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A fib
atrial fibrillation
AAA
abdominal aortic aneurysm
A/O
alert + oriented — physical exam
abd
abdominal/abdomen — spell out in notes
ABG
arterial blood gas — labs
Abx
antibiotics — spell out in notes
ADD
attention deficit disorder
ADHD
attention deficit + hyperactivity disorder
AICD
automated implantable cardiac defibrillator
AIDS
acquired immunodeficiency syndrome
ALOC
altered level of consciousness — spell out in note
AMA
against medical device
AMS
altered mental status — spell out in note (HPI)
APGAR
appearance, pulse, grimace, activity, respiration (infants only)
appe
appendectomy
ARDS
acute respiratory distress syndrome
ASA
aspirin — spell out in notes
BAC
blood alcohol content
BG
blood glucose — spell out in notes
BID
twice a day
bilat
bilateral — spell out in notes
BiPAP
biphasic positive airway pressure
BLE
bilateral lower extremities — spell out in notes
BM
bowel movement — spell out in notes
BMP
basic metabolic panel
BNP
brain natriuretic peptide
BP
blood pressure — spell out in notes
BPH
benign prostate hyperplasia
BRBPR
bright red blood per rectum
BS
blood sugar, bowel sounds, breath sounds — spell out in notes
BTL
bilateral tubal ligation
BUE
bilateral upper extremities — spell out in notes
BUN
blood urea nitrogen
C. diff
clostridium difficile
CA
cancer — spell out in notes
CABG
coronary artery bypass graft
CAD
coronary artery disease
CT
computed tomography
cath
catheter
CBC
complete blood count
chole
cholecystectomy
CK
creatinine kinase
CKD
chronic kidney disease
CMP
comprehensive metabolic panel
CMT
cervical motion tenderness
CNS
central nervous system
c/o
complaints of
CO
carbon monoxide
COPD
chronic obstructive pulmonary disease
CP
cerebral palsy (chest pain) — spell out in notes
CPAP
continuous positive airway pressure
CPR
cardiopulmonary resuscitation
CRP
c-reactive protein
c-section
caesarean section
c-spine
cervical spine
CSF
cerebrospinal fluid
CTA
clear to auscultation OR computed tomography angiography
CV
cardiovascular
CVA
cerebrovascular accident OR costovertebral angle
CXR
chest x-ray — spell out in notes
DC
discontinue — spell out in notes
D/C
discharge
D&C
dilation and curettage
DDD
degenerative disc disease
DIP
distal interphalangeal (joint)
dispo
disposition
DJD
degenerative joint disease (osteoarthritis)
DKA
diabetic ketoacidosis
DM
diabetes mellitus
two types: insulin dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM)
DNR
do not resuscitate
DOA
dead on arrival
DOB
date of birth
DP
dorsalis pedis
DTR
deep tendon reflexes
DVT
deep vein thrombosis
Dx
diagnosis/assessment — spell out in notes
ECHO
echocardiogram
E. coli
escherichia coli
ED
emergency department OR erectile dysfunction
EDD
expected date of delivery
EENT
eyes, ears, nose, and throat
EF
ejection fraction
EGD
esophagogastoduodenoscopy
EJ
external jugular
EKG/ECG
electrocardiogram
EMR/EHR
electronic medical record / electronic health record
EMS
emergency medical services
EMT
emergency medical technician
EMTALA
emergency medical treatment and active labor act
ENT
ears, nose, and throat (both a body system and a specialty)
EOM
extraocular movements
EOMI
extraocular movements intact
Epi
epinephrine
ERCP
endoscopic retrograde cholangiopancreatography
ESR
erythrocyte sedimentation rate
ESRD
end stage renal disease
EtOH
ethanol
ET tube
endotracheal tube
FB
foreign body — spell out in notes
FHx
family history — spell out in notes