Preop evaluation

By now, you will have received the medical abbreviations pre-work assignment. The purpose of this assignment is to make you more conversant in medical-speak.  Abbreviations are important, not only because they are so common around the hospital, but, as you will come to learn, they are an indispensable means of efficient communication in a hectic and critical environment.

Everyone in healthcare uses abbreviations; from the anesthesiologist to the PACU nurses, the surgeons--even the janitors.  Abbreviations are particularly important when it comes to pre-operative evaluations (pre-ops) and anesthesia records (charts). Zoom in on the blank pre-op that I pulled from the web, below.  See how so many of the terms are abbreviated?

In the broader sense, learning abbreviations is an important step to becoming more confident and feeling like you belong in the OR.  It's easier to learn to walk-the-walk, when you already know how to talk-the-talk.

Now the truth is, just like the information on the drug card, you naturally pick-up abbreviations over time through daily exposure. Regardless, Gary wants you to have a good working knowledge of them by the time you start your first clinical rotation.


When I got this assignment last year, and perused those three epic lists of abbreviations, my initial reaction (in abbreviation form) was '...wtf?'   Each list contains hundreds, if not thousands of abbreviations;  many of the same abbreviations appear on all three lists; and I think one of the lists is missing the asterisks '*' to signify abbreviations that might show up on a test.

According to Gary, our class performed 'abysmally' on the abbreviations quizzes, and I think that was partly due to the confusing/chaotic nature of those three lists.  No one in my class really knew what to do, where to begin, etc etc; so we didn't study them very well (or much at all, in my case).

A shortcut to scoring in the C-B range on your first abbreviations quiz

I have made things a little easier by paring down all three long lists to one short list that contains only the most important terms. The terms I have selected are used by AA's on a daily basis, and for that reason, it is safe to assume they will constitute between 70-80% of the items on any given quiz the program throws at you.

Below, the same blank pre-op is broken down into individual categories--or, as they say in the industry, 'systems'--such as neurological, renal, cardiovascular, etc etc.  Abbreviations from each system have their own unique color, hopefully making them easier to memorize.  Finally, I have placed an asterisk next to 10-20 terms that are so ridiculously common, it's stupid.  You simply cannot function in the OR without knowing them.

Let's start from the top:

*****Abbreviations RE: Initial/Generic PRE-OP QUESTIONS*****

This is generally the first part of pre-op, when we ask the patient: "When was the last time you had something to eat or drink?" and "What medications are you currently taking" (terms in black)

*NPO--'nothing by mouth,' i.e. "the patient has not had anything to eat" since....
H/O--history of
MH--Malignant Hyperthermia
*PONV--Post-Operative Nausea and Vomiting
Hx--History

Not shown, but other abbreviations pertinent to this system are:

*NKDA--No Known Drug Allergy
N/V--Nausea/Vomiting
PO--'by mouth'
ASA--Aspirin (ASA is also the abbreviation for American Society of Anesthesiologists, which appears later on the pre-op)
bid--twice daily
tid--three times daily
qid--four times daily
Dx--Diagnosis
Dz--disease
*PMH--Past Medical History
*PSH--Past Surgical History

*****Abbreviations RE: LABS/PREGNANCY and the PHYSICAL EXAM*****

This section of the pre-op includes lab tests for blood (in red), pregnancy tests and questions related to pregnancy (light blue), and physical exam tests--such as listening to the patient's lungs (CTA), or making a visual assessment of their chin and throat (TMD) (green)

WBC--White Blood Cell

*H/H--Hematocrit and Hemoglobin

PLT--Platelet

Na--Sodium

K--Potassium

BUN--Blood Urea Nitrogen

Cr--Creatinine

PT--Prothrombin Time

PTT--Partial Thromboplastin Time

INR--International Normalized Ratio (a ratio of patient's PT versus the normal PT)

BTL--Bilateral Tubal Ligation
*LMP--Last Menstrual Period
TAH--Total Abdominal Hysterectomy

HCG--Human Chorionic Gonadotropin (for urine pregnancy test)

NEG--Negative

U/L--Upper/Lower 

*ROM--Range of Motion
TMD--Thyromental Distance
*CTA--Clear to Auscultation


Others:

HgB--Hemoglobin
CBC--Complete Blood Count
*RBC--Red Blood Cell
*ABG--Arterial Blood Gas

A/P:  Auscultation and Percussion
BBS--Bilateral Breath Sounds
PERRLA--Pupils Equal, Round, Reactive to Light and Accomodation
*A&O x4--Alert and Oriented to person, place, time and event

******Abbreviations RE: The CARDIOVASCULAR SYSTEM (CVS)******

A list of some of the most common cardiovascular diseases (purple)

*WNL--Within Normal Limits

*HTN--Hypertension

*CAD--Coronary Artery Disease

MVP/MR/AI/AS--Mitral Valve Prolapse, Mitral Regurgitation, Aortic Insufficiency, Aortic Stenosis (all diseases of the various heart valves)

PVD--Peripheral Vascular Disease

MI Hx--Myocardial Infarction history (heart attack history)

*CHF--Congestive Heart Failure

A. Fib--Atrial Fibrillation

A. Flutter--Atrial Flutter

PTCA--Percutaneous Transluminal Coronary Angioplasty

STENT--Stent (not an abbreviation)

*Hx CABG--Coronary Artery Bypass Graft history

AICD--Automatic Implantable Cardioverter Defibrillator

RBBB--Right Bundle Branch Block

LBBB--Left Bundle Branch Block

Others:

AAA--Abdominal Aortic Aneurysm 

EJ--External Jugular

IJ--Internal Jugular

SA Node--Sino-Atrial Node

That's it for this installment.  In Part II, we will finish out the second half of the pre-op, and I'll add a few endnotes about boot camp.  Have a good one!