Module 8
TB Surveillance and Case Management in Hospitals and Institutions
Appendix

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Appendix: Medical Record Abbreviations
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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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