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Physical Exam, General, Labs and Vitals

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nguyentp8's version from 2016-09-10 06:56

Physical Exam

Question Answer
A&PAuscultation and percussion; anterior and posterior; assessment and plan
AALAnterior axillary line
ABIAnkle brachial index
ADright ear (auris dextra)
APAnteroposterior
ASLeft ear (auris sinistra)
AUEach ear (auris uterque)
BSBowel sounds; breath sounds
CMCostal margin
CNCranial nerve
CTAClear to auscultation
CVACostovertebral angle
CVATCostovertebral angle tenderness
DPDorsalis pedis
EENTEyes, ears, nose, throat
EOMIExtraocular movements (or muscles) intact
HEENTHead, eyes, ears, nose, and throat
ICSIntercostal space
IJInternal jugular
IVCInferior vena cava
JVDJugular venous distention
JVPJugular venous pressure
LCMLeft costal margin
LELower extremity
LLELeft Lower extremity
LLLLeft lower lobe
LLQLeft lower quadrant (abdomen)
LLSBLeft lower sternal border
LUELeft upper extremity
LULleft upper lobe
LUQLeft upper quadrant
LVEFLeft ventricular ejection fraction
LVHLeft ventricular hypertrophy
MCLMidclavicular line
NADNo acute (or apparent) distress
NSRNormal sinus rhythm
NT/NDNontender / nondistended
ODRight eye
OSLeft eye
OUeach eye
PPulse, plan, percussion, pressure
P&APercussion and auscultation
PEPhysical exam
PERLAPupils equal, react to light and accommodation
PERRLAPupils equal, round, and reactive to light and accomodation
PTPosterior tibial
RAright atrium
RCARight coronary artery
RCMRight costal margin
RLERight lower extremity
RLLRight lower lobe
RLQRight lower quadrant (abdomen)
RMLRight middle lobe
RUERight upper extremity
RULRight upper lobe
RUQRight upper quadrant (abdomen)
RVHRight ventricular hypertrophy
S1First heart sound
S2Second heart sound
S3Third heart sound (ventricular gallop)
S4Fourth heart sound (atrial gallop)
SASinoatrial
UEUpper extremity
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General

Question Answer
ACLSAdvanced cardiac life support
ADEAdverse drug effect (or event)
ADLActivities of daily living
ADRAdverse drug reaction
AKAall known allergies
AMAAgainst medical advice
AmpAmpule
BBBBlood-brain barrier
CACancer; Calcium
CAMComplementary and alternative medicine
CCChief complaint
CCUCoronary care unit
c/oComplains of
CPRCardiopulmonary resuscitation
CTComputed tomography; chest tube
CxCulture; cervix
CXRChest X-ray
DNADeoxyribonucleic acid
DNRDo not resuscitate
DOADead on arrival; date of admission; duration of action
DOBdate of birth
DRGDiagnosis-related group
DxDiagnosis
EDEmergency Department
EndoEndotracheal; endoscopy
EREmergency room
ETEndotracheal
ETOHEthanol
FHFamily History
f/uFollow-up
FUOFever of unknown origin
GrGrain
H & PHistory and physical examination
H/OHistory of
HPIHistory of present illness
HxHistory
I & OIntake and output
ICUIntensive care unit
LLiter
LTCFLong-term care facility
MARMedication administration record
McgMicrogram
mEqMilliequivalent
mgMilligram
MICUMedical intensive care unit
mLMilliliter
MRIMagnetic resonance imaging
N/CNoncontributory; nasal cannula
NKANo known Allergies
NKDANo known drug allergies
NLnormal
NOSNot otherwise specified
ODOverdose
OROperating room
OTOccupational therapy
OTCOver the counter
PCPPrimary Care Physician
PETPositron emission tomography
PICCPeripherally inserted central catheter
PMHPast medical history
PODPostoperative day
PpdPacks per day
PSHPast surgical history
PTPhysical therapy; patient
QOLQuality of Life
RDARecommend daily allowance
REMRapid eye movement
RNARibonucleic acid
R/ORule out
ROSReview of systems
RRRecovery room
RTRadiation therapy
RTCReturn to clinic
SHSocial History
SIDSSudden infant death syndrome
SJSStevens-Johnson syndrome
SLESystemic lupus erythematosus
SNFSkilled nursing facility
S/PStatus post
SPFSun protection factor
SxSymptoms
TTemperature
TLCTherapeutic lifestyle changes
TxTreatment; Treat
UVUltraviolet
W/CWheelchair
WDWNWell-developed, well-nourished
WNLWithin normal limits
W/UWork-up
YoYear-old
YrYear
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Labs/Vitals

Question Answer
A1CHemoglobin A1C
ABGAterial blood gases
ABIAnkle brachial index
ABWActual body weight
ACRAlbumin: creatinine ratio
ACTActivated clotting time
ACTHAdrenocorticotropic hormone
ABCAbsolute band count; absolute basophil count; aspiration, biopsy, and cytology; artificial beta cells
ADHAntidiuretic hormone
ALPAlkaline phosphatase
ALTAlanine aminotransferase
aPTTActivated partial thromboplastin time
ASTAspartate aminotransferase
BACBlood alcohol concentration
BCBlood culture
BNPBrain natriuretic peptide
BPBlood Pressure
BpmBeats per minute
BUNBlood urea nitrogen
BxBiopsy
C & SCulture and sensitivity
CBCComplete blood count
CFUColony-forming unit
CKCreatine kinase
CLcrCreatine clearance
CPKCreatine phosphokinase
CRPC-reactive protein
CSFCerebrospinal fluid; colony-stimulating factor
DBPDiastolic blood pressure
D/CDiscontinue; discharge
DiffDifferential
dLDeciliter
eAGEstimated average glucose
ESRErythrocyte sedimentation rate
FBSFasting blood sugar
FOBTFecal occult blood test
FPGFasting plasma glucose
FSHFollicle-stimulating hormone
GFRGlomerular filtration rate
GTTGlucose tolerance test
H&HHemoglobin and Hematocrit
Hb, hgbHemoglobin
HbA1CHemoglobin A1C
HBPHigh Blood pressure
HCGHuman chorionic gonadotropin
HCO3Bicarbonate
HctHematocrit
HDLHigh-density lipoprotein
HRHeart rate
INRInternational normalized ratio
KPotassium
LDHLactate dehydrogenase
LDLLow-density lipoprotein
LFTLiver function test
MCHMean corpuscular hemoglobin
MCHCMean corpuscular hemoglobin concentration
MCVMean corpuscular volume
MICMinimum inhibitory concentration
NGTDNo growth to date (on culture)
OGTOral glucose tolerance test
pHHydrogen ion concentraion
PPBGPostprandial blood glucose
PSAProstate-specific antigen
PTProthrombin time;
PTHParathyroid hormone
PTTPartial thromboplastin time
RBCRed blood cell
RRRespiratory rate
RRRRegular rate and rhythm
SBPSystolic blood pressure
SCrSerum creatinine
SGOTSerum glutamic oxaloacetic transaminase
T. biliTotal bilirubin
TFTThyroid function test
TGTriglyceride
TIBCTotal iron-binding capacity
TNTCToo numerous to count
TSHThyroid-stimulating hormone
UAUrinalysis; uric acid
VLDLVery low-density lipoprotein
VSVital signs
WBCWhite blood cell
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