| 0 | Not Present OR No abnormality | Also in superscript e.g. ……..o |
| +/- | Uncertain/equivocal |
|
| + | Present or Noted |
|
| ++ | Present Significantly |
|
| +++ | Present in Excess | eg BMI +++ |
| = | Equivalent to |
|
| 3 | OK or satisfactory |
|
| A | Ankle Jerk/Reflex | Hitting the ankle with a patella hammer to test reflexes |
| AAA | Abdominal Aortic Aneurysm | Dilatation of abdominal aorta |
| AAL | Anterior Axillary Line | Imaginary line drawn from the front arm pit down the chest wall |
| ABG | Arterial Blood Gas "Sats" | Blood test to see how much oxygen there is in the blood (percentage ‘saturation’ with oxygen) |
| ACL | Anterior Clavicular Line or Anterior Cruciate Ligament | An imaginary line down the front of the body from the inner end of the collarbone OR a ligament in the knee |
| A.d | As Directed |
|
| A/E | Air Entry to Lungs OR
Accident & Emergency |
|
| AF | Atrial Fibrillation | Irregular heart beat |
| AI/R | Aortic Incompetence/regurgitation | Leaking heart valve. |
| AoR | Aortic Valve Replacement | AVR |
| AS | Abdominal System OR Aortic Stenosis | Aortic Stenosis is a narrowed heart valve |
| AXR | Abdominal X-Ray |
|
| bd/bid | Twice a Day |
|
| B | Biceps Jerk/Reflex | Hitting the arm with a patella hammer to test reflexes |
| BCC | Basal Cell Carcinoma | Skin Cancer – Very Low Malignancy |
| BMI | Body Mass Index | A measure of body size relating to height and weight |
| BNO | Bowels Not Opened |
|
| BOR | Bowels Open Regularly |
|
| BP | Blood Pressure |
|
| BPd | Diastolic Blood Pressure | The lower blood pressure (heart relaxed) |
| BPs | Systolic Blood Pressure | The higher blood pressure (heart contracted) |
| CA or Ca (also indicated by "*") | Carcinoma | Cancer |
| CABG/S or CAG/S | Coronary Artery (Bypass) Graft/Surgery | Heart surgery to bypass blocked blood supply |
| CFS | Chronic Fatigue Syndrome | Also called ME |
| CNS | Central Nervous System |
|
| C/o or C.o | Complains of |
|
| COAD | Chronic Obstructive Airways Disease | Chronic lung disease |
| COPD | Chronic Obstructive Pulmonary Disease | Chronic lung disease |
| CT or CAT | Computerised Axial Tomography | Body Scan |
| CVA | Cerebrovascular Accident | Stroke |
| CVS | Cardiovascular System | The heart and blood vessels |
| CX or Cx | Cervix OR Cervical Spine | Cervix is the neck of the womb
For example, Cx smear = Cervical smear |
| CXR | Chest X-ray |
|
| D+V | Diarrhoea and Vomiting |
|
| D/H | Drug History |
|
| DIP, PIP | Dorsal/proximal interphalangeal joints | Finger joints |
| DLE | Discoid Lupus Erythematosus | A connective tissue disorder |
| DNA | Did Not Attend |
|
| DS | Disseminated (Multiple) Sclerosis |
|
| DU | Duodenal Ulcer |
|
| DVT | Deep Vein Thrombosis | Blood clot |
| DXT | Deep X-ray Treatment | Radiotherapy |
| EAM | External Auditory Meatus | Ear canal opening |
| ECG | Electrocardiograph | Electrical heart trace |
| EMU | Early Morning Specimen of Urine |
|
| ENG | Head engaged (Baby) | Head of baby low in pelvis (in Womb) |
| ENT | Ear, Nose & Throat |
|
| ESR | Erythrocyte Sedimentation Rate | A blood test for inflammation |
| FBC | Full Blood Count |
|
| FBG/S | Fasting Blood Glucose/Sugar |
|
| FD | Forceps Delivery |
|
| F/H or FH | Family History |
|
| FHH/R | Foetal Heart Heard/Regular | Baby’s heartbeat in the womb |
| FROM | Full Range of Movement |
|
| FTD | Formal Thought Disorder | Psychiatric disorder |
| FTND | Full Term Normal Delivery |
|
| GCS | Glasgow Coma Scale | Consciousness state; score out of 15 |
| GI or GIT | Gastro Intestinal/Tract | To do with the intestines |
| GORD | Gastro-Oesophageal Reflux Disease | Back flow of stomach acid into the gullet |
| GU or GUT or GUS | Genito Urinary/Tract/ System | Relating to kidneys, bladder & genitals |
| GU | Gastric Ulcer |
|
| GUM | Genito-Urinary Medicine | For sexually transmitted diseases/infections |
| Hb | Haemoglobin | A measure of blood count (eg in Anaemia) |
| HH | Hiatus Hernia | Part of stomach displaced above diaphragm |
| HI | Head Injury |
|
| HNPU | Has Not Passed Urine |
|
| HR | Heart Rate |
|
| HS | Heart Sounds |
|
| HT | Height |
|
| Hx | History (of complaint) |
|
| IBS | Irritable Bowel Syndrome |
|
| IGT or IGTN | In Growing Toenail |
|
| IMB | Intermenstrual Bleeding | Vaginal bleeding between periods |
| ISQ | "In Status Quo" - Nothing has Changed |
|
| IVP | Intravenous Pyelogram | X-ray of kidneys using an injected dye |
| Ix | Investigations |
|
| JVP | Jugular Venous Pressure | Neck Vein – back pressure from the heart |
| K | Knee Jerk/Reflex OR serum potassium |
|
| KUB | Kidneys, Ureters, Bladder | X-ray or ultrasound of renal track (IVP) |
| LFT | Liver Function Test | Blood tests for liver function |
| LIF | Left Iliac Fossa | Left groin |
| LIH | Left Inguinal Hernia | Hernia of left groin |
| LKKS | Liver, kidney, kidney, spleen | Result of examination |
| LOC | Loss of Consciousness |
|
| LN | Lymph Node |
|
| LP | Lumbar puncture | Needle inserted into the spine for diagnostic purposes |
| L/R/ IH | Left or Right Inguinal Hernia | Hernia of groins |
| LS | Lymph System |
|
| LSCS or LUSCS | Lower (Uterine) Segment Caesarean section |
|
| LUQ | Left Upper Quadrant | Left upper part of abdomen |
| Mane | In the Morning |
|
| M&C (S) | Microscopy & Culture Sensitivity of Bacteria | Of a sample e.g. urine |
| MCL | Mid Clavicular Line | An imaginary line down the body from the middle of the collarbone to the described area |
| MCV | Mean Corpuscular Volume | A measure of the size of red blood cells |
| ME | Myalgic Encephalomyelitis | Also called Chronic Fatigue Syndrome |
| MET/S | Metastases | Cancer spread |
| MI | Myocardial Infarction OR Mitral Incompetence | Heart attack OR leaking heart valve (sometimes MR) |
| mitte or mite | Dispense this number of tablets |
|
| MRI | Magnetic Resonance Imaging | Body/Brain Scan |
| MS | Multiple Sclerosis OR Mitral Stenosis | Mitral Stenosis is a narrowed heart valve |
| MSS | Musculo-Skeletal System |
|
| MSE | Mental State Examination |
|
| MSU or MSSU | Mid-Stream Urine Sample |
|
| NAD | Nothing Abnormal Discovered |
|
| NBI | No Bone Injury |
|
| Nocte | At Night |
|
| NFR | Not For Resuscitation |
|
| N&V | Nausea & Vomiting |
|
| OA | Osteoarthritis | ‘Wear & Tear’ Arthritis |
| OC/COC | ( Combined) Oral Contracepti ve |
|
| OCT | Orthotopic Cardiac Transplant | Heart Transplant |
| o.d. | Once a Day |
|
| O/E or o.e | On Examination |
|
| OGD | Oesophago-gastro-duodenoscopy | Telescope examination of stomach and gullet |
| on | At Night |
|
| om | In the Morning |
|
| OM (R/L) | Otitis Media | Ear infection |
| ORIF | Open Reduction and Internal Fixation (of fracture) | Operation to set a broken bone |
| otc | Over the counter (bought medication) |
|
| P | Pulse |
|
| PC | Post Cibum | After a meal |
| PCB | Post Coital Bleeding | Vaginal bleeding after intercourse |
| PCC | Post Coital Contraception | "Morning after" pill |
| PE | Pulmonary Embolism | Blood clot on the lung |
| PERLA | Pupils equal and reacting to light and accommodation | On examination of nervous system/eyes |
| PF(R) | Peak Flow (Rate) | Breathing test – speed of expiration |
| PID | Pelvic Inflammatory Disease OR
Prolapsed Intervertebral Disc | Gynaecological infection OR
Slipped vertebral Disc |
| PM | Post mortem examination |
|
| PMH also PHx | Previous Medical History |
|
| PND | Paroxysmal Nocturnal Dyspnoea | Short of breath at night |
| PO | Per Orim | By Mouth |
| POP | Progesterone Only Pill OR
Plaster of Paris | Minipill
Cast |
| PPs | Peripheral pulses | Pulses felt for example in the feet, ankles etc… |
| PR | Per Rectum | Rectal examination |
| PRN | As Required |
|
| PTCA | Percutaneous transluminal coronary angioplasty | Opening up the main arteries of the heart using a balloon inserted usually near the groin |
| PTSD | Post Traumatic Stress Disorder |
|
| PU | Peptic Ulcer OR Passed urine | Peptic Ulcer – Stomach or Duodenal Ulcer |
| PV | Per Vagina | Vaginal examination |
| PVD | Peripheral Vascular Disease | Arterial disease of the limbs |
| qds (or) qid | Four times a day |
|
| R (R) | Respiration (Rate) | Rate of breathing in breaths per minute |
| RA | Rheumatoid Arthritis |
|
| RDS | Respiratory Distress Syndrome | Difficulty in breathing – usually in premature babies |
| RFT | Renal (Kidney) Function tests OR
Respiratory Function tests |
|
| RIF | Right Iliac Fossa | Right lower abdomen |
| RIH | Right Inguinal Hernia | Hernia in right groin |
| R/L | Right/Left |
|
| R/L HC | Right/Left Hypochordrium | Right/Left upper abdomen |
| R/LIF | Right/Left Iliacfossa | Right/Left groin |
| R/LOL or RLOP | Right/Left occipito lateral / posterior | Position of baby’s head in womb |
| RS | Respiratory System |
|
| RSI | Repetitive Strain Injury | Usually of wrist |
| RTA | Road Traffic Accident | Car smash |
| RUQ | Right Upper Quadrant | Right upper abdomen |
| Rx | Prescription or Treatment | Usually prescription |
| S | Supinator (jerk /reflex) | Hitting the am with a patella hammer to test reflexes |
| SBG | Serum Blood Glucose | Blood Sugar Level |
| SLR | Straight Leg Raising |
|
| SMR | Submucosal Resection | Nasal operation |
| SOB | Short of Breath |
|
| SOL | Space Occupying Lesion | Tumour, usually of head |
| SOM | Secretary Otitis Media | Middle ear infection/glue ear |
| SOS | In an Emergency |
|
| SR | Sinus rhythm | Normal heart beat |
| Stat | Immediately |
|
| STD | Sexually Transmitted Disease |
|
| STI | Sexually Transmitted Infection |
|
| SVD | Spontaneous Vertex Delivery | Normal delivery |
| Sx | Symptoms |
|
| SkXR | Skull X-ray |
|
| T | Triceps Jerk/Reflex OR Temperature | Hitting the arm with a patella hammer to test reflexes |
| Tá â | Temperature raised upwards or downwards |
|
| T (usually with a circle with a dot in the centre) | Trachea Central | Breathing tube not displaced. If displaced, direction of displacement usually indicated by an arrow |
| TATT | Tired all the Time |
|
| TB | Tuberculosis |
|
| TCI | To come in-date or fact that a person is due to be admitted to hospital |
|
| tds (or) tid | Three Times a Day |
|
| TFTs | Thyroid Function Test |
|
| THR | Total Hip Replacement |
|
| TIA | Transient Ischaemic Attack | Small, short lived stroke – often recurrent |
| TKR | Total Knee Replacement |
|
| TLC | Tender Loving Care | Treat only with symptom relief and nursing care, usually meaning that this is all that is needed. |
| TM or Tm | Tympanic Membrane | Ear drum |
| TOC | Tightness of Chest |
|
| Trauma Series | Cervical Spine, Chest and Pelvis Xray | Frquently requested after major trauma |
| Ts&As | Tonsilectomy and Adenoidectomy |
|
| TShR | Total Shoulder Replacement |
|
| TTO/A | To take home/away (medication) |
|
| TU(R)P | Transurethral (resection) of Prostate | Operation on the prostate gland carried out through the penis |
| UC | Ulcerative Colitis |
|
| U&Es | Urea and Electrolytes | Blood test for kidney function |
| US | Ultra Sound Scan |
|
| UTI | Urinary Tract Infection |
|
| VF | Ventricular Fibrillation | Rapid uncoordinated heart beat usually leading to collapse, and need for defibrillation (electric heart shock) |
| V/S/TOP | Vaginal suction termination of pregnancy |
|
| VT | Ventricular Tachycardia | Fast heart beat |
| wbc | White Blood Cell Count |
|
| Wt | Weight |
|
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