Beyond Neurological Status: Knowledge of Medical Terminology • Very valuable

Knowledge of Medical Terminology
• Very valuable
– Increases your understanding
– Saves you time
– Increases credibility with other providers
Beyond Neurological Status:
Finding and Recognizing Pertinent
Information in the Medical Record
Kyla C. Sherrard Ph.D., CCC-SLP
Chief, Speech-Language Pathology
Division of Otolaryngology
Scott & White Hospital
Temple, Texas
Carol A.Venus Ph.D., CCC-SLP
Supervisor, Speech-Language Pathology
Central Texas Veterans Healthcare System
Temple-Waco-Austin, Texas
To Review a Medical Record
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Decide what you need to know
Bypass irrelevant information
Locate and recognize useful information
Interpret useful information
Apply information to your
– Understanding of the case
– Evaluation
– Treatment Planning
• Inform your discussions with staff
• Easy to acquire
– Self-paced texts
– Courses
About Medical Terminology
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Uses components to build terms
Prefixes, suffixes and roots
Often derived from Latin or Greek
Example:
• “Dyspnea”
– “dys” = “difficulty”
– “pnea” = “breathing”
• More than jargon: increased precision
• “Edema” is not just a fancy word for “swelling”
Record Review
What you want to know
• Why were you consulted?
• When and why was pt. admitted?
• What medical conditions might be compromising
communication or swallow in this case?
• When did these conditions develop?
– Long before admission
– Around time of admission
– After admission
• Are these conditions improving/worsening?
• How are these conditions being treated?
More you want to know
• Are there other conditions or
circumstances that are important in this
case?
• What is the overall prognosis?
• How much do behavior and medical
conditions fluctuate from day to day or
hour to hour?
Chart Tabs
• PROGRESS NOTES OR “NOTES”
• Physicians’ and Surgeons’ notes
– May include History and Physical (HxPx)
– May include Consult Replies from specialists
– Frequency of notes depends on level of care (ICU, acute, long
term care)
– Distinguish between attending and consultant notes
– Distinguish between attending versus residents versus medical
students
• Nurses’ notes
– Nursing credentials vary
• Allied Healthcare Providers’notes:
– SLP, Audiology, PT, OT
– Dieticians
– Social Workers, Psychologists
How the Record is Organized
• Reverse chronological order
• Chart Tabs in order of Occurrence
– PROBLEM LIST
• Diagnoses and conditions with date first recorded
Limitations of the problem list
Chart Tabs
• ORDERS
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Activity Orders (bedrest? up in chair?)
Nursing Orders (isolation precautions?)
Diet Orders (what diet is pt receiving vs NPO)
Medications (anti-anxiety drugs? IV fluids?
antibiotics?)
• Orders for Lab Tests
• Radiology (or “Imaging” Orders)
• Consult Requests
Chart Tabs
• CONSULTS or “CONSULT REPLIES”
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Pulmonary Medicine
Gastroenterology
Cardiology
Nephrology
Infectious Diseases
Oncology
Endocrinology
Psychiatry
Opthalmology
Chart Tabs
• SURGICAL REPORTS or “Report of
Operation”
• Descriptions of surgical procedures that have been
done
• May include pathology reports, biopsies
• DISCHARGE SUMMARIES
• Summaries of previous hospital stays, dictated at
the time of discharge from hospital
Chart Tabs
• Lab Tests
• Radiology (or “Imaging”) Reports
• Other
Finding what you need to know
• Look in Notes, Consults, Labs, Imaging Reports
to find out:
– Are these conditions improving, maintaining or
worsening?
– How are these conditions being treated?
– Are there other conditions that are important in this
case? (as above, also HxPx)
– What is the overall prognosis?
• Look especially in notes by nurses, dieticians
and therapists to find:
– How much do behavior and medical conditions
fluctuate from day to day or hour to hour?
Finding what you need to know
• Why were you consulted?
– Check Consults for SLP request
– Note reason for request
– Note name and role of requester
RELEVANT MEDICAL
CONDITIONS
• If reason not clear, read progress notes by
requester and other progress notes around the
time the consult was requested
• If still not clear, discuss with requestor
• If consult not really for SLP, forward consult
Finding what you need to know
• When and why was pt. admitted? (HxPx)
• What medical conditions might be compromising
communication or swallow in this case? (HxPx,
Progress Notes, Consults)
• When did these conditions develop?
– Long before admission (HxPx, Discharge Summaries,
Consult Replies)
– Around time of admission (HxPx)
– After admission (Progress Notes, Consults)
Sensory Impairments
• Hearing Impairment
• Visual impairment
Congenital
Traumatic
Cataract
Glaucoma
Macular Degeneration
Diabetic Retinopathy
Visual field cut or visual inattention
Mental Status/Psychiatric Impairment
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Altered mental status or AMS (waste-basket term)
Agitation
Combativeness
Mental Confusion
disorientation and impaired attention-focus
• Delirium
acute and relatively sudden decline in
attention-focus
perception
cognition
Mental Status/Psychiatric Conditions
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Dementia
Definition
Severity
Etiology
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Multi-Infarct Dementia (MID)
Dementia of the Alzhemier’s Type (DAT)
Anoxic Encephalopathy
Parkinson’s Disease
Wernicke’s Encephalopathy
Many others
Mental Status/Psychiatric Conditions
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Post Traumatic Stress Disorder
Depressive Disorder
Anxiety Disorder
Personality Disorder
Conversion Disorder
Schizophrenia
Schizophrenia, Paranoid Type
Diabetes Mellitus
Type I due to failure to release insulin
- often childhood onset
- must control carbohydrate intake
- always insulin-dependent
Type II due to insulin resistance and impaired glucose
transport
- often adult onset (assoc with obesity, family
history, lack of physical exercise, ethnicity, age)
- must control carbohydrate intake
- can be managed with diet, oral medication
- can be insulin-dependent in later stages
Diabetes Mellitus
• Criterion is Fasting Blood Sugar (FBS) of 126mg/dl or
higher
• Effective treatment normalizes blood glucose and
decreases complications
• Glucometer used to measure blood sugar (glucose)
on day to day basis including on ward
Diabetes Mellitus
Blood Glucose Levels/Glucometer Readings
• Low: below 70mg/dl = hypoglycemia
can compromise mental status until normalized
• Normal: 70 to 100mg/dl
can be higher if less than 2hrs after a meal
• High: 100mg/dl to more than 600mg/dl
the greater the elevation the greater the risk of
complications such nephropathy, retinopathy, and
peripheral neuropathy.
Infection
Diabetes Mellitus
• Regardless of glucose control, diabetics have increased
risk for
- Cardiovascular disease and other heart disease
- Cerebrovascular disease such as stroke
• Many diabetics also have HTN and hyperlipidemia,
further increasing their risk of vascular disease
Nephropathy – Kidney Disease
• Renal Failure
• Often caused by vascular disease
• Hepatic encephalopathy
• waste products and toxins accumulate in the blood and brain
• lethargy, AMS, paranoia, hallucinations, slurred speec
• Kidney Dialysis
– Temporarily cleanses the blood
– Can alter mental status temporarily
– Usually must be repeated indefinitely once it is
needed
Creatinine Level
• Breakdown of creatine phosphate in
muscle, usually produced at a fairly
constant rate
– Most commonly used measure of renal
function
– BUN (blood urea nitrogen) to creatinine ration
with BUN higher is suggestive of dehydration
• Systemic such as septicemia or localized such
as pneumonitis, UTI or infected wound
• Isolation precautions?
• Infectious organisms seen in hospitals
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Staphalococcus aureus “staph”
Methycillin resistant staphalococcus aureus “MRSA”
Clostridium difficile (“c-diff”)
Tuberculosis
HIV
Infection
• Sepsis, whole-body inflammatory state
caused by infection
– Systemic inflammatory response syndrome
– General inflammation, fever, leukocytosis,
tachycardia, tachypnea
– Septic shock, decreased tissue perfusion and
oxygen delivery causing organ failure and
death
Electrolyte Imbalance:
Altered Blood Chemistry
• Sodium
hyponatremia – overhydrated or diuretic use
hypernatremia – dehydrated or diuretic use
• Potassium
hypokalemia – diuretic or N/V
hyperkalemia – kidney failure
• Calcium
hypocalcemia – widespread infection, decreased
parathyroid hormone, Vit D deficiency
hypercalcemia – seen with cancer
Albumin
• Used to diagnose disease, monitor
changes in nutrition/health status or
disease progression
• Indicative of kidney or liver dysfunction
• Low = inflammation, shock, malnutrition
(impairs healing process)
• High = dehydration (goes along with AMS)
Blood Pressure/Hypertension
• Systolic – pressure generated when heart
contracts
• Diastolic – pressure generated when heart
relaxes
120-139/80-89
prehypertensive
140-159/90-99
Stage I HTN
160+/100+
Stage II HTN
Metabolic acidosis/alkalosis
Altered Blood Chemistry
• Acidosis – excess acid
– H/A, lethargy, CNS depression
• Alkalosis – excess base bicarbonate
– Alkalosis – excess base bicarbonate
hypoventilation, twitching, irritability, N/V,
tachycardia, cyanosis, apnea
Cardiovascular Disease
• Either with or without accompanying
neurological symptoms, you will be asked to
evaluate patients with cardiac related cognitive
or swallow issues.
• Patients may be post MI, CHF, or surgery such
as CABG or Aortic valve replacement.
• Patients may have associated altered mental
status affecting communication and swallow.
Cardiac Rate/rhythm
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Normal resting heart rate for adults – 60-90 bpm
Tachycardia, increased heart rate
Bradycardia, decreased heart rate
Atrial fibrillation (A-fib) or irregular heart beat of
the atria
– common source of emboli resulting in stroke
– high percentage of elderly experience either acute or
chronic a-fib
– can be treated medically or with cardioversion
Cardiovascular Diseases
• CAD, coronary artery disease
– blockages of heart vessels
– source of emboli to brain
• PVD, peripheral vascular disease
– blockages in peripheral vessels
– souce of emboli to brain
• MI/NSTEMI, myocardial infarction/heart attack
– death of heart tissue
– possible anoxic event, generalized decrease in brain
function
– possible emboli with resultant CVA
Cardiovascular Diseases
• CHF, congestive heart failure
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heart pumping decreases, oxygenation decreases
leads to decreased kidney function
build-up of fluid and respiratory failure
pulmonary edema will directly impact ability to inhibit
inhalation during swallow
• Endocarditis, inflammation/infection of heart
– vegetative growth on the valves or lining of the heart
– produces emboli that can travel to brain and cause
infection/CVA
– patients frequently have AMS/aphasia with resultant
affects on communication and swallow
Pulmonary
• Consults will be primarily for swallow
assessment as patients will have higher
risk involved with aspiration due to
compromised pulmonary status.
• Again, mental status may be impaired and
patients may be medically complex and
debilitated.
Oxygen
• Oxygen Saturation
amount of oxygen dissolved in a given
medium
• Hypoxia = <90%
• Pulse oximeter relies on light absorption
characteristics of saturated hemoglobin
• ABG, arterial blood gas analysis is more
accurate
Breath Sounds
• Rales, rhonchi, and crackles
• Site of sound – tracheal, bronchi, lung
• Timing of sound – beginning or end of
cycle, on inspiration or expiration
• Wet phlegmy breathing/voicing
• Interferes with bedside swallow
assessment
Pulmonary Conditions
• Pneumonia
– chronic illness and debilitation are
predisposing factors
– Viral
– Bacterial
– Aspiration pneumonia
– All sources are aspirated whether by
breathing in particulates (noxious
fumes/chemicals, viruses, oral intake, reflux,
poor oral hygiene, impaired cough reflex)
Pulmonary Conditions
• Pulmonary edema
– Multiple causes, symptom
– Swelling and/or fluid accumulation in lungs
(thoracentesis may be required to remove
fluid)
– Impaired gas exchange
– Respiratory failure
– Altered mental status
– Difficulty inhibiting inhalation in swallow cycle
Pulmonary Conditions
Tracheostomy Tube
• Adult respiratory distress syndrome
(ARDS)
– Form of pulmonary edema that causes
respiratory failure requiring ventilation and
possibly tracheostomy in vent weaning
– Causes stiffening of the lung tissue and
impairs oxygenation of pulmonary capillary
blood, possible fatal hypoxemia
Ventilation
• Ventilation through oral intubation, facial mask,
or tracheostomy
– mechanical insufflation/exsufflation, provides deep
volume of air followed by a forced expiration
– CPAP – continuous positive airway pressure,
delivered by mask, keeps obstructed airway open and
expands lungs, does not help the muscles of
inspiration
– BiPAP – bi-level positive airway pressure, a method
of ventillatory assistance
Ventilation
• Indications for cuffed tube
– Normally the initial tube inserted in ICU
– Necessary to maintain appropriate ventilation pressures
– Not to prevent aspiration
• Protocol of weaning from ventilation and tracheostomy
tube
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Ventilation
• Speech involvement with trach care varies
• Tracheotomy – open surgical vs. percutaneous
opening of the trachea
• Trach tubes (Shiley or Bivona)
– Outer cannula, inner cannula, obturator
– Cuffed or cuffless
• Air or water cuff
• Tight to shank
• Single or double
– fenestrated
Fully assisted/controlled respiration
CPAP
BiPAP
T-collar (mini trach mask) with deflation of cuff
Downsizing from initial diameter
Speaking valve
Capping of trach
Decannulation
Communication/Swallow
• Communication
– Speaking valve (Passey-Muir), in-line or on trach tube
– Finger occlusion of trach
• Swallow
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Bedside or fluorographic assessment
Cuff deflated
Risks of tracheal irritation/perforation if inflated
Possible generalized debility and/or tethering of
laryngeal excursion for airway protection
Gastroenterology
• Interpretation of the assessment of oral
and pharyngeal levels of swallow often
requires incorporation of information
provided by the radiologist about the
esophagram, barium swallow, or UGI.
• This requires understanding of esophageal
function as well as gastric and intestinal
functions.
GI Conditions
• Achalasia – esophageal dysmotility
– Pt c/o food sticking and getting full quickly
– Impaired peristalsis
– LES (lower esophageal sphincter) fails to relax
• Esophageal stricture
– pt c/o food sticking midsternum
• Esophageal diverticulae
– most common with dysphagia is Zenker’s diverticula
at the UES
Gastroenterology
• Patients referred with oral-pharyngeal
swallow deficits may have co-occurring
gastroenterological problems that impact
the oral-pharyngeal level.
• Slow gastric emptying can give distention
and slow down esophageal emptying
putting pressure at the UES and
decreasing appetite due to a feeling of
fullness.
Gastroenterology
• Esophageal contractions
– primary – triggered by volitional swallow,
travels length of esophagus
– secondary – circular contraction triggered by
distention of the primary wave
– tertiary – simultaneous contractions at
multiple levels
GI Conditions
• Esophagitis
• inflammation secondary to caustic irritation or
fungal infection
• Candidiasis – fungal infection
• Oral – creamy to bluish-white patches, burning
sensation, odynophagia
• GI – retrosternal pain, regurgitation, odynophagia
• Stomatitis
• Inflammation of gums and oral mucosa
• Difficulty chewing, odynophagia
GI Conditions
• GERD – gastroesophageal reflux disease
• cough especially at night
• heartburn
• feeling of lump in throat and food sticking at UES
• LPR – laryngopharyngeal reflux
• cough, hoarse voice, may not have heartburn
GI Conditions Negating
Immediate Swallow Assessment
• Paralytic ileus
– a section of intestine that does not function post
abdominal surgery or due to electrolyte imbalance,
particularly hypokalemia
– Precipitates NPO status and hold on tube feeds until
bowel sounds return
• PUD – peptic ulcer disease
• may be cause of upper GI bleed
• Pancreatitis – inflammation of the pancreas
• complication of gall bladder disease or ETOH use
• severe abdominal cramping/pain, n/v
Types of Cancer
• Cancers are named for type of cells from which
they originate
– Carcinoma: skin cells or from tissues that line or
cover internal organs
– Neuroma: nerve cells
– Sarcoma: bone, cartilage, fat, muscle, blood vessels,
other connective or supportive tissues
– Leukemia: blood-forming tissues such as bone
marrow
– Lymphoma, multiple myeloma: cells of the immune
system
Nutrition Support
• Oral supplementation at and between
meals to improve nutritional status
• Enteral supplementation in an oral feeder
• Total enteral feeds
– Nasal feeding tube (Dobhoff) – relatively short
term – not NG-tube for stomach emptying
– Gastic or jejunal tube – longer term or better
choice in agitated pt or one with severe reflux
– TPN – total parenteral nutrition (thru vein)
Cancer
Staging of Carcinoma
(Amer. Joint Committee on Cancer)
• Stages
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A general term
Abnormal cells divide without control
Can invade nearby tissues
Can spread to other parts of the body
– Through bloodstream
– Through lymphatic system
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Stage 0 (minimally extensive carcinoma)
Stage 1
Stage 2
Stage 3
Stage 4 (very extensive carcinoma)
• Stages are derived from TNM Classification
– Primary Tumor (T), (0 to 4)
– Regional Lymph nodes (N), ( 0 to 3)
– Distant Metastasis (M), ( 0 or 1)
Treatments for Cancer
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Chemotherapy: treatment with drugs toxic to cancer cells (less
toxic to slower-growing cells)
•
Radiation therapy (XRT): treatment with high-energy radiation to
kill cancer cells and shrink tumors
– Radiation burn is a temporary side-effect
– Radiation fibrosis can be a permanent side-effect
– Frequently generates swallow assessment or communication
assessment consults
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Surgery: excision or surgical reduction of tumors
– Adjacent structures may be affected
Life After Chart Review
• Until you gain experience, chart review can
seem daunting, but with time you will be able to
weed out what you don’t need and feel prepared
to:
– Discuss current status with nursing
– Assess the patient
– Discuss assessment/treatment with caregivers,
nursing, and physicians
– Document
– Write orders at the doctor’s discretion
– Treat your patient!
Appendix
• Medical abbreviation list
• Resources
– Nursing Education Texts, e.g. Handbook of
Diseases, Springhouse
– Medical dictionary
– eMedicine.com
– Nursing, RT, OT/PT, and MD colleagues
COMMON MEDICAL ABBREVIATIONS
AAA
AAO
ABG
ABR
ADA
ADL
AF
AFO
AHA
AKA
Alb
ALL
ALS
AMA
AMI
AML
Angio
A-P
A&P
AMS
APS
ARC
ARDS
ARF
AROM
ASCVD
ASD
ASHD
AVM
AVR
Ba
BCLS
BiPAP
BP
BPD
BPH
BS
Bx
A
abdominal aortic aneurysm
awake, alert, oriented
arterial blood gas
auditory brainstem response test
American Diabetic Association
activities of daily living
anterior fontanel
ankle foot arthosis
American Heart Association
above the knee amputation
albumin
acute lymphocytic leukemia
amyotrophic lateral sclerosis
American Medical Assoc.
Against medical advice
Advanced maternal age
acute myocardial infarction
acute myelogenous leukemia
angiogram
anterior to posterior
auscultation and percussion
altered mental status
adult protective services
AIDS related complex
adult respiratory distress syndrome
acute renal failure
active range of motion
atherosclerotic cardiovascular disease
atrial septal defect
atherosclerotic heart disease
arteriovenous malformation
aortic valve replacement
B
barium
basic cardiac life support
biphasic positive airway pressure
blood pressure
borderline personality disorder
Bronchopulmonary dysplasia
benign prostatic hypertrophy
breath sounds
biopsy
CA
CABG
CAD
Cal
CAT or CT
CBC
CBF
CC
c/o
CHF
CHI
Chole
CLL
CNS
COPD
C-P
CPAP
Creat
CTA
CUC
CV
CVA
D/C
DJD
DM
DME
DNKA
DNR/DNI
DOB
DTR
DTs
Dx
ECG/EKG
ECHO
EEG
EDG
EOB
EOM
ESRD
ETOH
C
carcinoma (cancer)
Central apnea
coronary artery bypass graft
cornary artery disease
calorie
computerized axial tomography
complete blood count
cerebral blood flow
chief complaint
complains of
congestive heart failure
closed head injury
cholecystectomy
chronic lymphocytic leukemia
central nervous system
chronic obstructive pulmonary disease
cerebral palsy
continuous positive airway pressure
creatinine
clear to auscultation
chronic ulcerative colitis
cardiovascular
cerebrovascular accident
D
discharge
Discontinue
degenerative joint disease
diabetes mellitus
durable medical equipment
did not keep appt
do not rescusitate/do not intubate
date of birth
deep tendon reflexe
delirium tremens
diagnosis
E
electrocardiogram
echocardiogram
electroencephalogram
esophagogastroduodenoscopy
edge of bed
extra-ocular movement
end stage renal disease
alcohol
FEF
FEV1
FNA
FT
Fx
GSW
GT
G-tube
HA
HEENT
HO
HOB
HR
HTN
Hx
IC
ICH
ICP
I/E
IPH
IV
IVF
IVH
JPEG
J-tube
K+
Kcal
KCl
Kg
Lap
LE
LES
LLE
LLL
LTAC
LUE
F
forced expiratory flow
forced expiratory volume in 1 second
fine needle aspiration (biopsy)
feeding tube
fracture
G
gunshot wound
gastrostomy tube
gastric tube
H
headache
head, ears, eyes, nose, throat
house officer
head of bed
heart rate
hypertension
history
I
inspiratory capacity
intracranial hemorrhage
intracranial pressure
inspiratory/expiratory
intraparenchymal hemorrhage
intravenous
intravenous fluids
intraventricular hemorrhage
J
jejunal percutaneous endoscopic gastrostomy
jejunostomy tube
K
potassium
kilocalorie
potassium chloride
kilogram
L
laparotomy
lower extremity
Lupus erythematous
lower esophageal sphincter
left lower extremity
left lower lobe (lung)
long term acute care
left upper extremity
LUL
LVH
MAO
MAOI
MCC
Med/meds
MEFR
Mets
MI
MIFR
MRI
MRN
MS
MVA
MVC
MVPA
Na
NaCl
NG-tube
NH
NHL
NIDDM
NKA
NKDA
NPO
n/s
NSTEMI
OBS
OD
OM
OOB
ORIF
OS
OTC
PCP
PEEP
PEG
left upper lobe (lung)
left ventricular hypertrophy
M
monoamine oxidase
monoamine oxidase inhibitor
motorcycle collision
medication/s
maximum expiratory flow rate
metastasis
myocardial infarction
maximum inspiratory flow rate
magnetic resonance imaging
medical record number
multiple sclerosis
Mental status
motor vehicle accident
motor vehicle collision
motor vehicle pedestrian accident
N
sodium
sodium chloride
nasogastric tube
nursing home
non-Hodgkins lymphoma
non-insulin dependent diabetes mellitus
no known allergies
no known drug allergies
nothing by mouth
normal saline
non ST elevated myocardial infarct
O
organic brain syndrome
overdose
Right eye (occulus dexter)
otitis media
out of bed
open reduction internal fixation (hip)
left eye (occulus sinister)
over the counter
P
pneumocystis carinii pneumonia
positive end expiratory pressure
percutaneous endoscopic gastrostomy
PERRLA
PMHx
POD#
PPD#
prn
PROM
PT
pt
PTA
PUD
PVR
q
qd
qh
q4h
qhs
qid
qn
qod
RA
RBC
RDS
re
Rehab
REM
RLE
RLL
r/o
ROM
RT
RTC
RUE
RUL
SAH
SCI
Sed rate
SNF
pupils equal, react to light and accommodation
prior medical history
post operative day (1,2, etc.)
post partum day
as needed
When required
passive range of motion
physical therapy
patient
prior to admission
PT aide
peptic ulcer disease
post void residual
Q
every
every day
every hour
every 4 hours
every night at bedtime
four times a day
every night
every other day
R
room air
Rheumatoid arthritis
Right atrium
red blood count
respiratory distress syndrome
regarding
rehabilitation
rapid eye movement
right lower extremity
right lower lobe (lung)
rule out
range of motion
Right otitis media
respiratory therapy
recreational therapy
return to clinic
right upper extremity
right upper lobe (lung)
S
subarachnoid hemorrhage
spinal cord injury
sedimentation rate
skilled nursing facility
SOAP
SOB
SOM
s/s
STAT
sx
T&A
TB
TD
TFs
tid
TORB
TPN
Trach
Tx
UES
UGI
URI
UTI
Vent
VORB
VS
WBC
w/c
WNL
w/
w/o
y/o
subjective, objective, assessment, plan
short of breath
serous otitis media
signs and symptoms
immediately
suction
T
tonsillectomy & adenoidectomy
tuberculosis
tardive dyskinesia
tube feedings
three times a day
telephone order read back
total parenteral nutrition
tracheostomy
therapy
treatment
transfusion
U
upper esophageal sphincter
upper gastrointestinal
upper respiratory infection
urinary tract infection
V
ventilator
verbal order read back
vital signs
W
white blood count
wheelchair
within normal limits
with
without
Y
year old