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Some useful tips on filling physicians records and sample physicians record of a history and examination of a health patient.
An approximate example of normal physical examination brief writeup is given here. Abbreviations are often used in busy outpatient settings to describe patient's complaints, physical findings, diagnostic tests, etc. Mind not to overuse them, though. It might be a good idea to use abbreviations to write indicated diagnostic tests, prescriptions or questioner results (e.g. MMSE or GDS), but it is really confusing when clinical diagnosis is fool of abbreviations, especially of those very specific so that even a GP cant guess. List of some commonly used abbreviations is given below. Be sure to write your abbreviations READABLY! Some examinations, like thyroid, breast and gynaecological (genitourinary) examination, DRE, part of HEENT examination requiring devices (like ophtalmoscope), may not be written down (though may also be), if they are already described during periodic examinations in the above chapters or are not performed by a physician in case there are no devices required or they are performed by other specialists or patient if referred to specialists for such examinations (but note, that a general practitioner/outpatient internist can perform all these physical examinations). Write down additional information in additions to anamnesis if you lack free space in physicians records.
A&O x 3 Awake and oriented to person, place and time A/O - Alert and oriented AF, AFIB - atrial fibrillation AFB acid-fast bacilli ALT - Alanine Transaminase ANA - Antinuclear Antibody AST - Alanine Aminotransferase ATPO , also TPO antibodies to Thyroid Peroxidase Antibodies AXR adominal X-ray BAC - Blood Alcohol Concentration bd two times daily BNP - Beta Natriuretic Peptide BP blood pressure BPH - benign prostatic hyperplasia bpm beats per minute BUN blood urea nitrogen C/O - complains of CHF congestive heart failure CI - contraindications CK MB heart CK CK, (sometimes CPK) - creatine (phospho)kinase CN cranial nerves Cr ceatinine CRP C-reactive protein CT computer tomography CVD cardiovascular disease CXR chest X-ray DM - diabetes mellitus DQS dementia quick screen DVT deep venous thrombosis EGD, EGDS, OGDS - (o)esophagogastroduodenoscopy ESR erythrocyte sedimentation rate FBC fool blood count, the same as CBC common, or complete, blood count. FH family history FM - Family Medicine FOBT faecal occult blood test FT4 free T4 GDS geriatric depression scale GFR - glomerular filtration rate GGT - gamma-glutamyl transferase GP General Practice, General Practitioner GU - genitourinary HBSAg - hepatitis B surface antigen HSV - herpes simplex virus HDL high-density lipoproteins HEENT head, ears, eyes, neck, throat examination HPI history of present illness HPV human papillomavirus HR - heart rate HTN hypertension, sometimes also AH arterial hypertension ΡHD, IHD, ASCVD - coronary heart disease, ischemic heart disease, atherosclerotic heart disease OEM/EOM - orbital eye muscles/extraocular muscle basically the same. IM - intramascular INR - international normalized ratio IV- intravenous JVP jugular venous pressure KUB kidney, ureters, bladder (X-ray) LAD lymphoadenopathy LD - lactate dehydrogenase LDL low-density lipids LFT liver function tests LIF - left iliac fossa LLQ - left lower quadrant (of abdomen) LOC level of consciousness LUQ - left upper quadrant (of abdomen) LV - left ventricle of the heart MC&S - microscopy, culture, and sensitivity (investigations of microbiology samples) MMSE mini mental state examination MRI magnetic resonance imaging MSU - midstream urine MVP mitral valve prolaps N&V nausea, vomiting NAD - nothing abnormal detected NBM - nil by mouth NKDA- no known drug allergies NR normal range O&P ova and parasites (stool test) O/E on examination OGTT oral glucose tolerance test P&A - percussion and auscultation PAP Papanicolau ( e.g. pap smear). PE pulmonary embolysm PERLA - pupils equal and reactive to light and accommodation PFT pulmonary function tests PMH past medical history PO - per os, by mouth, orally PR - per rectum, rectally PRN - as needed, per need PSA prostate specific antigen PT - prothrombin Time PV per vaginum qd every day, once daily qHS before sleep, before bedtime qid - for times daily QoL quality of life RF rheumatic factor RIF - right iliac fossa RLQ right lower quadrant (of abdomen) ROM - range of motion RR respiratory rate RUQ - right upper quadrant (of abdomen) Rx - recipe (Latin for treat with) AP alkaline phosphotase S1, S2, S3, S4 1st, 2nd, 3rd, 4th heart sounds SC subcutaneous SE - side-effect(s) SG serum glucose SL sublingual SOB - Shortness of Breath SpO2- peripheral oxygen saturation (%) STD(I) - sexually transmitted disease (infection) TC, Chol total cholesterol, cholesterol TD transdermal TG, Trig - triglycerides tid three times daily TM eardrum (tympanum) TORCH toxoplasmosis, other infections(like chlamydia,) rubella, cytomegalovirus, herpes simplex virus. TSH thyroid stimulating hormone U&E urea(or blood urea nitrogen), createnine and electrolytes, generally means kidney function test UA urinalysis ULN upper limit of normal ULN upper limit of normal URTI - upper respiratory tract infection US - ultrasound UTI - urinary tract infection Vaccines: Hib - Haemophilus influenzae type b IPV - inactivated poliovirus MenACWY/ MPSV4 Meningococcal 4-valent conjugate/Meningococcal polysaccharide MMR measles, mumps, rubella Date: 2016-04-22; view: 1046
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