H/P Write-up Abbreviations

[Stillwater45]

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I'm a second year who is just learning to write up my History and Physicals. I am hoping to find an example write-up with all of the pertinent positive abbreviations for the appropriate systems...PEER, RRR, ect. Is there a magical document like this anywhere on the internet? Thanks

 

[Doc Ivy]

Don't know of one. But I can get you started and maybe others can add more:

PEX= Physical Exam
no m/r/g= no murmurs, rubs, gallops
no c/c/e= no clubbing, cyanosis, edema
no w/r/r= no wheezes, rubs, or rhonchi
LAD= lymphadenopathy
PERRL= pupils equal round and reactive to light
PNA= pneumonia
PTX= pneumothorax
PE= pulmonary embolism
RRR= regular rate and rhythm
CTAB= clear to auscultation bilaterally
no CVAT= no costophrenic angle tenderness
NCAT= normocephalic atraumatic
WDWN= well developed, well nourished
c/d/i= clean, dry, intact
UOP= urine output
NABS= normoactive bowel sounds
NTND= non-tender non distended


MMP= multiple medical problems
PTA= prior to admission
s/p= status post
c= with
p/w= presents with
c/w= consistent with
HD= hemodialysis

 

[Random]

Some hospitals are kind of particular about which abbreviations you're supposed to use. At the beginning of second year, my entire class was given the "official" book of abbreviations. In any event, the UCSD page on physical exam's as close to a magical document as I've found. The site's: http://medicine.ucsd.edu/clinicalmed/abbreviation.htm.

 

[Samir Desai]

Whenever possible, we should use only approved abbreviations. Many hospitals have a list of approved abbreviations. Keep in mind that this list will vary from one hospital to another. Hospitals often have a "do not use" list as well. Since med schools often send students to several affiliated hospitals, it's good practice to inquire about such lists on the first day or two at a new institution.

The use or misuse of medical abbreviations has received considerable attention in recent years from various organizations like the Institute of Medicine. This has been particularly true of abbreviations used with medication orders. This has sometimes led to a patient receiving the wrong drug or the wrong dose, etc.

 

[bpayh]

+BSx4 = bowel sounds present in all 4 quadrants

abdomen is often written SNTND (soft nontender nondistended)

heart sounds can be written no MGRT (murmurs gallops rubs thrills)

c/o = complaint of
pt. s&e = pt. seen and examined
EOMI = extra-ocular muscles intact
A&Ox3 or AOx3 = alert and oriented x3 (to person, place, time) (or to mean the patient doesn't appear confused, but this is a little sloppy because some patients can actually hide a disorientation quite well)
NAD = no acute distress
TME = toxic metabolic encephalopathy (took me awhile to figure this one out)
NCNC anemia = normocytic normochromic anemia
AFib = atrial fibrillation