| 0 |
Not Present OR No abnormality |
Also in superscript e.g. ……..o |
| +/- |
Uncertain/equivocal |
|
| + |
Present or Noted |
|
| ++ |
Present Significantly |
|
| +++ |
Present in Excess |
|
| = |
Equivalent to |
|
| 3 |
OK or satisfactory |
|
| A |
Ankle Jerk/Reflex |
Hitting the ankle with a patella hammer to test reflexes |
| AAA |
Abdominal Aortic Aneurysm |
Swelling of the main artery in the abdomen |
| AAL |
Anterior Axillary Line |
Imaginary line drawn from the front arm pit down the chest
wall |
| ABG |
Arterial Blood Gas also "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 |
|
| 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 – usually in leg |
| 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 |
|
| 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 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 |
Furring up of the blood vessels 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 groin |
| 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 |
|
| RUQ |
Right Upper Quadrant |
Right upper abdomen |
| Rx |
Prescription or Treatment |
Usually prescription |
| S |
Supinator (jerk /reflex) |
Hitting the arm 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 |
| 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 |
| USS |
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 |
|