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Module 8: Tuberculosis Surveillance and Case Management in Hospitals

Appendix: Medical Records Abbreviations

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

A-- assessment

AB -- antibody; abortion; antibiotic (any of the three)

ABD -- abdomen

ABG -- arterial blood gas (a test for oxygen and other blood gases)

ABX -- antibiotics

AC -- before meals

ACLS -- advanced cardiac life support

AD LIB -- as much as needed

AF -- afebrile (without a fever); aortofemoral (blood vessels); atrial fibrillation (irregular heart beat)

AFB -- acid-fast bacilli

AKA -- also known as; or above the knee amputation

AODM -- adult onset diabetes mellitus

AP -- anteroposterior (front to back); abdominal-perineal

ARDS -- adult respiratory distress syndrome

ARF -- acute renal (kidney) failure

B

BAL -- bronchoalveolar lavage

BCG -- bacille Calmette-Gurin (vaccination against TB)

BE -- barium enema (radiograph of the lower intestines)

BF -- black female

BID -- twice a day

BM -- black male; bone marrow (sometimes biopsied for TB); bowel movement

BP -- blood pressure

BPM -- heart beats per minute

BS -- bowel or breath sounds

BW -- body weight

BX -- biopsy

C

C -- with

C/O -- complaining of

C&S -- culture and sensitivity

Ca -- calcium

CA -- cancer

CABG -- coronary artery bypass graft (heart surgery)

CAD -- coronary artery disease

capreo -- capreomycin

CAT -- computerized axial tomography (specialized radiograph, also called CT scan)

CBC -- complete blood count

CC -- chief complaint

CCU -- clean catch urine; coronary care unit

CF -- cystic fibrosis

CHF -- congestive heart failure

Cipro -- ciprofloxacin, a 2nd-line anti-TB medication

CMV -- cytomegalovirus

CN -- cranial nerves

CNS -- central nervous system

COPD -- chronic obstructive pulmonary disease

CP -- chest pain; cerebral palsy

CPR -- cardiopulmonary resuscitation

CRF -- chronic renal (kidney) failure

CSF -- cerebrospinal fluid

CT -- computerized tomography (specialized radiograph)

CVA -- cerebrovascular accident (stroke); costovertebral angle

CXR -- chest x-ray (radiograph)

D

D&C -- dilation and curettage (uterine scraping)

DC, D/C -- discontinue; discharge

DDx -- differential diagnosis (list of possible diagnoses)

DKA -- diabetic ketoacidosis

dL -- deciliter

DM -- diabetes mellitus

DNR -- do not resuscitate

DOA -- dead on arrival

DOE -- dyspnea (shortness of breath) on exertion

DT -- diptheria tetanus (vaccine)

Dx -- diagnosis

E

ECG -- electrocardiogram

E

D -- emergency department

EDC -- estimated date of confinement (estimated date of giving birth)

EKG -- electrocardiogram

EMB -- ethambutol

ENT -- ear, nose, and throat

EOD -- every other day

ER -- emergency room

ESR -- erythrocyte sedimentation rate

ET -- endotracheal

ETA, ETH -- ethionamide

ETOH -- ethanol (alcohol)

ETT -- endotracheal tube

F

FH -- family history

FHX -- family history

FTT -- failure to thrive

FU, F/U -- follow-up

FUO -- fever of unknown origin

FX -- fracture

G

G -- gravida (pregnant)

GA -- gastric aspiration

GC -- gonorrhea ("clap")

GI -- gastrointestinal

GSW -- gun-shot wound

GU -- genitourinary

H

H&P -- history and physical exam

H/H -- hemoglobin/hematocrit

H/O -- history of

HA -- headache

HBP -- high blood pressure

HBV -- hepatitis B virus

HCT -- hematocrit

HEENT -- head, eyes, ear, nose, throat

HF -- Hispanic female

HGB -- hemoglobin

HIV -- human immunodeficiency virus

HM -- Hispanic male

HPI -- history of present illness

HR -- heart rate

HS -- at bedtime

HSV -- herpes simplex virus

HTN -- hypertension

HX -- history

I

I&D -- incision and drainage

I&O -- intake and output

IAN -- intern admit note

ICU -- intensive care unit

ID -- identification; infectious disease

IDDM -- insulin-dependent diabetes mellitus

IM -- intramuscular

INH -- isoniazid

IPN -- intern progress note

IV -- intravenous

K

KUB -- x-ray of kidneys, ureters, and bladder

KVO -- keep vein open (slow drip IV)

L

L -- left

LLL -- left lower lobe

LLQ -- left lower quadrant

LMP -- last menstrual period

LOC -- loss of consciousness

LP -- lumbar puncture

LUL -- left upper lobe

LUQ -- left upper quadrant

M

MAC -- Mycobacterium avium complex

MI -- myocardial infarction (heart attack); mitral insufficiency (leaky valve)

mL, ml -- milliliter

MMR -- measles, mumps, rubella vaccination

MRI -- magnetic resonance imaging (specialized radiograph)

MRSA -- methicillin-resistant Staphylococcus aureus (drug-resistant bacterial infection)

MTB -- Mycobacterium tuberculosis

MVA -- motor vehicle accident

N

NG -- nasogastric

NIDDM -- non-insulin-dependent diabetes mellitus

NKA -- no known allergies

NKDA -- no known drug allergies

NPO -- nothing by mouth

NSAID -- nonsteroidal anti-inflammatory drugs

O

O -- objective

OB -- obstetrics

OD -- overdose or right eye or every day

Oflox -- oflaxacin

OM -- otitis media

OOB -- out of bed

OPV -- oral polio vaccine

OR -- operating room

P

P -- plan

PA -- posteroanterior (back to front, x-ray view)

PAS -- para-aminosalicylic acid, a 2nd line anti-TB medication

PC -- after meals

PCP -- pneumocystis carinii pneumonia

PE -- pulmonary embolus; physical exam; pleural effusion

PERRLA -- pupils equal, round, reactive to light with accommodation

PFT -- pulmonary function tests (tests of lung strength and volume)

PMH -- past medical history

PMHX -- past medical history

PO -- by mouth

POB -- place of birth

PPD -- purified protein derivative

PR -- by rectum

PRBC -- packed red blood cells (for transfusion)

PRN -- as often as needed

PT -- prothrombin time; physical therapy; patient

PUD -- peptic ulcer disease

PZA -- pyrazinamide

Q

Q -- every

QD -- every day

QH -- every hour

QID -- four times a day

QNS -- quantity not sufficient (on specimen sent to laboratory)

QOD -- every other day

R

R -- right

R/O -- rule out

RAN -- resident admit note

RBC -- red blood cell

RIF -- rifampin

RLL -- right lower lobe

RLQ -- right lower quadrant

RML -- right middle lobe

ROM -- range of motion

ROS -- review of symptoms

RR -- respiratory rate

RRR -- regular heart rate and rhythm

RT -- rubella titer; radiation therapy

RTC -- return to clinic

RUL -- right upper lobe

RUQ -- right upper quadrant

Rx -- treatment

S

S -- without; subjective

S/P -- status post (after)

SH, SHx -- social history

SIG -- write on label

SL -- sublingual (medicine taken under the tongue)

SM -- streptomycin

SOB -- shortness of breath

SQ -- subcutaneous

STAT -- immediately

SubQ -- subcutaneous

Sx -- symptoms

T

TB -- tuberculosis

TIA -- transient ischemic attack (mini-stroke)

TID -- three times a day

TKO -- to keep open (IV fluid rate)

TNTC -- too numerous to count

TORCH -- toxoplasma, other = syphilis, rubella, cytomegalovirus, herpes virus

TU -- tuberculin units

Tx -- treatment; transplant

U

UA -- urinalysis

UGI -- upper gastrointestinal

URI -- upper respiratory tract infection

US -- ultrasound

UTI -- urinary tract infection

V

VSS -- vital signs stable

W

WBC -- white blood cell count

WD -- well-developed

WF -- white female

WM -- white male

WN -- well-nourished

WNL -- within normal limits

Y

YO -- years old

 
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