Professional Documents
Culture Documents
General
_ _
c = with _s = without
PRN = as needed p = after
NTE = not to exceed
Frequency of Medications or Other Activities (i.e., labs, inspiratory
spirometry, ambulation, etc.)
Q = every QHS = at night
BID = twice daily QAM = in morning
TID = three times daily QID = four times daily
BID, TID, and QID are not equivalent to q12h, q8h, or q6h
Route of Medications
PO = by mouth NPO = nothing by mouth
IV = intravenous SQ = subcutaneous
PR = per rectum
Normal Physical Exam
GEN:
AOx3 (alert and oriented)
sick vs. not sick/ill-appearing
HEENT (head/eye/ear/nose/throat):
NC/AT (normocephalic atraumatic)
PERRLA (pupils equal round reactive to light and accommodation)
EOMI (extraocular movements intact)
O/P clear (oropharynx)
Neck:
Na Cl BUN
supple Glucose
K HCO3 Cr
Ø thyromegaly
Ø LAD (lymphadenopathy) PT
INR
CV: Hgb PTT
RRR (regular rate & rhythm) S1, S2 WBC plts
Hct
Ø M/R/G (murmurs/rubs/gallops) T.Bili
Chest: AST ALT
Alk
CTAB (clear to auscultation bilaterally) Write out
Ca, Mg, and PO4 Phos Albumin
Ø W/R/R (wheezes/rhonchi/rales)
ABD:
S/NT/ND (soft/non-tender/non-distended)
Ø R/G (rebound/guarding)
⊕ BS (bowel sounds)
Ø masses
Ø HSM (hepatosplenomegaly)
EXT:
Ø C/C/E (clubbing/cyanosis/edema)
Skin:
WD (warm & dry)
Ø visible lesions
Neuro:
non-focal
CN 2-12 intact (cranial nerves)
Special note:
1. PRN meds: you need to specify: the dose (i.e. 325 mg); the number of
tablets (i.e. = 1-2); how often the patient can receive these (i.e., every 6
hours = q 6°); as well as the specific indication for the medicine. For
example: Tylenol 325 mg PO q 4-6 ° PRN headache, temp > 38.5
Always think about NTE (not to exceed) and hold orders!
2. IV medicines are generally written in hourly increments. For example, if the
medicine should be given every 8 hours, it should be written specifically as
q 8°, NOT TID, because TID is three times daily, which doesn’t necessarily
mean every 8 hours.
Additional references
Nerd’s Guide to Pre-Rounding: Rick Loftus ’01, a resident in the UCSF
Department of General Internal Medicine – Primary Care, has prepared an additional
document about life on the wards. The “Nerd’s Guide to Pre-Rounding” (version 2.01)
can be found at http://medstudents.ucsf.edu under “Clinical Guide.”
First Aid for the Wards and 101 Biggest Mistakes 3rd Year Medical Students Make:
If you’re ambitious, read these before each rotation for tips and general knowledge.
UCSF’s Internal Medicine Hospitalist/Housestaff Handbook: This invaluable
guide and resource for the clerkships is available to download in a Palm/PocketPC
version at http://medicine.ucsf.edu/housestaff/handbook