1. ABBREVIATION PRACTICE
a Withoutor absence of This 3 YO HM presentsp MVA. VS WNL. PERRLA.
A & O Alertand oriented
This3 yearold healthymale presentsfromamotor
vehicle accidentwithvitalsignswithinnormal
limits.Pupilsequal and reactive tolightand
accommodations.
AMA Againstmedical advice
Pt c/o GIsx X 1 week. Taking TUMS b.i.d.s
improvement. Has beenNPO X 1 day.
b.i.d. Twice daily
Patient’schief complaintisgastrointestinal
symptomsfor1 week.TakingTUMS twice daily
withoutanyimprovement.Hashadnothingby
mouthfor a day.
CHF Congestive heartfailure Pt is to monitor BS pc t.i.d.
COPD
Chronicobstructive pulmonary
disease
Patient’sbloodsugaristobe monitoredafter
meals3 timesa day.
d/c Discharge/discontinue
A 33 YO WF presentswitha CC of cough s SOB or
fever. PMH is + for pneumoniaX 1. BS WNL.
DM Diabetesmellitus
A 33 yearold white femalepresentswiththe chief
complaintof a cough withoutshortnessof breath
or fever.Pastmedical historyispositive for
pneumoniaonce.Bloodsugarswithinnormal
limits.
Fx Fracture Pt takes SS insulina.c. and PRN
f/u Followup
Patienttakesslidingscale insulinbefore mealsand
as necessary.
h Hour Pt advisedto d/c ASA due to  GI sx.
HTN Hypertension
Patientadvisedtodiscontinue Aspirindue to
increasedgastrointestinal symptoms.
Lac Laceration Pt is A & O, appears in NAD.
LOC Level of consciousness
Patientisalertandorientedandappearsinno
apparentdistress.
NKDA No knowndrugallergies
Tx: PCNt.i.d. X 14 days. F/u PRN if sx not
improving.
npo Nothingbymouth
Treatment:Penicillin3timesdailyfor14 days.
Follow upas neededissymptomsdon’timprove.
OB Obstetrics Dx: r/o asthma
OD Righteye Diagnosis:Rule outasthma
PMH Past medical history Pt is to monitor BS ac and hs

2. po By mouth
Patientisto monitorbloodsugarbefore mealsand
at bedtime.
sx symptoms
Pt c/o LLQ pain+ N/V x 4days. BM 4 daysago, T-
102°, ↓appetite,LMP04/15/15, OTC Med: Miralax
–relief,NKDA,
t.i.d. Three timesdaily
Patientcomplainsof leftlowerquadrantpainplus
nauseaand vomitingfor4 days.Bowel movement
4 daysago, Temperature of 102, decreased
appetite,lastmenstrual period04/15/15. Overthe
countermedicine:Miralax forrelief.Noknown
drug allergies.