroenteritis
AGE
Upper Respiratory Infection
URI
Osteoarthritis
OA
PostOp Day
POD
Laparoscopic Appendectomy
Lap. Appy
Laparoscopic Cholecystectomy
Lap. Chole
Hemoglobin
Hb
Hemoglobin and Hematocrit
H/H
Bronchio-Alveolar Lavage
BAL
status post
s/p
history of
h/o
Within Normal Limits
WNL
Non Contributory (written under fam. hx)
NC
Rotator Cuff Tear
RCT
Return to Clinic
RTC
Fecal Occult Blood
FOB
Abdominal Aortic Aneurysm
AAA
Aortic Insufficiency
AI (murmur)
Aortic Stenosis
AS (murmur)
Mitral Regurgitation
MR (murmur)
Mitral Stenosis
MS (murmur)
Tricuspid Insufficiency
TI (murmur)
Pulmonic Stenosis
PS (murmur)
Pulmonic Insufficiency
PI (murmur)
Mitral Valve Prolapse
MVP
AtrioVentricular
AV
Arterio-Venous Malformation
AVM
Urinalysis with Culture & Sensitivity
UA c C&S
Vital Signs Stable
VSS
Trans Uretheral Prostatectomy
TURP
Therapeutic Abortion
TAB
Voluntary Interruption of Pregnancy
VIP
Pneumonia
PNA
Differential Diagnosis
DDx
antibiotics
abx
biopsy
bx
culture
cx
#NAME?
Ad lib
#NAME?
QD
#NAME?
bid
#NAME?
tid
#NAME?
qid
#NAME?
Q.O.D.
Neurosurgical Examination
NSx