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1、SIR RUN RUN SHAW HOSPITALCommon Medical AbbreviationsAngela Lai, ms4 Michigan state universityCollege of human medicine Example67 y/o male c/o CP and SOB x 2 h. Pain is sev (8 / 10), under sternum and radiates to the L arm and jaw. Pain woke pt from sleep, and denies DOE or w/breathing. PMH: Pt. has
2、 a h/o CAD, MI 1/15/01, HTN, and DM. Meds: ASA, insulin, lasix, and lisinopril. Allx: PCNPE: Pt is A+O x 4, diaphoretic anxious.HEENT: PERRLNeck: JVD, + use of accessory musclesPulm: BS crackles bases, + rtxnsAbd: soft, NTTPExtrem: LE edema67 year old male complains of chest pain and shortness of br
3、eath for 2 hours. Pain is severe (8/10), under sternum and radiates to the Left arm and jaw. Pain woke patient from sleep, and denies dyspnea on exertion or with breathing. Past medical history: patient has a history of coronary artery disease, myocardial infarction 1/15/10, hypertension, and diabet
4、es mellitus. Medications: Aspirin, Insulin, Lasix, LisinoprilAllergies: Penicillin Physical exam: Patient is alert and oriented x4, diaphoretic, anxiousHead Ears Eyes Nose Throat: Pupils equal round and reactive to light Neck: no jugular venous distension, positive use of accessory musclesPulmonary:
5、 breath sounds, crackles at bases, positive retractionsAbdomen: soft, non-tender to palpationExtremities: 3/4 lower extremity edemaIntroductionAbbreviations are often used in medicineIt Boosts efficiency to save time in documentationBUT it should be used cautiously! Certain abbreviations should be a
6、voided TYPSPhases initial letters: e.g. CP, SOB, DOE, CAD,JVD,DOA,PE, PMH,PERRL,ESRD,ESLD,GSWWords pronouncing letters: e.g. HTN, PNA, PCN, ASA, etOH, LAD, HSM, Pt, retxn, mcg, gmRelated words combined initial letters: e.g. HEENT, n/v/d/c, m/r/g, A+O, H&P, h/r/s/t,H&MEnd with “/o”or “/”: e.g. y/o, w
7、/o, c/o , D/C, D/S,End with “x”: e.g. Hx, Sx, Tx, Dx, DDx, abx, allx,RxPartially short: Abbrevs. Meds. Info. Imp. Lab. Extr.Symbols: e.g.+ x (+) (-) Latins: P.O., B.I.D, tid, prnTaking a HistoryCC: 69 y/0 M c hx bronchiectasis c/o cough x 10d.HPI: The Pt has a hx of chronic bronchitis and PNA as a c
8、hild. He states he would have SOB, HA, DOE, and occasional URI symptoms treated with Abx. He now has a non-productive cough w/o fever, ST, n/v/d/c. OTC meds sometimes help. He was recently discharged from the ED last month. He has a 40pack year smoking hx. y/o = year old c/o = complains ofc = Caucas
9、ianPt = Patient hx = history PNA = pneumonia SOB = shortness of breathHA = headacheDOE = dyspnea on exertionURI = Upper Respiratory InfectionAbx = Antibiotics w/o = withoutST = Sort Throatn/v/d/c = nausea / vomiting/diarrhea / constipationOTC = Over The CounterED = Emergency DepartmentHistoryPMH: ID
10、DM type 2, HTN, COPD, CADPSH: CABG 2007Meds: ACEi, Insulin, ASA, Blker, CCB, CS inhaler, LABAAllx: NKMAPast Medical HistoryIDDM (DM) = insulin dependent diabetes mellitusHTN = hypertensionCOPD = chronic obstructive pulmonary diseaseCAD = coronary artery diseasePast Surgical HistoryCABG = coronary ar
11、tery bypass graft MedicationsACEi = Angiotensin converting enzyme inhibitor ASA = aspirin Blker = Beta blocker CCB = Calcium channel blocker LABA = long-acting beta agonistAllergiesNKMA = no known medical allergies HistorySocHx: married; occupation- teacher, smokes 1ppd (40 pack-yrs), EtOH socially,
12、 hx IVDAFamHx: Father 65 MIMother HTN, DMMGM CAD, COPDPGF 71 ESRDROS: negative except as mentioned in the HPISocial History Ppd = pack per dayEtOH = alcohol (ethanol)IVDA = IV drug abuseFamily History = deceased MGM = maternal grandmotherPGF = paternal grandfather ESRD = end stage renal diseaseRevie
13、w of Systems HPI = history of present illnessPhysical Exam Gen: Awake alert, NAD （A+O x3）VS: BP, P, RR, T, 95% 2L NCHEENT: NCAT, PERRL, EOMI, no conjunctivitis or icterus, TMs pearly gray, no nasal d/c, MMM, no oral lesions or ulcersNeck: LAD,fullROM,JVDGeneral AppearanceNAD = no acute distressVital
14、 Signs NC = nasal cannulaHead/Ears/Eyes/Nose/ThroatNCAT = normocephalic atraumatic PERRL = pupils equal round and reactive to lightEOMI = extraocular movements intact TMs = tympanic membranesd/c = dischargeMMM = moist mucus membranesNeck =noLAD=lymphadenopathyROM=rangeofmotionJVD=juglarvenousdistens
15、ionPhysical ExamPulm: BS equal BL, cracklesorwheezes,consolidationCV:RRR,m/r/g,caprefill2s,PMInondisplacedGI/Abd:(+)BS,soft,NTTP,rebound,gaurdingordistension,HSM,BRBPR,(-)FOBT,DREnlPulmonary BS = breath sounds BL = bilaterally CardiovascularRRR = regular rate & rhythmm/r/g = murmurs/rubs/gallopsCap
16、refill = capillary refill2s = less than 2 secondsPMI = point of maximum impulse Gastrointestinal / Abdomen (+)BS = positive bowel sounds NTTP = non-tender to palpation HSM = hepatosplenomegalyBRBPR = bright red blood per rectum FOBT = fecal occult blood testDRE = Digital Rectal Exam nl = normal Phys
17、ical Exam Back: scoliosis,CVAtendernessExtrem:LEedema,periphpulsesstrongand=,DIP/PIPjointswellingNeuro:A&Ox3,CNII-XIIgrosslyintact,motor5/5,DTRs2+BackCVA = costovertebral angleExtremitiesLE = lower extremitiy Periph = peripheral DIP = distal interphalangeal joint PIP = proximal interphalangeal joint
18、 Neurologic A&O = alert and oriented CN = cranial nerveDTRs = deep tendon reflexesSummary of History & PECC: 69 y/0 M c hx bronchiectasis c/o cough x10d.HPI: The Pt has a hx of chronic bronchitis and PNA as a child. He states he would have SOB, HA, DOE, and occasional URI symptoms treated with Abx.
19、He now has a non-productive cough w/o fever, ST, n/v/d/c. OTC meds sometimes help. He was recently discharged from the ED last month. He has a 40pack year smoking hx. PMH: IDDM type II, HTN, COPD, CADPSH: CABG 2007Meds: ACEi, Insulin, ASA, Blker, CCB, CS inhaler, LABAAllx: NKMASocHx: married; occupa
20、tion- teacher, smokes 1ppd (40 pack-yrs), EtOH socially, hx IVDAFamHx: Father 65 MI, Mother HTN, DM; MGM CAD, COPD; PGF 71 ESRDROS: negative except as mentioned in the HPIPHYSICAL EXAMGen: Awake alert, NADVS: BP, P, RR, T, 95% 2L NCHEENT: NCAT, PERRL, EOMI, no conjunctivitis or icterus, TMs pearly g
21、ray, no nasal d/c, MMM, no oral lesions or ulcersNeck: LAD, full ROM, JVDPulm: BS equal BL, crackles or wheezes, consolidation CV: RRR, m/r/g, cap refill 2s, PMI nondisplaced GI/Abd: (+)BS, soft, NTTP, rebound, gaurding or distension, HSM, BRBPR, (-) FOBT, DRE nlBack: scoliosis, CVA tendernessExtrem
22、: LE edema, periph pulses strong and =, DIP/PIP joint swelling Neuro: A&Ox3, CNII-XII grossly intact, motor 5/5, DTRs 2+Abbreviations to avoid*Do Not UsePotential ProblemUse insteadU (unit)Mistake for “0” (zero), “4” or “cc”UnitIU (international unit)Mistake for “IV” or “10”International UnitQD, qd,
23、 QOD, qodMistaken for each other or qod for “q.i.d.”Daily, every other dayX.O mg or .XmgMissed decimal pointXmg or 0.XmgMSMorphine sulfate or Magnesium sulfateMorphine sulphateMSO4 and MgSO4Mistaken for each otherMorphine sulfate and Magnesium sulfate*Based on the United States based Joint Commisssion on Accredidation of Healthcare Organizations “do not use” list. In addition to the minimum listCommon AbbreviationsQuestions? Thank you!
