Can any 3rd, 4th year, or resident please help...

[YellowRose]

Hi, can you just take a second to type out some of the medical "lingo" used in soap notes. i'm volunteering with a doctor in san diego, and he looked at me like i was stupid because i didn't know what RRR was. one example which he gave me was "something" times 3, and i still don't know what it means, i tried looking it up. and DOE?? something about short breath.

to anyone with experience writing soap notes, i would love it if you could take a minute or two to help me out. and if there are other terms that you know, feel free to post. Thanks alot.

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[neutropeniaboy]

•••quote:•••Originally posted by YellowRose:
•Hi, can you just take a second to type out some of the medical "lingo" used in soap notes. i'm volunteering with a doctor in san diego, and he looked at me like i was stupid because i didn't know what RRR was. one example which he gave me was "something" times 3, and i still don't know what it means, i tried looking it up. and DOE??•••••HEENT: head, eyes, ears, nose, throat
PERRLA: pupils equal round reactive to light and accomodation
EOMI: extra-ocular movements (or is it muscles) intact
HA: headache
c/o: complains of
c: with
s: without
d/o: disorder
RRR: regular rate and rhythm
SOB: short of breath
DOE: dyspnea on exertion
M/G/R: murmurs, gallops, rubs
BS: bowel sounds
PR: per rectum

There's just a **** load...

 

[NuMD97]

Your examples are as follows:

RRR = regular rate and rhythm (i.e.: normal cardiac exam)

DOE = dyspnea on exertion

Here's a website that might be of value to you (medical acronyms): <a href="http://uhsweb.edu/rb/acr.htm" target="_blank">http://uhsweb.edu/rb/acr.htm</a>

Hope this helps.

 

[YellowRose]

thanks guys, that helped alot. but can you give me some of the ones that are commonly seen on a regular physical exam of a sick patient in a IM/FP setting. The ones you already gave me help alot. thanks.

 

[med student]

Don't feel bad I am in medical school and I don't know what most abreviations mean yet. I am suprised a Dr would expect you to know things like that. It was like the nurses and Dr who asked me if I could give shots as a pre-med.

 

[Whisker Barrel Cortex]

-A&O X 3: Alert and oriented x 3, which means oriented to person (their name), place (city, hospital, etc), time (day, date, month,year).
-EOMI: Extraocular muscles intact
-PERRL: Pupils equal and reactive to light
-MMM: Mucous membranes moist
-LAD: Lymphadenopathy (enlarged lymph nodes, usually in neck, armpits)
LUNGS:
-CTA: Clear to auscultation (lungs clear)
-No w/r: no wheezes or crackles in lungs.
HEART:
-RRR: regular rate and rhythm. Means rate is between 50 and 100 and regular.
-No m/r/g: No heart murmurs, rubs, gallops.
ABDOMEN:
-S, NT, ND, +BSx4: Soft, non-tender, non-distended, bowel sounds present in all four abdominal quadrants.

The above are some shorthand that many people use for physical exam findings. Most common abreviations are for normal findings since if something is significant it is usually written out. I didn't learn most of these until third year in med school so I think its kind of funny for him to think you'd know them.

 

[YellowRose]

whisker, you're great. that was good stuff. got any more? thanx a bunch

i just finish my MSI year, and trying to get adjusted to the clinical aspect of medicine, as opposed to the book aspect of it.

 

[Goofy]

Just a quick tidbit of advice. When writing your notes, substitute 'regular rate' for 'rrr'. It is impossible to know a rhythm based solely on physical exam. Many people still use the 'rrr' abbreviation, even though it conveys something rather silly and impossible. If you want to comment on heart rhythm, the more appropriate place would be under your EKG evaluation.

 

[neutropeniaboy]

•••quote:•••Originally posted by YellowRose:
•thanks guys, that helped alot. but can you give me some of the ones that are commonly seen on a regular physical exam of a sick patient in a IM/FP setting. The ones you already gave me help alot. thanks.•••••As an aside, you need to know these abbreviations, but I suggest you don't use them. Don't be sloppy. Don't be ambiguous. At the very least, you're editing a medical-legal document and signing your name to it.

 

[lrg]

•••quote:•••Originally posted by Klebsiella:
•Just a quick tidbit of advice. When writing your notes, substitute 'regular rate' for 'rrr'. It is impossible to know a rhythm based solely on physical exam. Many people still use the 'rrr' abbreviation, even though it conveys something rather silly and impossible. If you want to comment on heart rhythm, the more appropriate place would be under your EKG evaluation.•••••I think it is understood that by "regular rhythm," you are only referring to the fact that it is regular within the limits of what can be determined by physical exam (that is, not grossly irregular). For example, I can definitely tell if someone is in AFib or having PVCs on physical exam. Of course, everyone has their preferences and the only right way to do anything as a medical student is to do it the way your senior resident or attending wants it done.

 

[Winged Scapula]

The above are great...here are just a few off the top of my head...

WNL - within normal limits
WF - white female
WM - white male
AAM(F) - African American Male(female)...and so on
No C/C/E - no clubbing/cyanosis/edema
PTA - prior to admission
NGT - nasogastric tube
CP - chest pain
CNII-XII - cranial nerves 2-12
C/D/I - clean, dry and intact (referring to a dressing or wound)

I'm sure what you've gotten here will serve you well (and I also cannot believe you would be expected to know these).

 

[Goofy]

•••quote:•••I think it is understood that by "regular rhythm," you are only referring to the fact that it is regular within the limits of what can be determined by physical exam (that is, not grossly irregular). ••••Whether it is understood or not is irrelevant. It is just plain wrong, and making such a comment is really rather silly. The more knowledgeable practitioners make this distinction. Perpetuating a habit that is wrong is well, a bad habit.

•••quote:••• For example, I can definitely tell if someone is in AFib or having PVCs on physical exam. ••••No you cannot. I'm afraid you are severely confused and wholly uninformed. And to suggest as much reflects a rather disturbing lack of knowledge of cardiac physiology. You can comment on rate all you want. Rhythm is impossible to determine by taking someone's pulse. There are any number of 'rhythms' and beats that can easily be confused with Afib and PVC. While you can be strongly suspicious, you do need a electical map of the heart to determine if indeed it is regular. If you can indeed determine heart rhythm with a pulse, than you posess skills the most seasoned Electrophysiologist doesn't have. I recommend 'The only EKG book you'll ever need' as the definitive beginner's text. (Toss out your Dubin's)

•••quote:••• Of course, everyone has their preferences and the only right way to do anything as a medical student is to do it the way your senior resident or attending wants it done. ••••Wrong. I assure you that as a medical student I was no slave to the school of misinformation. If I saw something wrong I pointed it out with tact and assertiveness. I can also assure you that my medical students who follow me blindly, without taking initiative to correct something that is glaringly wrong, will have a real hard time with me. No one is perfect, and it is assanine to levy such an absurd conclusion about a medical student's role.

 

[ckent]

This is actually pretty funny because I have been arguing with my classmates all year over my ability to auscultate an irregular rhythm with my stethescope. I say that I can, I don't know why you wouldn't be able to. It's just lub-dup..lub-dup........lubdup..lubdup....lubdup. I'm just a second year, but my physical diagnosis preceptor agreed with me that it is possible to detect an irregular rhythm in a physical exam. He's a GI fellow though, so I don't know who is right.

 

[Goofy]

•••quote:•••Originally posted by ckent:
•This is actually pretty funny because I have been arguing with my classmates all year over my ability to auscultate an irregular rhythm with my stethescope. I say that I can, I don't know why you wouldn't be able to. It's just lub-dup..lub-dup........lubdup..lubdup....lubdup. I'm just a second year, but my physical diagnosis preceptor agreed with me that it is possible to detect an irregular rhythm in a physical exam. He's a GI fellow though, so I don't know who is right.•••••I'm afraid both you and your fellow are wrong. To understand what seems to be a complicated concept, you need to appreciate basic physiology of the heart. At face value, it appears to be merely a pump. Looking deeper reveals an intricate and efficient electrical system that serves as the trigger for the pump. Auscultation and palpation reflect pump activity. Just because the pump appears to be pumping 'regularly' says nothing about the electrical conduction system which can be grossly irregular despite a seemingly normal pulse or sound. For a picture of what is happening in the wiring, you must at least have an EKG. Refer to the title I listed above for an excellent and quick synopsis of how this all works.

 

[PimplePopperMD]

•••quote:•••Originally posted by Klebsiella:
•

You can comment on rate all you want. Rhythm is impossible to determine by taking someone's pulse. There are any number of 'rhythms' and beats that can easily be confused with Afib and PVC. While you can be strongly suspicious, you do need a electical map of the heart to determine if indeed it is regular. If you can indeed determine heart rhythm with a pulse, than you posess skills the most seasoned Electrophysiologist doesn't have. I recommend 'The only EKG book you'll ever need' as the definitive beginner's text. (Toss out your Dubin's)
.... If I saw something wrong I pointed it out with tact and assertiveness. •••••In that vein, please refer to Bates, which is a highly regarded text of physical examination. The seventh edition, page 292, tells of how one can assess rhythm. One cannot with certainty diagnose any electrical disturbance of the heart with the exception of a fib, which an irregularly irregular rhythm "reliably indicates". I have first hand experience with this, as I diagnosed a patient with this very ailment, which was later verified by ECG.

Rhythm is entirely possible to assess by one's exam, and ought to be assessed. To neglect this very key aspect of the exam would be a shame.

 

[Whisker Barrel Cortex]

Klebsiella,

I agree with you that you cannot tell for sure that a rhythm is regular on physical exam alone. However, I do not think it is wrong to note this on physical exam for several reasons.

Of course there are limits to how much you can tell about the rhythm on physical exam, there is no question about that. However, it is not wrong to report hearing a regular rhthym on auscultation of the hear or feeling a regular pulse on palpation. First of all, as Irg pointed out, it is assumed that there are limitations to your examination and can only pick out gross irregularities. Secondly, not every patient will have or needs an EKG. Thus, when you note a regular rhythm on exam and EKG will not be necessary unless there are other reasons for it. However, if you detect an irregular rhythm that was previously undiagnosed, than an EKG is indicated. True, you cannot tell exactly what the rhythm is until the EKG.

In cardiology clinic last year, I saw a gentleman CAD who had no diagnosis of arrhythmia and no reason for an EKG. On physical exam, I noted that he indeed had an irregularly irregular rhythm which prompted us to do an EKG. On EKG, he indeed had atrial fibrillation. If I hadn't noticed this on phsyical exam it would be undiagnosed.

 

[Goofy]

Hi WBC,

Perhaps the issue is semantics, but it really makes all the difference in the world. Saying a patient has an irregularly irregular pulse is not the same thing as saying it's an irregularly irregular rhythm.

I fully understand the implications of describing the rate, and this is really what the guist of your post speaks to. But absent a more comprehensive test, you simply cannot tell me that you heard or felt any kind of rhythm at all. It is simply wrong to do so.

Having said that, you can and should be as descriptive as possible when commenting on the rate, as it very often can indicate A-Fib, prompting more investigation. But as simple as A-Fib may seem on palpation, you simply cannot comment on rhythm absent the study.

 

[Whisker Barrel Cortex]

My above post reminded me of some other abbreviations you may see in the history of a patient:

CAD: Coronary Artery Disease
HTN: Hypertension
CHF: Congestive heart failure
DM: Diabetes Mellitus
CA: Cancer
AFIB: Atrial fibrillation
A. Flutter: atrial flutter
CABG: coronary artery bypass graft
EtOH abuse: alcohol abuse
TB: tuberculosis
COPD: chronic obstructive pulmonary disease (emphysema or chronic bronchitis)
IBD: Inflammatory bowel disease
IBS: Irritable bowel syndrome

 

[Goofy]

Hi Pimple,

You said:

•••quote:••• which an irregularly irregular rhythm "reliably indicates". ••••I never took issue with this comment at all. Perhaps my assertions are confusing. Allow me to elaborate.

Many cardiac ailments can be 'reliably indicated' by physical exam. But saying that heart sounds and pulse 'indicate' a particular rhythm is entirely different than saying specifically what that rhythm is because you 'felt' or 'heard' the rhythm. You simply cannot evaluate rhythm in this way. Certainly there are physical cues that indicate a diagnosis or even a rhythm. For example a patient with long standing heart disease and previous history of code passing out might very well indicate v-fib. But to suggest you can hear or feel v-fib is preposterous. EKG may be a crude tool, but it can tell you information about rhythm that cannot possibly be concluded by physical exam alone.

There is a difference.

 

[PimplePopperMD]

Kleb;

The distinction you make is an important one, and one that many will deem "semantics".

One cannot diagnose detrussor instability when "urge incontinence" is suspected; it must be diagnosed based on urodynamic testing.

And although the history and physical are as important as they teach in second year medical school, oftentimes one needs further evaluation for a definitive diagnosis. That is to say, exam can "suggest" a disease process, or make it "less likely". But a negative HCG will rule out pregnancy. (not that pregnancy is a disease; it depends on whether you wanted the baby!)

Good to find someone who highlights the important distinction between AFib and "suspicious for AFib". Though in clinical practice, on the whole, they are seen as one and the same, intellectually (and by the occasional zebra) they most certainly are not.

 

[lilycat]

Interesting discussion of "rhythm" on here. Who would have guessed that it would spawn a whole sub-thread.

By the way, it's "gist" not "guist" for those who care. I usually don't get too carried away with spelling mistakes on here, but since people are being very particular on this thread, it only made sense.

As an additional aside -- there are ways of respectfully disagreeing with people without being rude or insulting them. It may be a difference of personal style, but I've gotten a lot of feedback that at least on this board, it tends to rub people the wrong way, to say the least. If anything, I think the art of learning to respectfully disagree or offer a dissenting a viewpoint is exactly that, an "art," and if it's well done, can be far more effective in getting the point across.

 

[MUN2005]

<img border="0" title="" alt="[Eek!]" src="eek.gif" /> You mean someone who is in v-fib can be concious?

 

[Goofy]

Hi Lilycat,

You said:

•••quote:••• As an additional aside -- there are ways of respectfully disagreeing with people without being rude or insulting them. It may be a difference of personal style, but I've gotten a lot of feedback that at least on this board, it tends to rub people the wrong way, to say the least. If anything, I think the art of learning to respectfully disagree or offer a dissenting a viewpoint is exactly that, an "art," and if it's well done, can be far more effective in getting the point across. ••••Thanks for the lecture. Let me be very clear about this, since your comments seem most directed at me. I am not here to coddle people's emotions or massage their feelings. Life is way too short to invest that kind of emotional currency on a student doctor forum.

I am here for spirited debated and charged conversation. To the best of my knowledge I am not in violation of your TOS based upon the above post that you find so appalling.

Having said that, when I reply, I largely don't consider the poster so much as the post. I attack messages and ideas, and to the best of my ability, try to avoid direct assaults. I am certain that over 90% of those I criticize are fine human beings. We are all wrong at some point in time. Heck, at the 95 percentile, I'm still wrong 5% of the time.

I understand that there are those who find this demeanor offensive. I find discussions about indian women, thongs, the best position 'to do it' in equally offensive, yet your site seems to sanction this kind of high school locker room discussion without recourse.

Since I have become the subject of debate lately, I would make the following recommendation. Decide on your private board whether or not you wish to have an opinionated, charged yet cogent and knowledgeable poster within your ranks. I fully understand if you choose not to, it's your site and perogative. If you would rather not have me, I will simply disappear. No need to delete my account and my internet skeleton will not be exhumed much like the late 'davidgreen'.

If you do decide to have me, I would recommend you attempt to take your job a bit more seriously. As a moderator/administrator, you represent your company. Singling out individual posters in this way is terribly unprofessional. Further, your juvenile quip about my spelling snafu is equally unprofessional. If my editing or lack thereof is so offensive, install a spell checker. Many internet forums have em.

I wont change my writing style, and certainly wont take lessons from you. I have enough professional experience to know what works. I will abide by your TOS. If your TOS are too abrasive for me to handle, than I will stop posting as well.

What I can offer you is my wealth of experience and knowledge. I will not adhere to some whimsical style that you may find warm and pleasing. I certainly wont be lectured on professionalism by those who wage battles that are, quite frankly, unprofessional.

Let me know.

K.P.

 

[neutropeniaboy]

Well said.

 

[carddr]

Going to squeeze in here between a rock and a hard place...

Just a word of caution on soap notes, make sure EVERYONE is on the same page and understands completly what these acronyms stand for, needless to say what the outcome would be if someone fails to understand the language here. Don't assume anything, it may cost a life or you your career... sheesh I sound like my father here!! Sorry about that. Just ask someone for further clarification if you don't know something you see on the notes. <img border="0" title="" alt="[Frown]" src="frown.gif" />

 

[acurarte]

MENTAL MASTERBATION!!!!!!!!! I am so glad I am doing surgery so I don't have to listen to lame symantecs such as on this thread....... It is a freakin physical exam... Get over it........ If it doesn't sound right do an EKG..... Whatever..... Just let me cut on it and I'll be happy... Little surgeon humor.......

 

[Goofy]

•••quote:•••symantecs ••••Isn't that a software company? <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />

 

[lrg]

•••quote:•••Originally posted by Klebsiella:
• •••quote:••• For example, I can definitely tell if someone is in AFib or having PVCs on physical exam. ••••No you cannot. I'm afraid you are severely confused and wholly uninformed. And to suggest as much reflects a rather disturbing lack of knowledge of cardiac physiology. You can comment on rate all you want. Rhythm is impossible to determine by taking someone's pulse. There are any number of 'rhythms' and beats that can easily be confused with Afib and PVC. While you can be strongly suspicious, you do need a electical map of the heart to determine if indeed it is regular. If you can indeed determine heart rhythm with a pulse, than you posess skills the most seasoned Electrophysiologist doesn't have.
•••••You have correctly taken me to task on my vague wording. My point was that if a person is in AFib or having PVCs, I can recognize that there is an irregularity to the rhythm of the pulse. The way I worded it I can see how it could be interpreted that I was claiming the converse - that I could with certainty diagnose a specific electrical rhythm disturbance based on an abnormal rhythm to the pulse.

If one is to insist that the only one true rhythm is the electrical rhythm and there are no other rhythms then one must also dispense with the "severely confused and wholly uninformed" notion that the rate can also be determined by physical exam. After all, without an ECG, one cannot be certain that there is not some bizarre electromechanic dissociation such that there is a normal pulse rate in the setting of an abnormal electrical rate.

Your point that one cannot be certain that there is not an underlying electrical rhythm disturbance in the setting of a normal pulse is an important one for everyone to keep in mind. By writing "RRR" I am not ruling out the possibility of an electrical rhythm abnormality, I am only stating that I find no evidence of one by physical exam (using auscultation and palpation as an insensitive proxy) and my experience is that that is understood by my colleagues.

 

[Goofy]

•••quote:••• You have correctly taken me to task on my vague wording. ••••Actually 'rhythm' and 'rate' are not vague terms at all. They only become vague when used in a loose and haphazard way.

•••quote:••• My point was that if a person is in AFib or having PVCs, I can recognize that there is an irregularity to the rhythm of the pulse. ••••Wrong. You can recognize that there is an irregular rate. I'm afraid you are confusing two seperate terms.

•••quote:••• The way I worded it I can see how it could be interpreted that I was claiming the converse - that I could with certainty diagnose a specific electrical rhythm disturbance based on an abnormal rhythm to the pulse. ••••Perhaps I have been vague in my explanations. Assesing a pulse yields information about a pump and it's rate, not it's rhythm. An irregular pulse might suggest an irregular electrical rhythm, because it's the electrical circuit that powers the pump. But when you palpate a pulse or listen to a heart, you are assesing pump activity.

•••quote:••• After all, without an ECG, one cannot be certain that there is not some bizarre electromechanic dissociation such that there is a normal pulse rate in the setting of an abnormal electrical rate. ••••Irg, I say this with the utmost care and concern; you are confusing two specific terms. While they may seem like loose medical jargon, rhythm and rate have some very specific meaning in this regard. Rate applies to the pump and rhythm applies to the electrical circuit. I can most certainly describe a rate by physical exam. One can infer what they want about the rhythm from this. But without a picture of the electrical circuit, I.E. ekg, you cannot say a rhythm is regular or irregular. It is simply wrong.

•••quote:••• By writing "RRR" I am not ruling out the possibility of an electrical rhythm abnormality, I am only stating that I find no evidence of one by physical exam (using auscultation and palpation as an insensitive proxy) and my experience is that that is understood by my colleagues. ••••You are not ruling in 'the possibility of an electrical rhythm' either. Once again, you cannot assess a heart rhythm on physical exam, and writing 'rrr' implies you can achieve the impossible. By writing RRR you are conveying misinformation. I admit that this convention is rampant. That doesn't mean it's correct. I can tell you from my experiences, which includes two years of clerkships at this point, attendings very often sneer at med-students who write PE's in this way. It is wrong, innacurate, and misleading. The fact that it is commonplace doesn't mean it's correct.

K.P.

 

[neutropeniaboy]

•••quote:••• My point was that if a person is in AFib or having PVCs, I can recognize that there is an irregularity to the rhythm of the pulse.

Wrong. You can recognize that there is an irregular rate. I'm afraid you are confusing two seperate terms.••••Well, Kleb, I have to disagree with you here. I was actually corrected twice after using this terminology. You are indeed detecthing an abnormal rhythm in pulse. The rate, if calculated over an established period of time and averaged would be very similar. So, you aren't truly detecting -- by auscultation, anyway -- an abnormal rate, just a rhythm.

But, I agree with you wholely that you can't establish the type of rhythm without proper electrophysiological workup. And that leads me to wonder why this discussion has persisted for so long...

 

[acurarte]

Hey Kleb,

I really think "innacurate" is not quite aCCurate.

SNEER, SNEER!

 

[lilycat]

Klebsiella,

I appreciate your lengthy post. However, I was not trying to single you out in particular. If I sense a thread taking a particular direction based on multiple posts from multiple users, I will add a generalized message such as my previous one. If I have a specific problem with a specific poster, I usually reply to the post in question or reply privately to the poster. It was not so much your post, but a general tone of the previous posts that prompted me. I don't expect you to change your style of debate, or expect that of other posters, but as a general member of this site, I do feel I'm entitled to express my opinion regarding the debating styles that are being employed.

As for your comments regarding the typical threads found in the Lounge, while I'm one of the moderators for that forum, that does not mean that I necessarily agree with or promote much of the content in that forum. As for what is appropriate or not, that has been debated to death recently, and I would refer you to one of the many threads that covers it -- I'm too tired and too busy to rehash it at this point. These threads also describe changes that are being made to the method of moderating the boards in general, changes which you seemed to allude to in your post.

I do sincerely apologize if you found my comment regarding the spelling error unprofessional or offensive. It honestly just amused me at the time while I was reading through the thread given the debate that was going on. I honestly did not mean it to be a "dig" at you, but unfortunately it did not come through the way I saw it in my mind. For that I do apologize.

 

[Goofy]

•••quote:•••Originally posted by acurarte:
•Hey Kleb,

I really think "innacurate" is not quite aCCurate.

SNEER, SNEER! •••••<img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />

I thought my spelling was quite acurarte.

 

[Goofy]

Hi Neutropenia,

I guess we are gonna have to agree to disagree. Agreed?

K.P.