Decoding Medical Abbreviations for Diagnosis: A Comprehensive Guide

Medical abbreviations are an integral part of healthcare, acting as a shorthand for complex medical terms and procedures. Their use is pervasive across all medical disciplines, from doctor’s notes and prescriptions to lab reports and diagnostic imaging results. For anyone working in the medical field, or even patients trying to understand their own health information, deciphering these abbreviations is crucial. This guide aims to provide a comprehensive overview of common medical abbreviations specifically related to diagnosis, helping to clarify this essential aspect of medical language. Understanding these abbreviations is not just about decoding jargon; it’s about ensuring accuracy in communication and ultimately, in patient care and effective diagnosis.

Understanding the language of medicine starts with grasping its abbreviations. In the realm of diagnosis, medical abbreviations are used to quickly and efficiently denote conditions, procedures, and findings. This section will explore a range of these abbreviations, organized alphabetically for easy navigation, providing clarity on their meanings and diagnostic contexts.

A.A.R.O.M. – Active Assistive Range of Motion: This abbreviation refers to exercises where the patient uses their own muscles with some assistance to move a joint. It’s diagnostically relevant in assessing physical therapy needs and tracking recovery after injury or surgery.
AAC – Augmentative and Alternative Communication: AAC encompasses methods used to communicate for individuals with speech impairments. Diagnostically, understanding AAC needs is vital in patient evaluation and care planning, especially in neurology and rehabilitation.
A.B.G – Arterial Blood Gas: An ABG test measures the oxygen and carbon dioxide levels, as well as the pH balance, in arterial blood. It’s a critical diagnostic tool for respiratory and metabolic disorders, guiding treatment in emergency and intensive care settings.
a.c. – Before Meals (Ante Cibum): While seemingly simple, this abbreviation is crucial in medication prescriptions and dietary instructions, particularly for diabetic patients where timing of medication with meals is diagnostically significant for blood sugar control.
A/C – Assist Control: In respiratory care, A/C refers to a mode of mechanical ventilation. It’s diagnostically relevant in managing patients with respiratory failure, indicating the level of breathing support required.
ADA Diet – American Diabetes Association Diet: This dietary guideline is fundamental in the diagnosis and management of diabetes. Understanding ADA Diet recommendations is essential for nutritional counseling and controlling blood glucose levels.
A.D.L. – Activities of Daily Living: ADLs encompass basic self-care tasks like eating, bathing, and dressing. Assessing ADLs is diagnostically important in geriatrics, rehabilitation, and for evaluating the functional status of patients with chronic illnesses or disabilities.
A.Fib. – Atrial Fibrillation: A.Fib. denotes a common heart rhythm disorder. Diagnosing A.Fib. is crucial due to its association with increased risk of stroke and heart failure, often requiring anticoagulation therapy.
AKA – Above-Knee Amputation: While describing a procedure, AKA in patient history provides diagnostic context regarding mobility limitations and potential related complications such as phantom limb pain or infection.
ALS – Amyotrophic Lateral Sclerosis: ALS, also known as Lou Gehrig’s disease, is a progressive neurodegenerative disease. Diagnosing ALS requires neurological exams and tests, and it carries a significant prognostic implication.
AMA – Against Medical Advice: Documenting AMA is important when a patient chooses to leave the hospital against medical recommendations. This has diagnostic implications in understanding patient compliance and potential risks of readmission or worsening condition.
A&O – Alert and Oriented: A&O status, often followed by x1, x2, x3, or x4 (oriented to person, place, time, and situation), is a fundamental neurological assessment. It’s diagnostically valuable in evaluating consciousness and cognitive function, especially in cases of head injury or altered mental status.
A/P – Anterior-Posterior: In radiology, A/P view refers to the direction of X-ray beam. It’s diagnostically relevant when interpreting images, as different views can highlight different anatomical structures or pathologies.
A.R.O.M. – Active Range of Motion: AROM refers to the range of movement a patient can achieve independently. Assessing AROM is crucial in orthopedic and neurological exams to diagnose joint and muscle dysfunctions.
ASAP – As Soon As Possible: This common abbreviation emphasizes urgency in medical orders, including diagnostic tests or treatments, when timely intervention is critical.
ASD – Autism Spectrum Disorder: ASD is a developmental condition affecting communication and social interaction. Diagnosing ASD involves behavioral assessments and is crucial for early intervention and support.
ASL – American Sign Language: Knowing if a patient uses ASL is diagnostically important for communication and ensuring effective patient-provider interaction, particularly in hearing-impaired individuals.

b.i.d. – Twice a Day (Bis in Die): Similar to ‘a.c.’, ‘b.i.d.’ is essential in prescriptions, indicating medication frequency. It’s diagnostically relevant for maintaining therapeutic drug levels and treatment adherence.
BKA – Below-Knee Amputation: Like AKA, BKA in a patient’s history provides diagnostic context regarding mobility and potential complications.
B/L – Bilateral: ‘Bilateral’ indicates ‘both sides’. Diagnostically, ‘B/L’ findings, such as ‘B/L lower extremity edema’, help localize and characterize symptoms.
B.L.BS – Bilateral Breath Sounds: Auscultating and documenting ‘B.L.BS present and clear’ indicates normal respiratory function. Absence or abnormal breath sounds are key diagnostic indicators of respiratory conditions.
BMR – Basal Metabolic Rate: BMR measures the energy expended at rest. It’s diagnostically used in nutritional assessments and in managing conditions affecting metabolism, like thyroid disorders.
BP – Blood Pressure: BP is a vital sign measured routinely. Diagnosing hypertension or hypotension is based on BP readings, guiding cardiovascular risk assessment and management.
BR – Bed Rest: ‘Bed Rest’ orders are diagnostically relevant in managing various conditions, from acute back pain to post-operative recovery, indicating limitations on patient activity.
bs – Bowel Sounds: Auscultating bowel sounds is part of abdominal exams. Absent or abnormal bowel sounds are diagnostic clues for gastrointestinal issues like obstruction or ileus.
BS – Breath Sounds: Similar to B.L.BS, assessing breath sounds is fundamental in respiratory diagnosis. Wheezing, crackles, or diminished breath sounds are all diagnostically significant.
B/S – Bedside: ‘Bedside’ procedures or tests indicate immediate patient care. For example, ‘B/S glucose monitoring’ is crucial in managing diabetic emergencies.
bx – Biopsy: A biopsy involves tissue sampling for microscopic examination. It’s a definitive diagnostic procedure for cancer and various inflammatory or infectious conditions.

c̅ – With (Cum): This Latin abbreviation, though less common now, might still be seen in older records, indicating ‘with’ – for example, ‘c̅ pain’ (with pain).
C – Celsius, Centigrade: Temperature in Celsius is a standard measurement in medicine. Fever, measured in Celsius, is a key diagnostic sign of infection or inflammation.
C1, C2, etc. – First Cervical Vertebrae, Second Cervical Vertebrae, etc.: Used in neurology, orthopedics, and radiology, indicating specific levels of the cervical spine. Diagnosing spinal cord injuries or cervical radiculopathy relies on precise vertebral level identification.
CA – Cardiac Arrest or Cancer: Context is critical here. CA can mean ‘cardiac arrest’, a life-threatening emergency requiring immediate diagnosis and intervention. It can also mean ‘cancer’ or ‘carcinoma’, a broad diagnostic category requiring further specification (e.g., lung CA).
CABG – Coronary Artery Bypass Graft: CABG is a surgical procedure, but in patient history, it’s diagnostically relevant, indicating prior coronary artery disease and influencing cardiac risk assessment.
CAD – Coronary Artery Disease: CAD is a common heart condition diagnosed through ECG, stress tests, and angiography. Diagnosing CAD is crucial for preventing myocardial infarction and heart failure.
cal – Calorie: Calorie intake is diagnostically important in nutritional assessments, weight management, and conditions like malnutrition or obesity.
cath – Catheter: ‘Cath’ can refer to urinary catheterization or cardiac catheterization. Urinary cath is diagnostically used for urine collection or managing urinary retention. Cardiac cath is a diagnostic and interventional procedure for heart conditions.
CBC – Complete Blood Count: CBC is a common blood test providing counts of red blood cells, white blood cells, and platelets, as well as hemoglobin levels. It’s a broad diagnostic tool for anemia, infection, leukemia, and many other conditions.
cc – Cubic Centimeter: cc is a unit of volume, often used for medication dosages or fluid measurements. Accurate dosage, often in cc, is critical in treatment and avoiding medication errors.
CC – Chief Complaint: CC is the patient’s primary reason for seeking medical attention. Documenting the CC is the starting point of the diagnostic process, guiding history taking and examination.
CHF – Congestive Heart Failure or Chronic Heart Failure: CHF is a condition where the heart cannot pump blood effectively. Diagnosing CHF involves clinical exams, echocardiography, and managing symptoms is crucial to improve quality of life and prognosis.
CCU – Coronary Care Unit: CCU is a specialized hospital unit for patients with serious cardiac conditions. Admission to CCU signifies a critical cardiac diagnosis requiring intensive monitoring and treatment.
CHI – Closed Head Injury: CHI indicates head trauma without skull fracture. Diagnosing CHI involves neurological assessments and imaging to rule out brain damage and manage potential complications like concussion or hematoma.
cm – Centimeter: cm is a unit of length, used for measuring wounds, anatomical structures, or growth parameters, especially in pediatrics.
CMT – Continuing Medication and Treatment: CMT orders ensure ongoing treatment. Reviewing CMT is important in patient handovers and discharge planning to maintain therapeutic continuity.
CN – Cranial Nerve: CN followed by a number (e.g., CN III) refers to a specific cranial nerve. Cranial nerve exams are crucial in neurological diagnoses, localizing lesions in the brain or peripheral nervous system.
CNA – Certified Nursing Assistant: While a professional title, understanding the role of CNAs in patient care is diagnostically relevant as they provide direct observation and report changes in patient condition.
CNS – Central Nervous System: CNS refers to the brain and spinal cord. CNS disorders encompass a wide range of neurological diagnoses, from stroke to multiple sclerosis.
c/o – Complains Of: ‘c/o’ precedes the patient’s reported symptoms. Documenting ‘patient c/o chest pain’ is crucial in history taking and guides further diagnostic evaluation.
COTA – Certified Occupational Therapy Assistant: Similar to CNA, understanding the role of COTAs is diagnostically relevant in rehabilitation settings, as they contribute to functional assessments and therapy progress.
cont – Continue(d): ‘cont’ in medical orders means to continue the current treatment or medication. It’s important for ongoing care and medication reconciliation.
COPD – Chronic Obstructive Pulmonary Disease: COPD encompasses chronic bronchitis and emphysema, diagnosed through pulmonary function tests and clinical history. Diagnosing COPD is crucial for managing respiratory symptoms and preventing exacerbations.
CP – Cerebral Palsy: CP is a group of disorders affecting movement and posture, caused by brain injury during development. Diagnosing CP involves neurological assessments in early childhood and guides supportive care and therapy.
CPAP – Continuous Positive Airway Pressure: CPAP is a mode of respiratory support, often used for sleep apnea or respiratory distress. Prescribing CPAP is a therapeutic intervention following a diagnosis of sleep apnea or respiratory insufficiency.
CPR – Cardiopulmonary Resuscitation: CPR is an emergency procedure for cardiac arrest. Documenting ‘CPR initiated’ is crucial in emergency medical records.
CRF – Chronic Renal Failure: CRF, now often termed Chronic Kidney Disease (CKD), is a progressive loss of kidney function. Diagnosing CRF involves blood tests (creatinine, BUN) and urine tests, and it requires long-term management and potential dialysis or transplant.
CRNP – Certified Registered Nurse Practitioner: Like CNA and COTA, understanding the role of CRNPs is relevant in healthcare teams, as they can perform diagnostic assessments and manage patient care under physician supervision.
CSF – Cerebrospinal Fluid: CSF is the fluid surrounding the brain and spinal cord. CSF analysis, obtained via lumbar puncture, is diagnostically crucial for meningitis, encephalitis, and subarachnoid hemorrhage.
CT – Computerized Tomography: CT scans use X-rays to create detailed cross-sectional images. CT is a versatile diagnostic imaging modality used for brain, chest, abdomen, and musculoskeletal imaging.
CV – Cardiovascular: ‘CV’ relates to the heart and blood vessels. CV risk assessment, CV disease, are broad diagnostic categories in cardiology.
CVA – Cerebral Vascular Accident: CVA, or stroke, is a neurological emergency. Diagnosing CVA rapidly is critical for initiating thrombolytic therapy or other interventions to minimize brain damage.
CXR – Chest X-Ray: CXR is a common diagnostic imaging test for evaluating lungs, heart, and chest wall. It’s used to diagnose pneumonia, pneumothorax, heart failure, and many other chest conditions.

d – Day: ‘d’ for day is used in medication schedules (e.g., ‘q.d.’ – every day) and duration of illness (e.g., ‘fever x 3d’ – fever for 3 days).
d/c – Discontinue: ‘d/c’ means to stop a medication or treatment. ‘d/c order’ is crucial for medication reconciliation and preventing medication errors.
DC – Discharge: ‘DC’ refers to patient discharge from the hospital. ‘DC summary’ documents the hospital stay, diagnoses, and discharge plan.
DM – Diabetes Mellitus: DM, or diabetes, is a metabolic disorder characterized by hyperglycemia. Diagnosing DM involves blood glucose tests (fasting glucose, HbA1c) and is crucial for initiating lifestyle modifications and medication.
DNK – Do Not Know: ‘DNK’ is used in medical history taking when a patient is unsure of information, such as allergies or past medical history.
DNKA – Did Not Keep Appointment: Documenting DNKA is important for tracking patient follow-up and identifying potential barriers to care.
DNR – Do Not Resuscitate: DNR is a legal order indicating a patient’s wish not to receive CPR. DNR orders are ethically and legally crucial in end-of-life care decisions.
DNT – Did Not Test: ‘DNT’ indicates a test was not performed, often in allergy testing or neurological exams, and helps clarify the extent of examination.
DOA – Dead On Arrival: ‘DOA’ is used in emergency medicine when a patient is pronounced dead upon arrival at the hospital.
DOB – Date Of Birth: DOB is fundamental patient identification information in all medical records.
DOE – Dyspnea On Exertion: DOE, or shortness of breath with activity, is a symptom diagnostically relevant to cardiac and pulmonary conditions.
d/t – Due To: ‘d/t’ indicates causality, e.g., ‘cough d/t URI’ (cough due to upper respiratory infection).
Dx – Diagnosis: ‘Dx’ is a direct abbreviation for ‘diagnosis’, often followed by the specific medical condition.

ECC, EKG – Electrocardiogram: ECG or EKG records the electrical activity of the heart. It’s a primary diagnostic test for arrhythmias, myocardial infarction, and other cardiac conditions.
ED – Emergency Department: ED is the hospital department for emergency care. ED visits are often for acute diagnostic evaluations and treatments.
EEG – Electroencephalogram: EEG measures brain electrical activity. It’s diagnostically used for seizures, epilepsy, and evaluating brain function in coma or encephalopathy.
EENT – Eyes, Ears, Nose, Throat: EENT refers to the general area of otolaryngology. EENT exam is a routine part of physical check-ups and for diagnosing ENT infections or disorders.
EMG – Electromyogram: EMG measures muscle electrical activity. It’s diagnostically used for neuromuscular disorders, nerve injuries, and muscle diseases.
ENT – Ears, Nose, Throat: ENT is the specialty of otolaryngology. ENT disorders include infections, hearing loss, sinusitis, and tonsillitis.
ER – Emergency Room: ER is synonymous with ED, Emergency Department.
ETOH – Ethanol (Alcohol): ETOH in medical context often refers to alcohol use or intoxication, which is diagnostically relevant in trauma, altered mental status, and liver disease.
exam – Examination: ‘exam’ refers to physical examination. ‘Physical exam findings’ are crucial data in the diagnostic process.
ext – External, Exterior: ‘External’ or ‘exterior’ describes location, e.g., ‘external rotation of hip’ in orthopedic exams.

F – Fahrenheit: Temperature in Fahrenheit is also used in some settings. Fever measured in Fahrenheit is diagnostically significant.
FH – Family History: FH is a crucial part of medical history. Family history of certain diseases (e.g., heart disease, cancer) increases a patient’s risk and diagnostic suspicion.
fib – Fibrillation: ‘fib’ usually refers to atrial fibrillation or ventricular fibrillation, both heart rhythm disorders diagnosed by ECG.
fl, fld – Fluid: ‘Fluid’ intake, output, or restriction is diagnostically managed in conditions like heart failure, kidney disease, and dehydration.
FOB – Foot Of Bed: ‘FOB elevated’ is a positioning instruction, often for respiratory or circulatory conditions.
f/u – Follow-Up: ‘f/u appt’ indicates a follow-up appointment needed for monitoring a condition or treatment response.
FWB – Full Weight Bearing: ‘FWB’ indicates weight-bearing status, relevant in orthopedic and post-surgical care.
Fx – Fracture: ‘Fx’ denotes a bone fracture, diagnosed by X-ray or CT scan. Fracture type and location are crucial diagnostic details.

GB – Gall Bladder: GB, or gallbladder, disorders include gallstones and cholecystitis, diagnosed by ultrasound or CT scan.
GCS – Glasgow Coma Scale: GCS is a neurological scale assessing level of consciousness in patients with head injuries or altered mental status. GCS score is diagnostically and prognostically important.
GE – Gastroenterology: GE is the specialty focusing on the digestive system. GE disorders include GERD, peptic ulcers, and inflammatory bowel disease.
GERD – Gastroesophageal Reflux Disease: GERD is a common digestive disorder diagnosed based on symptoms and sometimes endoscopy.
G/E – Gastroenteritis: G/E, or ‘gastro’, is inflammation of the stomach and intestines, often due to infection. Diagnosing gastroenteritis is usually clinical, based on symptoms like nausea, vomiting, and diarrhea.
gen – General: ‘General’ can mean ‘general appearance’ in physical exam, or ‘general anesthesia’ in surgery.
gest. – Gestation: ‘Gestation’ refers to pregnancy duration, important in obstetrics and prenatal care.
G.I. – Gastrointestinal: G.I. relates to the digestive system. G.I. bleed, G.I. upset are common medical terms.
GNA – Geriatric Nursing Assistant: Similar to CNA, understanding GNA role is relevant in geriatric care settings.
gluc – Glucose: ‘Glucose’ refers to blood sugar levels. ‘Blood glucose monitoring’ is crucial in diabetes management and diagnosing hypo- or hyperglycemia.
GP – General Practitioner, General Paralysis: ‘GP’ usually means ‘general practitioner’ or primary care physician. ‘General paralysis’ is a less common term referring to widespread paralysis.
GSW – Gunshot Wound: GSW is a type of penetrating trauma, requiring immediate diagnostic evaluation and surgical intervention.
GTT – Glucose Tolerance Test: GTT is used to diagnose gestational diabetes or impaired glucose tolerance.
Gt. tr. – Gait Training: ‘Gait training’ is part of rehabilitation, especially after stroke or orthopedic surgery, assessing and improving walking ability.
GYN – Gynecology: GYN is the medical specialty focusing on the female reproductive system. GYN exams and diagnoses include Pap smears, pelvic exams, and managing menstrual disorders.

h – Hour: ‘h’ for hour is used in medication frequency (e.g., ‘q.h.’ – every hour).
H/A – Headache: H/A, or headache, is a common symptom. Diagnosing headache involves characterizing the pain, associated symptoms, and neurological exam to rule out serious causes.
HAV – Hepatitis A Virus: HAV causes Hepatitis A, a viral liver infection diagnosed by blood tests.
Hb. – Hemoglobin: Hb, or hemoglobin, is the oxygen-carrying protein in red blood cells. Hb level is part of CBC and important for diagnosing anemia.
HB – Heart Block: HB, or heart block, is a type of arrhythmia diagnosed by ECG.
HBP – High Blood Pressure: HBP, or hypertension, is diagnosed by repeated elevated blood pressure readings.
h.d. – At Bedtime (Hora Decubitus): ‘h.d.’ in prescriptions means ‘at bedtime’ or ‘at night’.
HEENT – Head, Eyes, Ears, Nose, Throat: HEENT exam is a more detailed version of EENT exam.
HEP – Home Exercise Program: HEP is prescribed by physical therapists for patients to continue therapy at home.
H2O – Water: H2O refers to water intake or output. ‘Encourage H2O intake’ is a common instruction for hydration.
h/o – History Of: ‘h/o’ precedes past medical conditions, e.g., ‘h/o MI’ (history of myocardial infarction).
HOB – Head Of Bed: ‘HOB elevated’ is a positioning instruction, especially for patients with respiratory or cardiac conditions.
H&P – History and Physical: H&P is the initial comprehensive medical evaluation, including patient history and physical exam findings.
HR – Heart Rate: HR is a vital sign measured in beats per minute. Abnormal HR (tachycardia, bradycardia) is diagnostically significant in cardiac conditions.
HTN – Hypertension: HTN is synonymous with HBP, high blood pressure.
HVD – Hypertensive Vascular Disease: HVD refers to vascular damage caused by chronic hypertension.
Hx – History: ‘Hx’ is a general abbreviation for ‘history’, often used for ‘medical history’ or ‘past medical history’.
Hz – Hertz (Cycles/Second): Hz is a unit of frequency, used in audiology (hearing tests) and neurology (EEG).

ICCU – Intensive Coronary Care Unit: ICCU is a specialized unit within CCU for more intensive cardiac care.
ICP – Intracranial Pressure: ICP is the pressure inside the skull. Elevated ICP is a critical condition in head trauma, stroke, and brain tumors, requiring monitoring and management.
ICU – Intensive Care Unit: ICU is a general intensive care unit for critically ill patients. Admission to ICU indicates a severe diagnosis requiring life support.
imp. – Impression: ‘Impression’ or ‘clinical impression’ is the physician’s preliminary diagnosis based on initial evaluation, before definitive tests.
incr. – Increased(ing): ‘incr.’ indicates an increase in symptoms, lab values, or medication dosage.
inf – Infusion, Inferior: ‘Infusion’ refers to IV fluid or medication administration. ‘Inferior’ describes anatomical location, e.g., ‘inferior wall MI’.
inspire – Inspiration, Inspiratory: ‘Inspiration’ or ‘inspiratory’ relates to breathing in. ‘Inspiratory wheezes’ are abnormal breath sounds.
int. – Internal: ‘Internal’ describes location, e.g., ‘internal rotation of hip’.
I&O – Intake and Output: ‘I&O’ monitoring tracks fluid intake and output, crucial in managing fluid balance in heart failure, kidney disease, and dehydration.
IPPB – Intermittent Positive Pressure Breathing: IPPB is a type of respiratory therapy.
irreg. – Irregular: ‘Irregular’ describes heart rhythm (irregular heart beat), bowel movements, or menstruation.
IV – Intravenous(ly): IV refers to administration of fluids or medications directly into a vein. IV access is common in hospital settings for medication and fluid delivery.

J, jt. – Joint: ‘Joint’ pain, ‘joint swelling’ are common musculoskeletal symptoms.

K – Potassium, Kidney: ‘K’ is the chemical symbol for potassium. ‘Serum K’ is a blood test for potassium level. ‘Renal’ or ‘kidney’ also starts with K and might be implied by context.

L – Left, Liver, Liter, Lower, Light, Lumbar: Context is crucial for ‘L’. ‘L’ can mean ‘left’ (left arm, left lung), ‘liver’ (liver function tests), ‘liter’ (unit of volume), ‘lower’ (lower extremity), ‘light’ (react to light), or ‘lumbar’ (lumbar spine).
L2, L3 – Second Lumbar Vertebrae, Third Lumbar Vertebrae: Specific lumbar vertebral levels, important in back pain diagnosis, spinal stenosis, and nerve root compression.
lab – Laboratory: ‘Lab tests’ or ‘lab results’ refer to laboratory investigations (blood tests, urine tests, etc.).
lac. – Laceration: ‘Lac.’ or ‘laceration’ is a type of wound (cut or tear). ‘Scalp lac.’ (scalp laceration) is a common injury in trauma.
lat. – Lateral: ‘Lateral’ describes anatomical location, meaning ‘to the side’. ‘Lateral knee pain’ is pain on the outer side of the knee.
LBW – Low Birth Weight: LBW is a birth parameter, diagnostically relevant for infant health and development.
L.E. – Lower Extremities: L.E. refers to legs and feet. ‘L.E. edema’ (lower extremity swelling) is a sign of heart failure, venous insufficiency, or kidney disease.
liq. – Liquid: ‘Liquid diet’ or ‘liquids per oral’ are dietary orders, often post-surgery or for GI issues.
L.O.C. – Loss Of Consciousness, Level Of Consciousness, Laxative Of Choice: Context is crucial for L.O.C. ‘Loss of consciousness’ is a serious neurological symptom. ‘Level of consciousness’ is assessed using GCS or A&O status. ‘Laxative of choice’ is less common but could be in medication lists.
LOS – Length Of Stay: LOS refers to hospital length of stay, used in healthcare statistics and resource management.
LP – Lumbar Puncture: LP, or spinal tap, is a procedure to collect CSF. LP is diagnostically used for meningitis, subarachnoid hemorrhage, and multiple sclerosis.
LPN – Licensed Practical Nurse: LPN is a nursing professional.
LUE – Left Upper Extremity: LUE refers to the left arm and hand. ‘LUE weakness’ (left arm weakness) is a neurological sign, possibly stroke.
Lx – Larynx: ‘Laryngeal’ or ‘larynx’ refers to the voice box. Laryngitis is inflammation of the larynx.
L&W – Living And Well: ‘Living and well’ is often used in family history to indicate family members’ health status.

m, M – Married, Male, Mother, Murmur, Meter, Mass, Molar: Context is crucial for ‘m’ or ‘M’. ‘M’ can mean ‘married’ (marital status), ‘male’ (gender), ‘mother’ (maternal history), ‘murmur’ (heart murmur), ‘meter’ (unit of length), ‘mass’ (abdominal mass), or ‘molar’ (dentistry).
max. – Maximum, Maxillary: ‘Maximum’ dose, ‘maximum heart rate’. ‘Maxillary sinus’ is a sinus in the upper jaw.
MBC – Maximum Breathing Capacity: MBC, or vital capacity, is a pulmonary function test measuring lung volume.
MBSS – Modified Barium Swallow Study: MBSS is a swallowing study using barium contrast, diagnostically used for dysphagia (swallowing difficulty).
MCA – Middle Cerebral Artery: MCA is a major artery in the brain. ‘MCA stroke’ (middle cerebral artery stroke) is a common type of stroke.
MD – Muscular Dystrophy, Medical Doctor: ‘MD’ can mean ‘muscular dystrophy’, a group of genetic muscle diseases, or ‘Medical Doctor’.
mdnt. – Midnight: ‘mdnt.’ or ‘midnight’ for medication timing.
med. – Medicine, Medical, Medication: ‘Medication list’, ‘medical history’, ‘internal medicine’.
mets. – Metastasis: ‘Mets’ or metastasis refers to cancer spread to other parts of the body. ‘Lung cancer with mets to bone’ indicates advanced cancer.
MG – Myasthenia Gravis: MG is an autoimmune neuromuscular disease causing muscle weakness. Diagnosing MG involves EMG and antibody tests.
MI – Myocardial Infarction: MI, or heart attack, is caused by coronary artery blockage. Diagnosing MI involves ECG, cardiac enzymes, and angiography.
min – Minute, Minimum: ‘Minute’ (unit of time). ‘Minimum dose’.
MICU – Medical Intensive Care Unit: MICU is an ICU specializing in medical conditions (non-surgical).
mod – Moderate: ‘Moderate pain’, ‘moderate shortness of breath’.
MRI – Magnetic Resonance Imaging: MRI uses magnetic fields and radio waves to create detailed images. MRI is excellent for soft tissue imaging, brain, spinal cord, joints, and ligaments.
MRSA – Methicillin-Resistant Staphylococcus Aureus: MRSA is a antibiotic-resistant bacteria, causing infections difficult to treat. Diagnosing MRSA infection involves bacterial cultures.
mss – Massage: ‘Massage therapy’ or ‘mss’ orders.
MVA – Motor Vehicle Accident: MVA, or car accident, is a common cause of trauma. ‘MVA patient’ in ER setting.

n. – Nerve: ‘Nerve pain’, ‘nerve damage’, ‘cranial nerve’.
Na – Sodium: ‘Na’ is the chemical symbol for sodium. ‘Serum Na’ is a blood test for sodium level.
NaCl – Sodium Chloride: NaCl is table salt or saline solution. ‘Normal saline’ (NS) is a common IV fluid.
NAD – No Abnormality Detected, No Apparent Distress: Context is crucial for NAD. ‘NAD on exam’ means no abnormality detected during physical exam. ‘Patient in NAD’ means patient is not in apparent distress.
neg. – Negative: ‘Negative test result’, ‘negative for infection’.
neur. – Neurology: ‘Neurology consult’, ‘neurological exam’.
NG – Nasogastric: NG tube is inserted through the nose into the stomach. ‘NG tube feeding’, ‘NG suction’.
NIC – Neonatal Intensive Care: NICU is Neonatal Intensive Care Unit for newborns.
NICU – Neonatal Intensive Care Unit: NICU is a specialized ICU for newborns.
NKA – No Known Allergies: NKA, or ‘no known drug allergies’ (NKDA), is crucial allergy information in medical records.
no. – Number: ‘No.’ or ‘number of’, e.g., ‘no. of seizures’.
NOS – Not Otherwise Specified: ‘Diagnosis NOS’ means the diagnosis is not specified further.
NPO – Nothing Per Os (Nothing By Mouth): NPO order means patient should not eat or drink anything by mouth, often before surgery or procedures.
NSA – No Specific Abnormality: ‘NSA on CXR’ (no specific abnormality on chest X-ray).
NST – Nonstress Test: NST is a prenatal test to monitor fetal heart rate.
N&V – Nausea And Vomiting: N&V are common symptoms, diagnostically relevant in gastroenteritis, pregnancy, and medication side effects.
NVD – Nausea, Vomiting, Diarrhea: NVD, or ‘gastroenteritis symptoms’.
N&W – Normal And Well: ‘Patient N&W’ (normal and well appearing).
NWB – Non-Weight Bearing: NWB means no weight should be placed on the leg or foot, relevant after fracture or surgery.
NYD – Not Yet Diagnosed: ‘Diagnosis NYD’ means the diagnosis is still pending further evaluation.

o – None, Without (Latin ‘sine’): ‘o’ or ‘s’ with a line over it (cannot be represented in plain text) means ‘without’. ‘s/o pain’ (without pain).
O – Oral: ‘Oral medication’, ‘oral intake’.
O2 – Oxygen: O2 administration, O2 saturation.
O2 cap. – Oxygen Capacity: Oxygen carrying capacity of blood.
O2 sat. – Oxygen Saturation: O2 sat, measured by pulse oximetry, indicates the percentage of hemoglobin saturated with oxygen. Normal O2 sat is above 95%. Low O2 sat (hypoxia) is a critical sign of respiratory or cardiac issues.
OA – Osteoarthritis: OA is degenerative joint disease, common in elderly. Diagnosing OA is based on X-rays and clinical exam.
OB, OBG – Obstetrics: OB or OBG is the medical specialty of pregnancy and childbirth.
OB/GYN – Obstetrics and Gynecology: OB/GYN combines obstetrics and gynecology.
Obs – Observation: ‘Under observation’, ‘hospital observation’.
OBS – Organic Brain Syndrome: OBS, now less common, refers to cognitive impairment due to organic causes (dementia, delirium).
ODD – Oppositional Defiant Disorder: ODD is a behavioral disorder in children. Diagnosing ODD involves psychological assessments.
O/E – On Examination: ‘O/E’ precedes physical exam findings. ‘O/E: lungs clear’.
OH – Occupational History: OH is part of social history, relevant in occupational medicine and exposure-related illnesses.
OHD – Organic Heart Disease: OHD refers to heart disease due to structural abnormalities.
oint. – Ointment: ‘Topical ointment’, ‘apply ointment’.
O.M. – Otitis Media: O.M., or middle ear infection, common in children, diagnosed by ear exam.
O.M.E. – Otitis Media With Effusion: OME is middle ear fluid without acute infection.
OOB, oob – Out Of Bed: ‘OOB to chair’ (out of bed to chair), mobility order.
Op. – Operation: ‘Surgical operation’, ‘post-op care’.
ot. – Ear (Otic): ‘Otic drops’ (ear drops), ‘otic exam’.
Oto – Otolaryngology: Oto is short for otolaryngology or ENT.
OTC – Over-The-Counter (Pharmaceuticals): OTC medications are available without prescription.
O.T. – Occupational Therapy, Old Tuberculin: ‘Occupational therapy’ for rehabilitation. ‘Old tuberculin’ is a type of TB skin test.
OR – Operating Room: OR is the surgical operating room.

PA – Physician’s Assistant, Posterior-Anterior: ‘Physician Assistant’ is a medical professional. ‘PA view’ on X-ray is posterior-anterior view.
p&a – Percussion and Auscultation: P&A are parts of physical exam technique, especially for chest and abdomen.
PACU – Post Anesthesia Care Unit: PACU, or recovery room, is for post-operative monitoring.
PAF – Paroxysmal Atrial Fibrillation: PAF is intermittent atrial fibrillation.
palp. – Palpate, Palpated, Palpable: ‘Palpate abdomen’, ‘abdominal mass palpable’. Palpation is physical exam technique using touch.
Path – Pathology: ‘Pathology report’, ‘pathology consult’. Pathology is the study of diseases.
PA view – Posterior-Anterior View on X-ray: PA view is a standard chest X-ray view.
p/c, p.c. – After Meals (Post Cibum): ‘p.c.’ in prescriptions means ‘after meals’.
PD – Parkinson’s Disease: PD is a neurodegenerative disease affecting movement. Diagnosing PD is based on neurological exam and symptoms.
pdr. – Powder: ‘Topical powder’, ‘apply powder’.
PDN – Private Duty Nurse: PDN is a private nurse for individual patient care.
PE – Physical Exam, Pulmonary Embolism, Pressure Equalizer (Tubes): Context is crucial for PE. ‘PE’ most commonly means ‘physical exam’. ‘Pulmonary embolism’ (PE) is a blood clot in the lung artery, a serious condition diagnosed by CT scan or VQ scan. ‘Pressure equalizer tubes’ (PE tubes) are ear tubes for children with recurrent ear infections.
Ped. – Pediatrics: ‘Pediatrician’, ‘pediatric clinic’. Pediatrics is the medical specialty for children.
PEEP – Positive End-Expiratory Pressure: PEEP is a setting on mechanical ventilators to improve oxygenation.
PEG – Percutaneous Endoscopic Gastrostomy: PEG tube is a feeding tube inserted into the stomach through the skin.
PET – Positron Emission Tomography: PET scan is an advanced imaging technique, often used for cancer staging and neurology.
PH – Past History, Pulmonary Hypertension: Context is crucial for PH. ‘PH’ often means ‘past history’ or ‘past medical history’. ‘Pulmonary hypertension’ is high blood pressure in the lung arteries.
pharm – Pharmacy, Pharmacology: ‘Pharmacy dispensing’, ‘pharmacology textbook’.
PHYS. – Physical, Physiology: ‘Physical therapy’, ‘physiology of respiration’.
PI – Present Illness, Pulmonary Insufficiency: ‘PI’ can mean ‘present illness’ (history of current medical problem) or ‘pulmonary insufficiency’ (respiratory failure).
PICU – Pediatric Intensive Care Unit: PICU is ICU for children.
PID – Pelvic Inflammatory Disease: PID is infection of the female pelvic organs. Diagnosing PID involves pelvic exam and cultures.
plts. – Platelets: ‘Platelet count’, ‘thrombocytopenia’ (low platelets). Platelets are blood cells for clotting.
P.M. – Afternoon, Postmortem: ‘P.M. medications’ (afternoon medications). ‘Postmortem exam’ (autopsy).
PMH – Past Medical History: PMH is synonymous with PH, past history.
PMR – Physical Medicine and Rehabilitation: PMR is the specialty of rehabilitation medicine.
PN – Poorly Nourished, Practical Nurse, Peripheral Nerve: Context is crucial for PN. ‘PN’ can mean ‘poorly nourished’ (nutritional status), ‘practical nurse’ (LPN), or ‘peripheral nerve’.
P&N – Psychiatry and Neurology: P&N combines psychiatry and neurology.
PNA – Pneumonia: PNA, or pneumonia, is lung infection. Diagnosing pneumonia involves CXR and clinical exam.
PNI – Peripheral Nerve Injury: PNI is injury to nerves outside the brain and spinal cord.
PNX – Pneumothorax: PNX, or collapsed lung, is air in the pleural space. Diagnosing pneumothorax involves CXR.
p.o. – Per Os (By Mouth): ‘p.o. medications’ (oral medications), ‘p.o. intake’ (oral intake).
p.o.d. – Postoperative Day: ‘POD #1’ (postoperative day number 1).
pos. – Positive: ‘Positive test result’, ‘positive for infection’.
post. – Posterior: ‘Posterior’ describes anatomical location, meaning ‘towards the back’. ‘Posterior knee pain’ is pain behind the knee.
POSTOP. – Postoperative: ‘Postoperative care’, ‘postop complications’.
pot. or potass. – Potassium: ‘Potassium level’, ‘potassium supplement’.
PR – Per Rectum, Proctology: ‘PR medications’ (rectal medications). ‘Proctology’ is the specialty of rectum and anus.
pre-op – Preoperative: ‘Preoperative evaluation’, ‘pre-op orders’.
prep. – Prepare For: ‘Prep for surgery’, ‘prep for procedure’.
p.r.m. – According To Circumstances (Pro Re Nata Mitto): Less common Latin abbreviation for ‘as needed’.
p.r.n., PRN – As Often As Necessary, As Needed (Pro Re Nata): PRN medications are given ‘as needed’ for pain, nausea, etc.
prod. – Productive: ‘Productive cough’ means cough with sputum.
Prog. – Prognosis: ‘Prognosis’ is the expected course of a disease. ‘Prognosis good’, ‘prognosis poor’.
PROM – Passive Range Of Motion: PROM is range of motion exercises done by therapist or caregiver, patient is passive.
pron. – Pronator, Pronation: ‘Pronator muscle’, ‘pronation of forearm’ (turning palm down).
prosth. – Prosthesis: ‘Prosthetic limb’, ‘hip prosthesis’ (hip replacement).
PSH – Past Surgical History: PSH is part of past medical history, focusing on surgeries.
Psych. – Psychiatry: ‘Psychiatric consult’, ‘psychiatric evaluation’. Psychiatry is the medical specialty of mental health.
pt., Pt. – Patient: ‘Patient education’, ‘patient care’.
PT, P.T. – Physical Therapy: ‘Physical therapy referral’, ‘physical therapist’.
PTA – Prior To Admission, Posterior Tibial Artery: Context is crucial for PTA. ‘PTA symptoms’ (prior to admission symptoms). ‘PTA pulse’ is posterior tibial artery pulse in the foot.
PTA pulse – Posterior Tibial Artery Pulse: PTA pulse is assessed in foot circulation exam.
PUD – Peptic Ulcer Disease: PUD is ulcers in the stomach or duodenum. Diagnosing PUD involves endoscopy and testing for H. pylori bacteria.
PVD – Peripheral Vascular Disease: PVD is blood vessel disease outside heart and brain, often affecting legs. Diagnosing PVD involves vascular exams and Doppler studies.
PVT – Previous Trouble: ‘PVT history’ (previous medical problems).
PWB% – Partial Weight Bearing With Percent: ‘PWB 50%’ means partial weight bearing, 50% of body weight allowed on the leg.
Px, PX – Physical Examination: Px or PX is synonymous with ‘exam’ or ‘physical exam’.

q – Every (Latin ‘quaque’): ‘q’ in medication frequency means ‘every’. ‘q.d.’ (every day), ‘q.h.’ (every hour).
q.h. – Every Hour (Quaque Hora): ‘Medication q.h.’ (medication every hour).
q.i.d. – Four Times A Day (Quater In Die): ‘Medication q.i.d.’ (medication four times a day).
qt. – Quart: ‘Fluid intake in quarts’, ‘urine output in quarts’.
quad. – Quadriplegic: ‘Quadriplegic patient’ (paralysis of all four limbs).

R, r – Right, Rectal, Respiration: Context is crucial for ‘R’ or ‘r’. ‘R’ can mean ‘right’ (right arm, right lung), ‘rectal’ (rectal temperature), or ‘respiration’ (respiratory rate).
R. – Rub, Rectal Temperature: ‘R/O pneumonia’ (rule out pneumonia). ‘R temp’ (rectal temperature).
RA – Rheumatoid Arthritis, Right Atrium: Context is crucial for RA. ‘Rheumatoid arthritis’ is an autoimmune joint disease. ‘Right atrium’ is a heart chamber.
rad. – Radial: ‘Radial pulse’ (pulse in the wrist, radial artery), ‘radial nerve’.
r.a.m. – Rapid Alternating Movements: RAM is a neurological test for coordination.
R.A.S. – Right Arm Sitting: ‘BP R.A.S.’ (blood pressure right arm sitting).
RAtx – Radiation Therapy: RAtx or ‘radiation therapy’ for cancer treatment.
rbc/RBC – Red Blood Cell, Red Blood Count: RBC count is part of CBC, important for diagnosing anemia.
RCA – Right Coronary Artery: RCA is a major coronary artery. ‘RCA occlusion’ (RCA blockage) in myocardial infarction.
RCU – Respiratory Care Unit: RCU is a specialized unit for respiratory patients, sometimes within ICU.
RD – Respiratory Distress, Registered Dietitian: ‘Respiratory distress’ (difficulty breathing). ‘Registered dietitian’ (nutrition professional).
RDS – Respiratory Distress Syndrome: RDS is respiratory distress syndrome in newborns (hyaline membrane disease).
RE – Reconditioning Exercise: RE is part of rehabilitation program.
reg. – Regular: ‘Regular diet’, ‘regular heart rhythm’.
rehab. – Rehabilitation: ‘Rehabilitation program’, ‘rehab facility’.
resp. – Respiratory, Respirations: ‘Respiratory rate’, ‘respiratory system’.
RF – Rheumatic Fever, Renal Failure: ‘Rheumatic fever’ is inflammatory disease after strep throat. ‘Renal failure’ is kidney failure.
RLAS – Rancho Los Amigos Scale: RLAS is a scale for cognitive recovery after brain injury.
R to L&A – React To Light And Accommodation: ‘Pupils R to L&A’ (pupils react to light and accommodation), neurological exam finding.
RLE – Right Lower Extremity: RLE refers to right leg and foot. ‘RLE weakness’ (right leg weakness).
RN – Registered Nurse: RN is a nursing professional.
RND – Radical Neck Dissection: RND is a surgery for neck cancer.
RO, R/O – Rule Out: ‘R/O appendicitis’ (rule out appendicitis), diagnostic consideration.
ROM – Range Of Motion, Rupture Of Membranes, Right Otitis Media: Context is crucial for ROM. ‘Range of motion exercises’. ‘ROM’ in obstetrics can mean ‘rupture of membranes’ (water breaking). ‘Right otitis media’ is right ear infection.
ROS – Review Of Symptoms: ROS is part of medical history, reviewing symptoms in different body systems.
Rt. – Right: ‘Rt. arm’, ‘Rt. lung’, synonymous with ‘R’.
RT – Radiation Therapy, Respiratory Therapy: ‘RT’ can mean ‘radiation therapy’ for cancer or ‘respiratory therapy’ for lung conditions.
RUE – Right Upper Extremity: RUE refers to right arm and hand. ‘RUE edema’ (right arm swelling).
RV – Residual Volume, Right Ventricle: ‘Residual volume’ is a pulmonary function test. ‘Right ventricle’ is a heart chamber.
RW – Rolling Walker: RW, or ‘walker’, mobility aid.
Rx – Therapy, Prescription: ‘Rx medications’, ‘Rx physical therapy’. ‘Rx’ is symbol for prescription or treatment.

s – Without (Latin ‘sine’): ‘s’ or ‘o’ with a line over it (cannot be represented in plain text) means ‘without’. ‘s/o pain’ (without pain).
S – Sensation, Sensitive, Serum: ‘Sensory exam’ (sensation testing). ‘Sensitive skin’. ‘Serum electrolytes’ (blood serum).
Sa. – Saline: ‘Saline solution’, ‘normal saline’ (NS).
s.c. – Subcutaneous(ly): ‘s.c. injection’ (subcutaneous injection, under the skin).
Scc – Squamous Cell Carcinoma: Scc is a type of skin cancer or cancer in other organs.
SCCA – Squamous Cell Carcinoma, Squamous Cell Carcinoma Antigen: SCCA can mean ‘squamous cell carcinoma’ or ‘squamous cell carcinoma antigen’ (tumor marker).
SCD – Sudden Cardiac Death: SCD is unexpected death from cardiac cause.
SCI – Spinal Cord Injury: SCI is injury to the spinal cord. Diagnosing SCI involves neurological exam and imaging (MRI, CT).
schiz – Schizophrenia: Schizophrenia is a chronic mental illness. Diagnosing schizophrenia involves psychiatric evaluation.
SCU – Special Care Unit: SCU is a general special care unit, less intensive than ICU.
sec – Second: ‘Second degree burn’, ‘second opinion’. ‘Second’ unit of time.
Sens. – Sensory, Sensation: ‘Sensory exam’, ‘sensory loss’.
sep. – Separated: ‘Sep. dressing’ (separate dressing).
SGA – Small For Gestational Age: SGA is a birth parameter, diagnostically relevant for newborn care.
s.gl. – Without Correction (Without Glasses): ‘VA s.gl.’ (visual acuity without glasses).
SH – Social History: SH is part of medical history, including social factors, smoking, alcohol use, occupation.
SI – Stroke Index: SI is a cardiac output measurement.
sib. – Sibling: ‘Family history: sib. with diabetes’ (sibling with diabetes).
SICU – Surgical Intensive Care Unit: SICU is ICU for surgical patients.
SIDS – Sudden Infant Death Syndrome: SIDS is unexplained death of infant.
skel. – Skeletal: ‘Skeletal muscle’, ‘skeletal system’.
Sl. – Slightly: ‘Sl. edema’ (slight edema).
SL – Sublingual: ‘SL medication’ (sublingual medication, under the tongue).
SLP – Speech-Language Pathologist: SLP is a professional for speech and swallowing disorders.
sm – Small: ‘Small amount’, ‘small lesion’.
SNF – Skilled Nursing Facility: SNF is a facility for rehabilitation or long-term care.
SOAP – Subjective, Objective, Assessment, Plan: SOAP note is a common medical record format.
SOB – Shortness Of Breath: SOB, or dyspnea, is a common symptom, diagnostically relevant to cardiac and pulmonary conditions.
S/P, s/p – Status Post (Previous Condition): ‘s/p appendectomy’ (status post appendectomy, after appendectomy).
sp. cd. – Spinal Cord: ‘Spinal cord injury’, ‘spinal cord compression’.
spec. – Specimen: ‘Urine specimen’, ‘blood specimen’ for lab tests.
sp. fl. – Spinal Fluid: ‘Spinal fluid analysis’, synonymous with CSF (cerebrospinal fluid).
sp&H – Speech and Hearing: ‘Speech and hearing exam’, ‘speech and hearing therapy’.
spin. – Spine, Spinal: ‘Spinal fracture’, ‘spinal stenosis’.
spont. – Spontaneous: ‘Spontaneous breathing’, ‘spontaneous abortion’.
s/s – Signs and Symptoms: ‘Signs and symptoms of infection’.
SS – Social Service, Social Services: ‘Social service consult’, ‘social services referral’.
ST – Speech Therapy: ‘Speech therapy referral’, ‘speech therapist’.
stat., STAT – Immediately (Latin ‘statim’): ‘STAT medication order’, ‘STAT lab test’ (do immediately).
STD – Sexually Transmitted Disease: STD, or STI (sexually transmitted infection), diagnosed by lab tests and clinical exam.
subcut. – Subcutaneous: ‘Subcutaneous tissue’, synonymous with ‘s.c.’.
subling. – Sublingual: ‘Sublingual medication’, synonymous with ‘SL’.
sup. – Superior: ‘Superior’ anatomical location, meaning ‘above’ or ‘higher’. ‘Superior vena cava’.
supin. – Supination: ‘Supination of forearm’ (turning palm up).
surg. – Surgery, Surgical: ‘Surgical procedure’, ‘surgical consult’, ‘post-surg care’.
Sx – Symptoms: ‘Sx of pneumonia’, ‘presenting symptoms’.
sys. – System: ‘Cardiovascular system’, ‘nervous system’.
Syst. – Systolic: ‘Systolic blood pressure’ (top number in BP reading).
Sz – Seizure: ‘Seizure disorder’, ‘seizure activity’. Diagnosing seizures involves EEG and neurological exam.

T – Temperature, Thoracic, Tablet, Tumor: Context is crucial for ‘T’. ‘T’ can mean ‘temperature’ (body temperature), ‘thoracic’ (thoracic spine), ‘tablet’ (medication form), or ‘tumor’ (cancer tumor).
T&A – Tonsils and Adenoids, Tonsillectomy and Adenoidectomy: ‘T&A’ refers to tonsils and adenoids. ‘T&A’ can also mean ‘tonsillectomy and adenoidectomy’ (surgical removal).
tab. – Tablet: ‘Medication in tablet form’, ‘take one tab p.o.’.
TAH – Total Abdominal Hysterectomy: TAH is surgical removal of uterus through abdomen.
TB – Tuberculosis: TB is bacterial infection, usually in lungs, diagnosed by chest X-ray, sputum tests, and TB skin test.
TBI – Traumatic Brain Injury: TBI is head injury causing brain damage. Diagnosing TBI involves neurological exam, GCS, and brain imaging (CT, MRI).
temp – Temperature: ‘Body temperature’, ‘temp check’.
THERAP. – Therapy, Therapeutic: ‘Physical therapy’, ‘therapeutic effect’.
THR – Total Hip Replacement: THR is surgical hip replacement.
TIA – Transient Ischemic Attack: TIA, or ‘mini-stroke’, is temporary neurological symptoms due to brief brain ischemia. TIA is a warning sign for stroke. Diagnosing TIA involves neurological exam and brain imaging.
TKR – Total Knee Replacement: TKR is surgical knee replacement.
TNM – Tumor, Nodes, and Metastases: TNM staging is cancer staging system, describing tumor size, lymph node involvement, and distant metastasis.
TO – Telephone Order: TO, or ‘verbal order’ (VO), is a doctor’s order given by phone.
TPN – Total Parenteral Nutrition: TPN is IV nutrition, bypassing digestive system.
TPR – Temperature, Pulse, Respiration: TPR are vital signs: temperature, pulse rate, and respiratory rate.
tr – Trace: ‘Trace protein in urine’, ‘trace edema’.
trach – Tracheostomy: Tracheostomy is surgical airway in trachea. ‘Trach care’, ‘trach suctioning’.
tsp. – Teaspoon: ‘Medication dose in teaspoons’.
Tx – Treatment, Traction: ‘Tx plan’ (treatment plan), ‘Rx’ (prescription or treatment). ‘Traction’ for orthopedic injuries.

U/A – Urinalysis: U/A, or urine test, is a common lab test. Urinalysis is used to diagnose urinary tract infection, kidney disease, diabetes, and other conditions.
UCD, UCHD – Usual Childhood Diseases: UCD or UCHD in past medical history, e.g., ‘no UCHD’.
UG – Upward Gaze: ‘Upward gaze palsy’, neurological exam finding.
Unilat. – Unilateral: ‘Unilateral weakness’ (weakness on one side of body).
u/o – Under Observation: ‘Patient u/o in ER’.
Ur. – Urine: ‘Urine specimen’, ‘urine output’.
URD – Upper Respiratory Disease: URD is general term for upper respiratory infections.
URI – Upper Respiratory Infection: URI, or common cold, is infection of nose, throat, and upper airways. Diagnosing URI is usually clinical.
Urol. – Urology: ‘Urology consult’, ‘urologist’. Urology is medical specialty of urinary system and male reproductive system.
u/s, US – Ultrasound: US, or ultrasound, uses sound waves to create images. Ultrasound is used for abdominal imaging, obstetrics, echocardiography, and vascular studies.
UTI – Urinary Tract Infection: UTI is infection of bladder, urethra, or kidneys. Diagnosing UTI involves urinalysis and urine culture.

V – Vein, Ventricle: ‘IV’ (intravenous, vein). ‘Left ventricle’ (heart ventricle).
VA – Visual Acuity: VA is sharpness of vision, tested with eye chart.
vag – Vagina, Vaginal: ‘Vaginal exam’, ‘vaginal discharge’.
VC, vit.cap. – Vital Capacity: VC, or vital capacity, is a pulmonary function test measuring lung volume.
VD – Venereal Disease: VD, older term for sexually transmitted disease (STD).
vent. – Ventilator: ‘Mechanical ventilator’ for respiratory support. ‘Vent settings’, ‘ventilator weaning’.
vert. – Vertical: ‘Vertical gaze’, ‘vertical fracture’.
VF – Visual Fields, Ventricular Fibrillation: Context is crucial for VF. ‘Visual field testing’ (eye exam). ‘Ventricular fibrillation’ (VFib) is a life-threatening heart arrhythmia.
VFSS – Videofluoroscopic Swallowing Study: VFSS, synonymous with MBSS, swallowing study using video X-ray.
Via – By Way Of: ‘Medication via NG tube’ (medication given through nasogastric tube).
vit. – Vitamin, Vital: ‘Vitamin supplement’, ‘vital signs’.
VN – Visiting Nurse: VN, or home health nurse.
VO – Verbal Order: VO, synonymous with TO (telephone order).
VS, V.S. – Vital Signs: VS, or vital signs, are temperature, pulse, respiration, blood pressure, and sometimes pain. VS monitoring is routine in patient care.

w, wk – Week: ‘Weeks gestation’, ‘symptoms for 2 wks’ (symptoms for 2 weeks).
W/C, wh.ch. – Wheelchair: ‘Wheelchair dependent’, ‘transfer to W/C’.
WBT – Weight Bearing Tolerance: ‘Weight bearing tolerance as tolerated’.
WFL – Within Functional Limits: ‘ROM WFL’ (range of motion within functional limits).
w/n – Within Normal Limits: ‘Vitals w/n’ (vital signs within normal limits), synonymous with WNL.
WNL – Within Normal Limits: ‘Exam WNL’ (physical exam within normal limits).
WP – Whirlpool: ‘Whirlpool therapy’ for wound care or physical therapy.
wt. – Weight: ‘Body weight’, ‘weight gain’, ‘weight loss’.
w/u – Workup: ‘Diagnostic workup’, ‘GI workup’ (gastrointestinal diagnostic evaluation).

x – Times: ‘Take medication 3 x day’ (take medication three times a day). ‘Pain x 5 days’ (pain for 5 days).

y.o. – Years Old: ‘5 y.o. child’ (5 years old child).
yrs. – Years: ‘History of symptoms for 2 yrs’ (history of symptoms for 2 years).

Medical abbreviations are indispensable tools in the medical field, streamlining communication and documentation. However, their effective use relies on a thorough understanding of their meanings and contexts. This guide has provided a comprehensive look at many common medical abbreviations relevant to diagnosis. Remember, when in doubt, always clarify the meaning to ensure patient safety and accurate interpretation of medical information. Continued learning and attention to detail are key to mastering this essential aspect of medical language and improving diagnostic accuracy.

Decoding Medical Abbreviations for Diagnosis: A Comprehensive Guide

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