Abbreviations

Useful Abbreviationsc/o : complains ofh/o : history ofDx : diagnosisRx : treatmentDz : diseasec : withs : withouts/p : status postPOD : post-op dayPEx : physical examUSOH : usual state of healthPTA : prior to admissionFHx / SHx / PMHx : family-, social-, past medical – historyROS : review of systemsNKDA : no known drug allergiesLOC : loss of consciousnessSOB : shortness of breathCP : chest painBRBPR : bright red blood per rectum (hematochesia)N / V / D: nausea, vomiting, diarrheaF / C: fevers / chillsSS Insulin: sliding scale insulinPRN: as necessaryQD: once per dayBID: twice per dayTID: three times per dayQID: four times per dayT#3: Tylenol #3 (Tylenol with codeine)ABx: antibioticsOOB: out of bed (ie when discussing plans for activity – OOB to chair)IS: incentive spirometry (see this a lot on surgical services)I/O’s: ins and outs (diet/waste)L / R : left / rightB : bilaterallyCABG : coronary artery bypass grafttxp : transplantLRRT : living related renal txpLURT : living unrelated renal txpTAH-BSO : total abdominal hysterectomy – bilateral salpingo-oopherectomyFem-Pop : Femoral-Popliteal bypassBKA / AKA : below-knee amputation / above-knee amputationTKA : total knee arthroplastyTHA : total hip arthroplastyLOA : lysis of adhesionsPNA: Pneumonia

Abbreviations

PEx abbreviations:

HEENT:NC/AT : normocephalic / atraumaticØ LAD: no lymphadenopathy

Cardiac exam (CV):Ø M/G/R : no murmurs, gallops, rubs2+ PT/DP B : 2+ posterior-tibial and dorsalis pedis pulses bilaterallyØ JVD : no jugular venous distensionØ LE edema: no lower extremity edema

Lung exam:CTA B : clear to auscultation bilaterally

Abdo exam:NT/ND : non-tender, non-distendedØ HSM : no hepatosplenomegaly+ BS : bowel sounds present

Back exam:Ø CVAT : no costovertebral angle tenderness

Neuro:EOMI / PERRL : extraocular mvmnts intact / pupils equal, round, reactive to light