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NCAT
Normocephalic Atraumatic (normal head, no trauma)
PERRLA
Pupils equal, round, reactive to light and accommodation
EOMI
Extraocular muscles intact
EEG
Electroencephalogram- measures electrical activity of brain
RRR
Regular rate and rhythm (heart)
CXR
Chest xray
Consolidation
area of lungs where air should be but ISN’T (fluid, blood, pus)
Infiltrate
dead cell, debris, pus commonly seen with pneumonia (lungs)
Atelectasis
partially or fully collapsed lung
Pleural Effusion
fluid in the space between chest wall and lungs
Aspiration
inhalation of food particles or stomach contents
CT Scan
Computed Tomography scan
- Assesses pulmonary embolism, lung masses, internal bleeding, edema
Echo
Echocardiogram- ultrasound of heart
EKG or ECG
Electrocardiogram- measures electrical activity of the heart
Cardio Catheterization
Look for disease of heart muscle, valves, or coronary arteries
Coronary Angiography
contrast dye used to visualize movement through arteries
■ Detects blocked arteries
PFT
Pulmonary function test- measure of lung volume
FEV1= forced expiratory volume in one second
FVC= forced vital capacity
EGD
Esophagogastroduodenoscopy- Endoscopic procedure that examines the esophagus, stomach, and duodenum
Doppler Ultrasound
Detects blood flow issues (like DVT)
Abx
Antibiotics
Empiric Coverage
Abx started before bacteria identified
○ Sample culture grown in lab
■ ID bacteria
■ ID effective and resistant ABX options
S vs R meaning on microbiology reports
S= sensitive (bacteria killed by Abx)
R= resistant (bacteria immune to Abx)
SOAP
Subjective- observed/what pt tells us
Objective- things that can be measured
Assessment
Plan
CC
Cheif complaint
HPI
History of present illness (what’s going on right now)
PMH
Past medical history- full list
FH
family history
SH
social history- what pt is doing to themselves, like smoking
ROS
Review of symptoms
NKDA
No known drug allergies
EMR/EHR
Electronic health/medical record
BP
Blood pressure
HR
Heart rate
RR
respiratory rate
BMP
Basic metabolic panel
CBC
Complete blood count
BG
blood glucose
A1c/HbA1c
Hemoglobin A1c
WNL
within normal limits