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1、SirrunrunshawhospitalCommon MedicalAbbreviationsAngelaLai,ms4MichiganstateuniversityCollegeofhumanmedicineExample67y/omalec/oCPandSOBx2h.Painissev(8/10),understernumandradiatestotheLarmandjaw.Painwokeptfromsleep,anddeniesDOEorw/breathing.PMH:Pt.hasah/oCAD,MI1/15/01,HTN,andDM.Meds:ASA,insulin,la
2、six,andlisinopril.Allx:PCNPE:PtisA+Ox4,diaphoreticanxious.HEENT:PERRLNeck:–JVD,+useofaccessorymusclesPulm:BScrackles@bases,+rtxnsAbd:soft,NTTPExtrem:¾LEedema67yearoldmalecomplainsofchestpainandshortnessofbreathfor2hours.Painissevere(8/10),understernumandradiatestotheLeftarmandjaw.Painwokepatien
3、tfromsleep,anddeniesdyspneaonexertionorwithbreathing.Pastmedicalhistory:patienthasahistoryofcoronaryarterydisease,myocardialinfarction1/15/10,hypertension,anddiabetesmellitus.Medications:Aspirin,Insulin,Lasix,LisinoprilAllergies:PenicillinPhysicalexam:Patientisalertandorientedx4,diaphoretic,anx
4、iousHeadEarsEyesNoseThroat:PupilsequalroundandreactivetolightNeck:nojugularvenousdistension,positiveuseofaccessorymusclesPulmonary:breathsounds,cracklesatbases,positiveretractionsAbdomen:soft,non-tendertopalpationExtremities:3/4lowerextremityedemaIntroductionAbbreviationsareoftenusedinmedicineI
5、tBoostsefficiencytosavetimeindocumentationBUTitshouldbeusedcautiously!CertainabbreviationsshouldbeavoidedTYPSPhases’initialletters:e.g.CP,SOB,DOE,CAD,JVD,DOA,PE,PMH,PERRL,ESRD,ESLD,GSWWord’spronouncingletters:e.g.HTN,PNA,PCN,ASA,etOH,LAD,HSM,Pt,retxn,mcg,gmRelatedwordscombinedinitialletters:e.g
6、.HEENT,n/v/d/c,m/r/g,A+O,H&P,h/r/s/t,H&MEndwith“/o”or“/”:e.g.y/o,w/o,c/o,D/C,D/S,Endwith“x”:e.g.Hx,Sx,Tx,Dx,DDx,abx,allx,RxPartiallyshort:Abbrevs.Meds.Info.Imp.Lab.Extr.Symbols:e.g.+x(+)(-)↓Ø@Latins:P.O.,B.I.D,tid,prnTakingaHistoryCC:69y/0Mchxbronchiectasisc/ocoughx10d.HPI:ThePthasahxofchronicb
7、ronchitisandPNAasachild.Hestateshewouldhave↑SOB,HA,DOE,andoccasionalURIsymptomstreatedwithAbx.Henowhasanon-productivecoughw/ofever,ST,n/v/d/c.OTCmedssometimeshelp.HewasrecentlydischargedfromtheEDlastmonth.Hehasa40packyearsmokinghx
