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Chronic Hypertensive Vascular Disease Creatinine kinase Cervical Lymph Adenopathy Cephalic not in labor Chronic Obstructive Pulmonary Disease Central Pulmonary Airway Pressure Creatinine clearance Chronic Renal Failure Capillary Refill Time Cerebrospinal Fluid Computed Tomography Chest Tube Thoracostomy Cardiovascular/ Cerebrovascular Accident Accident CVD Cerebrovascular Disease CVP Central Venous Pressure CVS Cardiovascular System CXR Chest X-ray D/C Discharge; discontinue DCMP Dilated Cardiomyopathy DHN Dehydration DHS Distinct Heart Sound DIC Disseminated Intravascular Intravasc ular Coagulopathy DKA Diabetic Ketoacidosis DM Diabetis Mellitus DOB Difficultly Difficultl y of Breathing DOE Dyspnea on Exertion DOI Date of Injury DTG Diffuse Toxic Goiter DTR Deep Tendon Reflex Dx/Dxic Diagnosis E/N Essentially normal EBRTL Equal briskly reactive to light ECE Equal Chest Expansion EEG Electroencephalogram EF Ejection Fraction EOM Extra Ocular Movement ESRD End-stage Renal Disease ESR Erythrocyte Sedimentation Rate FBS Fasting Blood Sugar F/D Fairly developed FC Functional Class, Foleycath FEP Full Equal Pulses FHT Fetal Heart Tone FHx Family History F/N Fairly nourished FT Full Term FTSVD Full Term Spontaneous Vaginal Delivery FWB Fresh Whole Blood Fxn Function GOPO Gravida para
GBS Guillain Barre Syndrome GFR Glomerular Filtration Rate GI/GIT Gastrointestinal Tract GIN Gastrointestinal Nutrition GN Glomerulonephritis GS/CS Gram Stain/Culture Sensitivity HA Headache HAA Home Against Advice HAP Hospital-acquired Pneumonia HBP High Blood Pressure HDL High Density Lipoprotein Hct Hematocrit HEENTHead, Ear, Eyes, Nose, Throat HF Heart Failure Hgb Hemoglobin HHD Hypertensive Heart Disease HPI History of Present Illness HPN/HTN Hypertension HR Heart Rate HSV Herpes Simplex Virus Hx History I&O Intake & Output ICM Intracostal Margin ICS Intercostal Space IDDM Insulin Dependent Diabetes Mellitus IE Infective Endocarditis IHD Ischemic Heart Disease INR International Normalized Ratio ITP Idiopathic Thrombocytopenic Purpura IVP Intravenous Pyelogram KUB Kidney, Ureter, Bladder KVO Keep vein open LA Left Atrium LAAL Left Anterior Axillary Line LDH Lactate Dehydrogenase LDL Low Density Lipoprotein LE Lower Extremities LFT Liver Function Tests LLE Left Lower Extremity LLL Left Lower Quadrant LLQ Left Lower Quadrant LMCA Left Mid Carotid Artery LMCL Left Mid Clavicular Line LMP Last Menstrual Period LOC Loss of Consciousness/Level Of consciousness LPF Lower power field LPM Liter per minute LPSB Left parasternal border LT Lumbar tap LUE Left Upper Extremity LUQ Left Upper Quadrant LV Left Ventricle
LWI Latest Working Impression MG Myasthenia Gravis MGH May go home MOB Medications on Board MOI Mechanism of Injury MRI MagneticResonance Imaging MRS Methicillin-resistant Strain MV Mechanical Ventrilator MVP Mitral Valve Prolapse NABS Normoactive Bowel Sounds NBS Normal Bowel Sound NGT Nasogastric Tube NIAE Not in acute exacerbation NICRD Not in cardiorespiratory distress NIDDM Non-insulin Dependent Diabetes Mellitus NIL Not in labor NIR Non-insulin requiring NIRD Not in respiratory distress NNO No new orders NNS No new Suggestions NO Non-obese NORF No other remarkable findings NPO Nothing per orem NRRR Normal Rate Regular Rhythm NRTL Non-reactive to light NSAID Non-steroidal AntiinflammatoryDrug NSNI Non-septic non-induced NSTEMI Non-ST wave elevationMyocardial Infarction NSSTWC Non-specific ST-wave changes NV Neurovascular NVE Neck Vein Engorgement OB Occult Blood OCP Oral Contraceptive Pill OD Once daily/ Right eye OF Osterized Feeding OS Left eye OU Both eye P/SHx Personal/Social History PE Physical Examination PEEP Positive end expiratory Pressure PGO Partial Gut Obstruction PHx Personal History Plt Platelet PMP Post Menstrual Period PNB Pink Nail Beds PND Paroxysmal Nocturnal Dyspnea POI Place of Injury PRBC Packed Red Blood Cells PS Pressure Support PT Prothrombin Time PTA Prior to Admission
PTB Pulmonary Tuberculosis PTC Prior to Consult PTH Parathyroid Hormone PTO/PTOR Prior to Operation PTT Partial Thromboplastin Time PU Pregnancy Uterine PUD Peptic Ulcer Disease PVC Premature Ventricular Contraction PVT Paroxysmal VentricularTachycardia PWI Present working Impression R/O Rule out RA Right atrium RBC Red Blood Cells RBS Random Blood Sugar RCM Right costal margin RF Renal Failure, Respiratory Failure RHD Rheumatic Heart Disease RLE Right Lower Extremity RMCA Right mid-carotid artery RMI Regular Menstrual Interval ROR Red orange reflect ROS Review of Systems RR Respiratory Rate RRE Round, regular and equal RRR Regular Rhythm and Rate RTC Round the Clock RUE Right Upper Extremity RUQ Right Upper Quadrant RV Right Ventricle RVR Rapid Ventricular Rate S/P Status Post SABE Sub-acute Bacterial Endocarditis SAH Sub-arachoid Hemorrhage SBP Systolic Blood Pressure SC Spinal Cord SC/SQ Subcutaneous SCI Spinal Cord Injury SCN Sternocleidomastoid SGOT Serum Glutamic Ovalo-Acetic Transaminase (also AST) SGPT Serum Glutamic PyruvicTransaminase (also ALT) SIADH Syndrome of Inappropriate Antidiuretic Hormone SLE Systemic Lupus Erythematosus SOB Shortness of Breath SrCr Serum Creatinine SSS Sick Sinus Syndrome SVT Supra-ventricular Tachycardia T/C To consider TCVS Thoracic Carrdiovascular Surgery TFI Total Fluid Intake
TIA Transient Ischemic Attack TKVO To keep vein open TOH Time of Injury TPC Tonsilopharyngeal Congestion TPR Temperature, pulse, Respiration TSB Tepid sponge bathe TTHD Thyrotoxic Heart Disease TVP Transvenous pacemaker Tx/Txic Treatment U/A Urinalysis UBP Usual Blood Pressure UE Upper Extremities UGIB Upper Gastrointestinal Bleeding UO Urine Output URTI Upper Respiratory Tract Infection UTI Urinary Tract Infection VA Vehicular Accident VF Visual field VS Vital signs WNL Within normal limits WOF Watch out for 1,25-DHCC 1,25-dihydrocholecalciferol 25-HCC 25-hydrocholecalciferol 3P’s Polyphagia, Polydipsia, Polyuria