History of present illness là gì

A-a gradient alveolar to arterial gradient

AAS acute abdominal series

ABG arterial blood gas

AC before eating

ACTH adrenocorticotropic hormone

AD autonomic dysreflexia

ADH anti-diuretic hormone

AF atrial fibrillation or afebrile

A/G albumin/globulin ratio

ANA antinuclear antibody

AODM adult o­nset diabetes mellitus

AS aortic stenosis

ASAP as soon as possible

ASCVD atherosclerotic cardiovascular disease

ASD atrial septal defect

ASHD atherosclerotic heart disease

ASIA American Spinal Injury Association

AV atrioventricular

A-V arteriovenous

A-VO2 arteriovenous oxygen

BEE basal energy expenditure

bid twice a day

BKA below the knee amputation

BM bone marrow or bowel movement

BMR basal metabolic rate

BOM bilateral otitis media

BP blood pressure

BPH benign prostatic hypertrophy

BPM beats per minute

BRBPR bright red blood per rectum

BRP bathroom privileges

BS bowel or breath sounds

BUN blood urea nitrogen

BW body weight

BX biopsy

C&S culture and sensitivity

CA cancer

Ca calcium

CAA crystalline amino acids

CABG coronary artery bypass graft

CAD coronary artery disease

CAT computerized axial tomography

CBC complete blood count

CBG capillary blood gas

CC chief complaint

CCU clean catch urine or cardiac care unit

CCV critical closing volume

CF cystic fibrosis

CGL chronic granulocytic leukemia

CHF congestive heart failure

CHO carbohydrate

CI cardiac index

CML chronic myelogenous leukemia

CMV cytomegalovirus

CN cranial nerves

CNS central nervous system

CO cardiac output

C/O complaining of

COLD chronic obstructive lung disease

COPD chronic obstructive pulmonary disease

CP chest pain or cerebral palsy

CPAP continuous positive airway pressure

CPK creatinine phosphokinase

CPR cardiopulmonary resuscitation

CRCL creatinine clearance

CRF chronic renal failure

CRP C-reactive protein

CRTS certified recreational therapy specialist

CSF cerebrospinal fluid

CSW certified social worker

CT computerized tomography

CVA cerebrovascular accident or costovertebral angle

CVAT CVA tenderness

CVP central venous pressure

CXR chest X-ray

DAT diet as tolerated

DAW dispense as written

DC discontinue or discharge

D&C dilation and curettage

DDx differential diagnosis

D5W 5% dextrose in water

DI diabetes insipidus

DIC disseminated intravascular coagulopathy

DIP distal interphalangeal joint

DJD degenerative joint disease

DKA diabetic ketoacidosis

dL deciliter

DM diabetes mellitus

DNA deoxyribonucleic acid

DNR do not resuscitate

DOA dead o­n arrival

DOE dyspnea o­n exertion

DPL diagnostic peritoneal lavage

DPT diphtheria, pertussis, tetanus

DTR deep tendon reflexes

DVT deep venous thrombosis

DX diagnosis

EAA essential amino acids

EBL estimated blood loss

ECD external continence device

ECG electrocardiogram

ECT electroconvulsive therapy

ED erectile dysfunction

EFAD essential fatty acid deficiency

EMG Electromyogram

EMV eyes, motor, verbal response [Glasgow coma scale]

ENT ears, nose, and throat

EOM extraocular muscles

ESR erythrocyte sedimentation rate

ET endotracheal

ETT endotracheal tube

ERCP endoscopic retrograde cholangio-pancreatography

ETOH ethanol

EUA examination under anesthesia

FBS fasting blood sugar

FES functional electrical stimulation

FEV forced expiratory volume

FFP fresh frozen plasma

FRC functional residual capacity

FTT failure to thrive

FU follow-up

FUO fever of unknown origin

FVC forced vital capacity

Fx fracture

GC gonorrhea

GETT general by endotracheal tube

GFR glomerular filtration rate

GI gastrointestinal

gr grain; 1 grain = 65mg

GSW gun shot wound

gt or gtt drops

GTT glucose tolerance test

GU genitourinary

GXT graded exercise tolerance [Stress test]

HA headache

HAA hepatitis B surface antigen

HAV hepatitis A virus

HBP high blood pressure

HCG human chorionic gonadotropin

HCT hematocrit

HDL high density lipoprotein

HEENT head, eyes, ears, nose, throat

Hgb hemoglobin

H/H Henderson-Hasselbach equation or hemoglobin/ hematocrit

HIV human immunodeficiency virus

HLA histocompatibility locus antigen

HJR hepatojugular reflex

HO history of

HOB head of bed

HPF high power field

HPI history of present illness

HR heart rate

HS at bedtime

HSM hepatosplenomegaly

HTLV-III human lymphotropic virus, type III [AIDS agent, HIV]

HSV herpes simplex virus

HTN hypertension

Hx history

I&D incision and drainage

I&O intake and output

ICS intercostal space

ICU intensive care unit

ID infectious disease or identification

IDDM insulin dependent diabetes mellitus

IG immunoglobulin

IHSS idiopathic hypertropic subaortic stenosis

IM intramuscular

IMV intermittent mandatory ventilation

INF intravenous nutritional fluid

IPPB intermittent positive pressure breathing

IRBBB incomplete right bundle branch block

IRDM insulin resistant diabetes mellitus

IT interthecal

ITP idiopathic thrombocytopenic purpura

IV intravenous

IVC intravenous cholangiogram or inferior vena cava

IVP intravenous pyelogram

L left

LAD left axis deviation or left anterior descending

LAE left atrial enlargement

LAHB left anterior hemiblock

LAP left atrial pressure or leukocyte alkaline phosphatase

LBBB left bundle branch block

LDH lactate dehydrogenase

LDL low density lipoprotein

LE lupus erythematosus

LIH left inguinal hernia

LLL left lower lobe

LMP last menstrual period

LNMP last normal menstrual period

LOC loss of consciousness or level of consciousness

LP lumbar puncture

LPN licensed practical nurse

LUL left upper quadrant

LV left ventricle

LVEDP left ventricular end diastolic pressure

LVH left ventricular hypertrophy

MAO monoamine oxidase

MAP mean arterial pressure

MAST medical antishock trousers

MBT maternal blood type

MCH mean cell hemoglobin

MCHC mean cell hemoglobin concentration

MCV mean cell volume

MI myocardial infarction or mitral insufficiency

mL milliliter

MLE midline episiotomy

MMEF maximal mid expiratory flow

mmol millimole

MMR measles, mumps, rubella

MRI magnetic resonance imaging

MRSA methicillin resistant staph aureus

MS multiple sclerosis or mitral stenosis, or morphine sulfate

MSSA methicillin-sensitive staph aureus

MVV maximum voluntary ventilation

MUSE medicated urethral system erection

MVA motor vehicle accident

MVI multivitamin injection

NAD no active disease

NAS no added salt

NCV nerve conduction velocity

NED no evidence of recurrent disease

ng nanogram

NG nasogastric

NIDDM non-insulin dependent diabetes mellitus

NKA no known allergies

NKDA no known drug allergies

NMR nuclear magnetic resonance

NPO nothing by mouth

NRM no regular medications

NSAID non-steroidal anti-inflammatory drugs

NSR normal sinus rhythm

NT nasotracheal

OB obstetrics

OCG oral cholecystogram

OD overdose or right eye

OM otitis media

OOB out of bed

OPV oral polio vaccine

OR operating room

OS left eye

OT occupational therapy or occupational therapist

OU both eyes

P para

PA posteroanterior

PAC premature atrial contraction

PAO2 alveolar oxygen

PaO2 peripheral arterial oxygen content

PAP pulmonary artery pressure

PAT paroxysymal atrial tachycardia

P&PD percussion and postural drainage

PC after eating

PCWP pulmonary capillary wedge pressure

PDA patent ductus arteriosus

PDR physicians desk reference

PE pulmonary embolus, or physical exam or pleural effusion

PEEP positive end expiratory pressure

PFT pulmonary function tests

pg picogram

PI pulmonic insufficiency disease

PKU phenylketonuria

PMH previous medical history

PMI point of maximal impulse

PMN polymorphonuclear leukocyte [neutrophil]

PND paroxysmal nocturnal dyspnea

PO by mouth

POD post-op day

PP postprandial or pulsus paradoxus

PPD purified protein derivative

PPMS primary progressive multiple sclerosis

PPS post-polio syndrome

PR by rectum

PRBC packed red blood cells

PRN as needed

PS pulmonic stenosis

PSA prostate-specific antigen

PT prothrombin time, or physical therapy

Pt patient

PTCA percutaneous transluminal coronary angioplasty

PTH parathyroid hormone

PTHC percutanous transhepatic cholangiogram

PTSD post-traumatic stress disorder

PTT partial thromboplastin time

PUD peptic ulcer disease

PVC premature ventricular contraction

PVD peripheral vascular disease

PVR post voiding residual

q every

qd every day

qh every hour

q4h, q6h. every 4 hours, every 6 hours etc.

qid four times a day

QNS quantity not sufficient

qod every other day

Qs/Qt shunt fraction

Qt total cardiac output

R right

RA rheumatoid arthritis or right atrium

RAD right atrial axis deviation

RAE right atrial enlargement

RAP right atrial pressure

RBBB right bundle branch block

RBC red blood cell

RBP retinol-binding protein

RDA recommended daily allowance

RDW red cell distribution width

RIA radioimmunoassay

RIH right inguinal hernia

RLL right lower lobe

RLQ right lower quadrant

RML right middle lobe

RNA ribonucleic acid

R/O rule out

ROM range of motion

ROS review of systems

RPG retrograde pyelogram

RPMS relapsing-progressive multiple sclerosis

RRMS relapsing-remitting multiple sclerosis

RRR regular rate and rhyth

RT respiratory or radiation therapy

RTA renal tubular acidosis

RTC return to clinic

RU resin uptake

RUG retrograde urethogram

RUL right upper lobe

RUQ right upper quadrant

RV residual volume

RVH right ventricular hyperthrophy

Rx treatment

s without

SA sinoatrial

SAA synthetic amino acid

S&E sugar and acetone

SBE subacute bacterial endocarditis

SBFT small bowel follow through

SBS short bowel syndrome

SCr serum creatinine

SCI spinal cord injury

SCI/D spinal cord injury and disorder

SEM systolic ejection murmur

SG Swan-Ganz

SGA small for gestational age

SGGT serum gamma-glutamyl transpeptidase

SGOT serum glutamic-oxaloacetic transaminase

SGPT serum glutamic-pyruvic transaminase

SIADH syndrome of inappropriate antidiuretic hormone

sig write o­n label

SIMV synchronous intermittent mandatory ventilation

sl sublingual

SLE systemic lupus erythematous

SMO slips made out

SOAP Subjective, Objective, Assessment, Plan

SOB shortness of breath

SPMS secondary preogressive multiple sclerosis

SQ subcutaneous

ss o­ne-half

STAT immediately

SVD spontaneous vaginal delivery

SW social worker

Sx symptoms

T&C type and cross

TAH total abdominal hysterectomy

T&H type and hold

TB tuberculosis

TBG total binding globulin

Td tetanus-diphtheria toxoid

TIA transient ischemic attack

TIBC total iron binding capacity

tid three times a day

TIG tetanus immune globulin

TKO to keep open

TLC total lung capacity

TMJ temporo mandibular joint

TNTC too numerous to count

TO telephone order

TOPV trivalent oral polio vaccine

TPN total parenteral nutrition

TSH thyroid stimulating hormone

TT thrombin time

TTP thrombotic thrombocytopenic purpura

TU tuberculin units

TUR transurethral resection

TURBT TUR bladder tumors

TURP transurethral resection of prostate

TV tidal volume

TVH total vaginal hysterectomy

tw twice a week

Tx treatment, transplant