Medical Jargon

I have racked my brain to blog about something about myself that might be interesting to someone else and I thought maybe something as simple as medical jargon would be interesting. Something I take for granted knowing every day I work.  

Here is a snippet of my job as a nurse. Each shift we have to do a full body assessment and these are the abbreviations for how a patient is doing:

Joe Montague

Dx: CAD, HTN, S/P CABG 5/3, POD #2

Hx: Stents x2 1992, DM, CVD

Neuro: A/O X3

CV: HRR, SR LBBB on tele, VSS

Resp: LCTA,  mild DOE and SOB. O2 @ 2L NC, SPO2 94%, 88% ORA

GI: BS+ X4 QUADS, Abd soft non-tender, no N/V. Last BM yest.

GU: Voids QS, CL YeL

Integ: ML Sternal inc CDI.  well approx. Ecchymotic

2+ pitting edema to bil LE's, PPP 

IV: LFA 20g Patent

       RAC PICC w/D5 LR @ 75 ml/hr

Drains: CT to 80 mm/Hg LIWS

Medical Jargon  

Interpretation:

Dx=Diagnosis, CAD=Coronary Artery Disease. HTN=Hypertension. S/P=Status Post. CABG (pronounced like cabbage)=Coronary Artery Bypass Graft.  POD=Post Op Day.

Hx=History, DM=Diabetes Mellitis. CVD=Cardiovascular Disease.  

Neuro=Neurological System. A/O x3= Alert/oriented  to (x3) person, place and time.

CV=Cardiovascular System. HRR=Heart Rate Regular, SR=Sinus Rhythm LBBB=Left Bundle Branch Block on telemetry.  VSS=Vital Signs Stable.

Resp=Respiratory System. LCTA=Lungs Clear To Auscultation. DOE=Dyspnea On Exertion. SOB=Shortness of Breath. O2=Oxygen.  2L= Two Liters.  NC=Nasal Cannula. SPO2=Saturation of Peripheral Oxygen. ORA=On Room Air.

GI=Gastrointestinal System BS=Bowel Sounds. Abd=Abdomen. N/V=Nausea/Vomiting. BM=Bowel Movement.

GU=Genitourinary System. Voids=Urinate (I'd never heard of voiding before nursing school).

QS=Quantity Sufficient CL=Clear. Yel=Yellow. 

Integ= Integument System. ML=Midline.  inc=incision. CDI=Clean Dry Intact. Well Approx= edges come together well. Ecchymotic=bruising. 2+ pitting edema= Means that when you push on their legs it sinks down for two seconds. Bil LE's= Bilateral Lower Extremities. PPP=Positive Pedal Pulses.

IV=Intervenous. LFA=Left Forearm. 20g=the gauge or size of the catheter or IV. Patent=It works and flushes with saline. RAC=Right Antecubital.  PICC=Peripherally Inserted Central Catheter (an IV that can stay in for months because it exits at the heart) D5LR=5% Dextrose Lactated Ringers (An IV fluid).  They want it to run at 75 milliliters an hour.

Drains. CT=Chest Tube connected to the wall suction and set at 80 (mm) millimeters of (Hg)mercury pressure on the wall suction. Set at LIWS=Low Intermittent Wall Suction.

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Compare the amount of writing saved with all the acronyms!  I remember learning all this stuff and now I write it like I was just talking to someone in another language.  And that's exactly what it is.  I think it's really cool. Just something I do every day!

The next step is to have the doctors put their orders into the computer so we don't have to interpret their incredibly AWFUL  handwriting.  Second graders have more legible handwriting!