Some useful tips on filling physician’s records and sample physician’s 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 can’t 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 physician’s 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

СHD, 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 – 1^st, 2^nd, 3^rd, 4^th 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: 1065