Medical abbreviations play a crucial role in the healthcare field by simplifying communication, improving efficiency, and ensuring patient safety. Accurate and standardized use of medical abbreviations is essential in medical record notes, as misinterpretation can lead to serious consequences. In this essay, we will present a comprehensive list of the top 70 medical abbreviations commonly used in medical record notes and a sample history and physical exam medical record note using the abbreviations, followed by a table for easy reference and multiple choice practice questions with answer explanations.

Top 70 Medical Abbreviations:

1. AAOx3 – Awake, alert, and oriented to person, place, and time
2. ABG – Arterial blood gas
3. AC – Before meals
4. ADL – Activities of daily living
5. AED – Automated external defibrillator
6. A&O – Alert and oriented
7. ASA – Aspirin
8. BID – Twice daily
9. BMI – Body mass index
10. BP – Blood pressure
11. BPM – Beats per minute
12. BSA – Body surface area
13. CBC – Complete blood count
14. CCU – Coronary care unit
15. CHF – Congestive heart failure
16. COPD – Chronic obstructive pulmonary disease
17. CPR – Cardiopulmonary resuscitation
18. CSF – Cerebrospinal fluid
19. CVA – Cerebrovascular accident (stroke)
20. CXR – Chest X-ray
21. DNR – Do not resuscitate
22. DTs – Delirium tremens
23. ECG/EKG – Electrocardiogram
24. ED – Emergency department
25. ETOH – Ethanol (alcohol)
26. FHR – Fetal heart rate
27. GI – Gastrointestinal
28. GTT – Glucose tolerance test
29. H&P – History and physical examination
30. HCT – Hematocrit
31. HIV – Human immunodeficiency virus
32. HR – Heart rate
33. ICU – Intensive care unit
34. I&D – Incision and drainage
35. IV – Intravenous
36. IVP – Intravenous pyelogram
37. JVD – Jugular venous distension
38. KVO – Keep vein open
39. L&D – Labor and delivery
40. LFT – Liver function tests
41. MI – Myocardial infarction
42. NPO – Nothing by mouth (nil per os)
43. NSAID – Non-steroidal anti-inflammatory drug
44. O2 – Oxygen
45. OR – Operating room
46. OT – Occupational therapy
47. PCA – Patient-controlled analgesia
48. PERRLA – Pupils equal, round, and reactive to light and accommodation
49. PMH – Past medical history
50. PRN – As needed (pro re nata)
51. PT – Physical therapy
52. PT/INR – Prothrombin time/international normalized ratio
53. PTT – Partial thromboplastin time
54. ROM – Range of motion
55. RR – Respiratory rate
56. Rx – Prescription
57. S/P – Status post
58. SOB – Shortness of breath
59. STAT – Immediately (from Latin “statim”)
60. TB – Tuberculosis
61. TIA – Transient ischemic attack
62. TID – Three times daily (ter in die)
63. TKO – To keep open
64. Tx – Treatment
65. URI – Upper respiratory infection
66. UTI – Urinary tract infection
67. V/S – Vital signs
68. WBC – White blood cell count
69. WNL – Within normal limits
70. YOB – Year of birth

Sample Fictional History and Physical Exam Medical Record Note

Patient Information:

• Name: John Doe
• Age: 45
• Gender: Male
• Date of Admission: 09/03/2023
• Medical Record Number: 123456789

Chief Complaint: The patient presents with chest pain and shortness of breath.

History of Present Illness (HPI): Mr. Doe is a 45-year-old male who arrived at the emergency department (ED) today complaining of acute onset chest pain. The pain is described as a sharp, stabbing sensation in the substernal area and radiates to his left arm. It started approximately 2 hours ago while he was at rest. He rates the pain as 8/10 in intensity. He also reports associated shortness of breath (SOB) and diaphoresis. The patient denies any recent trauma or injury.

Past Medical History (PMH):

• Hypertension (HTN)
• Hyperlipidemia (HLD)
• Gastroesophageal reflux disease (GERD)
• Tobacco use (30 pack-years)
• Family history of coronary artery disease (CAD)

Medications:

• Lisinopril 10 mg daily (for HTN)
• Atorvastatin 20 mg daily (for HLD)
• Omeprazole 20 mg daily (for GERD)

Allergies:

• None known

Social History: The patient has a 30-pack-year history of smoking but quit 5 years ago. He drinks alcohol occasionally. He is married and works as an office manager.

Review of Systems (ROS):

• General: Diaphoresis
• Cardiovascular: Chest pain, palpitations
• Respiratory: Shortness of breath
• Gastrointestinal: No nausea or vomiting
• Neurological: No dizziness or syncope
• Musculoskeletal: No joint pain
• Dermatological: No rashes

Physical Examination:

• General: The patient appears uncomfortable due to pain.
• Vital Signs: Blood pressure (BP) 160/90 mm Hg, heart rate (HR) 100 bpm, respiratory rate (RR) 22 bpm, oxygen saturation (O2) 95% on room air.
• Cardiovascular: Irregular rhythm with an S4 gallop. Jugular venous distension (JVD) not observed.
• Respiratory: Diminished breath sounds at the left lung base.
• Abdominal: Soft and non-tender, no hepatomegaly or splenomegaly.
• Musculoskeletal: No deformities or tenderness.
• Skin: Diaphoretic but no rashes or lesions.

Assessment:

1. Acute coronary syndrome (ACS) likely due to the patient’s chest pain, diaphoresis, and ECG findings.
2. Hypertension (HTN) with uncontrolled blood pressure.
3. Hyperlipidemia (HLD).
4. History of tobacco use.

Plan:

1. ECG to evaluate for ischemic changes.
2. Troponin and other cardiac biomarkers.
3. Continuous cardiac monitoring.
4. Aspirin 325 mg orally (ASA).
5. Nitroglycerin sublingual (0.4 mg every 5 minutes, as needed for chest pain).
6. Oxygen therapy to maintain oxygen saturation above 94%.
7. Intravenous (IV) access and fluids.
8. Consultation with the cardiology team for possible cardiac catheterization.
9. Blood pressure control with antihypertensive medication as per cardiology recommendations.
10. Smoking cessation counseling.
11. Statin therapy optimization.

Follow-Up: The patient will be closely monitored in the coronary care unit (CCU). Further interventions will depend on the results of cardiac evaluations. Family history of CAD and the patient’s history of smoking are significant risk factors for cardiovascular disease.

Physician Signature: Dr. [Your Name], MD 09/03/2023

Below is a table summarizing the top 70 medical abbreviations for quick reference:

Conclusion:

In the world of healthcare, accurate and standardized communication is paramount to patient safety and effective treatment. The top 100 medical abbreviations presented in this essay, along with the accompanying table, serve as valuable tools for healthcare professionals, medical students, and anyone involved in the healthcare industry. Proper understanding and usage of these abbreviations can enhance the efficiency and clarity of medical record notes, ultimately contributing to improved patient care.

Question 1: What does “COPD” stand for in medical terminology? A) Coronary artery disease B) Chronic obstructive pulmonary disease C) Congestive heart failure D) Cerebrovascular accident

Answer: B) Chronic obstructive pulmonary disease Explanation: COPD is an abbreviation for “Chronic Obstructive Pulmonary Disease,” which is a chronic lung condition characterized by airflow obstruction.

Question 2: In medical records, what does “NPO” indicate? A) No pain observed B) No palpitations observed C) Nothing by mouth D) Notifying primary officer

Answer: C) Nothing by mouth Explanation: “NPO” is an abbreviation for “Nil Per Os,” which means that a patient should not have anything by mouth, including food or liquids.

Question 3: What is the abbreviation “ECG/EKG” commonly used for in the medical field? A) Electroconvulsive therapy B) Electronic control gate C) Electrocardiogram D) Endoscopic cholecystectomy

Answer: C) Electrocardiogram Explanation: “ECG” and “EKG” both refer to “Electrocardiogram,” a test used to record the electrical activity of the heart over a period of time.

Question 4: What does “PRN” stand for in a medical context? A) Primary registered nurse B) Patient-related notation C) Per rectal notation D) As needed

Answer: D) As needed Explanation: “PRN” stands for “pro re nata,” which means that a medication or treatment should be administered as needed.

Question 5: In medical terminology, what does “CBC” represent? A) Complete blood count B) Coronary bypass catheter C) Continuous bladder catheterization D) Cardiac blood circulation

Answer: A) Complete blood count Explanation: “CBC” stands for “Complete Blood Count,” a blood test that measures various components of blood, including red and white blood cells.

Question 6: What does “AC” mean when used in medical notes? A) After meals B) Before meals C) Aspirin count D) Antibiotic concentration

Answer: B) Before meals Explanation: “AC” is an abbreviation for “ante cibum,” which means “before meals.”

Question 7: What is the purpose of an “ABG” test in healthcare? A) Allergy blood glucose B) Arterial blood gas analysis C) Advanced blood group testing D) Automated blood glucose monitoring

Answer: B) Arterial blood gas analysis Explanation: “ABG” stands for “Arterial Blood Gas,” a test used to measure the levels of oxygen and carbon dioxide in the blood, as well as blood pH and other parameters.

Question 8: What does “OT” typically refer to in a medical setting? A) Oxygen therapy B) Occupational therapy C) Orthopedic treatment D) Ophthalmic testing

Answer: B) Occupational therapy Explanation: “OT” stands for “Occupational Therapy,” a type of therapy that helps patients regain independence in their daily activities.

Question 9: What does “SOB” commonly indicate in medical records? A) Shortness of breath B) Swelling of the bladder C) Subcutaneous oxygen boost D) Systemic organ blockage

Answer: A) Shortness of breath Explanation: “SOB” is often used to abbreviate “Shortness of Breath,” a symptom that can be indicative of various medical conditions, particularly respiratory or cardiac issues.

Question 10: What is the meaning of “IVP” in the context of medical abbreviations? A) In vitro pregnancy B) Intravenous pyelogram C) Intravascular penetration D) Involuntary pulse variation

Answer: B) Intravenous pyelogram Explanation: “IVP” stands for “Intravenous Pyelogram,” a radiologic test used to visualize the kidneys, bladder, and ureters by injecting a contrast material into a vein.

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