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75 Cards in this Set
- Front
- Back
SOAP |
Subjective, Objective, Assessment, Plan |
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CABG |
Coronary Artery Bypass Graft |
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CVA |
Cerebrovascular Accident |
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DVT |
Deep Venous Thrombosis |
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PE |
Pulmonary Embolism |
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DM |
Diabetes Mellitus |
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MI |
Myocardial Infarction |
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CAD |
Coronary Artery Disease |
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HTN |
Hypertension |
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UTI |
Urinary Tract Infection |
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N/V/D |
Nausea/Vomiting/Diarrhea |
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HA |
Headache |
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CP |
Chest Pain |
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SOB |
Shortness of Breath |
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Sx |
Symptoms or Surgery |
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PO |
Per O's, By Mouth |
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s/p |
Status Post |
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LOC |
Loss/Level of Consciousness |
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FHx |
Hamily History |
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Abx |
Antibiotics |
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HEENT |
Head, Eyes, Ears, Nose, Throat |
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ROM |
Range of Motion |
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pt |
Patient |
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NKDA |
No Known Drug Allergies |
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CXR |
Chest X-Ray |
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RUQ |
Right Upper Quadrant |
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LLE |
Left Lower Extremity |
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HPI |
History of Present Illness |
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LNMP |
Last Normal Menstrual Period |
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BID |
Twice A Day |
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Afebrile |
Without Fever |
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Conjunctivitis |
Eye Infection |
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Myalgia |
Muscle Pain/Ache |
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Ecchymosis |
Bruising |
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Bradycardia |
Slow Heartrate |
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Medial |
Near(er) Midline |
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Pallor |
Pale |
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Pharyngitis |
Throat Infection |
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Epistaxis |
Nose Bleed |
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Sinusitis |
Sinus Infection |
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Redness |
Erythema |
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Swelling |
Edema |
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Sweating |
Diaphoresis |
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Scrape |
Abrasion |
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Pus-like |
Purulent |
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Stroke |
CVA |
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Puke |
Emesis |
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Room-spinning |
Vertigo |
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Runny-nose |
Rhinorrhea |
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Passing-out |
Syncope |
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Ischemia |
Restriction of Blood Supply to Tissue |
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Infarct |
Tissue Death Due to Loss of blood supply |
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Benign |
Nothing of Concern |
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Acute |
Rapid Onset, short course |
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Chronic |
Long lasting |
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Grossly |
Obviously |
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Febrile |
The state of having a fever (more than 100.4) |
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STEMI |
ST elevation myocardial infarction |
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Hemorrhage |
Bleeding, usually excessive bleeding |
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Hypoxia |
Inadequate oxygen supply |
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c/o |
complains of |
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I&D |
Incision and Drainage |
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IVDA |
Intravenous Drug Abuse |
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TIA |
Transient Ischemic Attack |
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UTD |
Up to date |
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qhs |
At Night |
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Fx |
Fracture |
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Tx |
Treatment |
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H&H |
Hemoglobin and hematocrit |
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G/P/Ab |
Gravida/para/abortion |
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IUP |
Intrauterine Pregnancy |
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DOE |
Dyspnea on Exertion |
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How to increase efficiency of the provider you work with in the clinic |
1. Complete documentation 2. Look up old records 3. Place phone calls 4. Transcribe special instructions |
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what do you think the suffix "-algia" means? |
pain or ache |
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Doctor is verbalizing their physical exam findings to you. You don't recognize a word. What do you do? |
Write it down phonetically and google it. If you are not 100% confident as the provider |