Module 8 TB Surveillance and Case Management in Hospitals and Institutions Appendix |
Appendix: Medical Record
Abbreviations
A | B | C | D | E | F | G | H | I | K | L | M | N | O | P | Q | R | S | T | U | V | W | Y | |
A — assessment AB — antibody; abortion; antibiotic (any of the three) ABD — abdomen ABG — arterial blood gas (a test for oxygen and other blood gases) ABX — antibiotics AC — before meals ACLS — advanced cardiac life support AD LIB — as much as needed AF — afebrile (without a fever); aortofemoral (blood vessels); atrial fibrillation (irregular heart beat) AFB — acid-fast bacilli AKA — also known as; or above the knee amputation AODM — adult onset diabetes mellitus AP — anteroposterior (front to back); abdominal-perineal ARDS — adult respiratory distress syndrome ARF — acute renal (kidney) failure BAL — bronchoalveolar lavage BCG — bacille Calmette-Guérin (vaccination against TB) BE — barium enema (radiograph of the lower intestines) BF — black female BID — twice a day BM — black male; bone marrow (sometimes biopsied for TB); bowel movement BP — blood pressure BPM — heart beats per minute BS — bowel or breath sounds BW — body weight BX — biopsy C — with C/O — complaining of C&S — culture and sensitivity Ca — calcium CA — cancer CABG — coronary artery bypass graft (heart surgery) CAD — coronary artery disease capreo — capreomycin CAT — computerized axial tomography (specialized radiograph, also called CT scan) CBC — complete blood count CC — chief complaint CCU — clean catch urine; coronary care unit CF — cystic fibrosis CHF — congestive heart failure Cipro — ciprofloxacin, a 2nd-line anti-TB medication CMV — cytomegalovirus CN — cranial nerves CNS — central nervous system COPD — chronic obstructive pulmonary disease CP — chest pain; cerebral palsy CPR — cardiopulmonary resuscitation CRF — chronic renal (kidney) failure CSF — cerebrospinal fluid CT — computerized tomography (specialized radiograph) CVA — cerebrovascular accident (stroke); costovertebral angle CXR — chest x-ray (radiograph) D&C — dilation and curettage (uterine scraping) DC, D/C — discontinue; discharge DDx — differential diagnosis (list of possible diagnoses) DKA — diabetic ketoacidosis dL — deciliter DM — diabetes mellitus DNR — do not resuscitate DOA — dead on arrival DOE — dyspnea (shortness of breath) on exertion DT — diptheria tetanus (vaccine) Dx — diagnosis ECG — electrocardiogram ED — emergency department EDC — estimated date of confinement (estimated date of giving birth) EKG — electrocardiogram EMB — ethambutol ENT — ear, nose, and throat EOD — every other day ER — emergency room ESR — erythrocyte sedimentation rate ET — endotracheal ETA, ETH — ethionamide ETOH — ethanol (alcohol) ETT — endotracheal tube FH — family history FHX — family history FTT — failure to thrive FU, F/U — follow-up FUO — fever of unknown origin FX — fracture G — gravida (pregnant) GA — gastric aspiration GC — gonorrhea ( “clap ”) GI — gastrointestinal GSW — gun-shot wound GU — genitourinary H&P — history and physical exam H/H — hemoglobin/hematocrit H/O — history of HA — headache HBP — high blood pressure HBV — hepatitis B virus HCT — hematocrit HEENT — head, eyes, ear, nose, throat HF — Hispanic female HGB — hemoglobin HIV — human immunodeficiency virus HM — Hispanic male HPI — history of present illness HR — heart rate HS — at bedtime HSV — herpes simplex virus HTN — hypertension HX — history I&D — incision and drainage I&O — intake and output IAN — intern admit note ICU — intensive care unit ID — identification; infectious disease IDDM — insulin-dependent diabetes mellitus IM — intramuscular INH — isoniazid IPN — intern progress note IV — intravenous KUB — x-ray of kidneys, ureters, and bladder KVO — keep vein open (slow drip IV) L — left LLL — left lower lobe LLQ — left lower quadrant LMP — last menstrual period LOC — loss of consciousness LP — lumbar puncture LUL — left upper lobe LUQ — left upper
quadrant MAC — Mycobacterium avium complex MI — myocardial infarction (heart attack); mitral insufficiency (leaky valve) mL, ml — milliliter MMR — measles, mumps, rubella vaccination MRI — magnetic resonance imaging (specialized radiograph) MRSA — methicillin-resistant Staphylococcus aureus (drug-resistant bacterial infection) MTB — Mycobacterium tuberculosis MVA — motor vehicle
accident NG — nasogastric NIDDM — non-insulin-dependent diabetes mellitus NKA — no known allergies NKDA — no known drug allergies NPO — nothing by mouth NSAID — nonsteroidal anti-inflammatory drugs O — objective OB — obstetrics OD — overdose or right eye or every day Oflox — oflaxacin OM — otitis media OOB — out of bed OPV — oral polio vaccine OR — operating room P — plan PA — posteroanterior (back to front, x-ray view) PAS — para-aminosalicylic acid, a 2nd line anti-TB medication PC — after meals PCP — pneumocystis carinii pneumonia PE — pulmonary embolus; physical exam; pleural effusion PERRLA — pupils equal, round, reactive to light with accommodation PFT — pulmonary function tests (tests of lung strength and volume) PMH — past medical history PMHX — past medical history PO — by mouth POB — place of birth PPD — purified protein derivative PR — by rectum PRBC — packed red blood cells (for transfusion) PRN — as often as needed PT — prothrombin time; physical therapy; patient PUD — peptic ulcer disease PZA — pyrazinamide Q — every QD — every day QH — every hour QID — four times a day QNS — quantity not sufficient (on specimen sent to laboratory) QOD — every other day R — right R/O — rule out RAN — resident admit note RBC — red blood cell RIF — rifampin RLL — right lower lobe RLQ — right lower quadrant RML — right middle lobe ROM — range of motion ROS — review of symptoms RR — respiratory rate RRR — regular heart rate and rhythm RT — rubella titer; radiation therapy RTC — return to clinic RUL — right upper lobe RUQ — right upper quadrant Rx — treatment S — without; subjective S/P — status post (after) SH, SHx — social history SIG — write on label SL — sublingual (medicine taken under the tongue) SM — streptomycin SOB — shortness of breath SQ — subcutaneous STAT — immediately SubQ — subcutaneous Sx — symptoms TB — tuberculosis TIA — transient ischemic attack (mini-stroke) TID — three times a day TKO — to keep open (IV fluid rate) TNTC — too numerous to count TORCH — toxoplasma, other = syphilis, rubella, cytomegalovirus, herpes virus TU — tuberculin units Tx — treatment; transplant UA — urinalysis UGI — upper gastrointestinal URI — upper respiratory tract infection US — ultrasound UTI — urinary tract infection VSS — vital signs stable WBC — white blood cell count WD — well-developed WF — white female WM — white male WN — well-nourished WNL — within normal limits YO — years old
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