Neurological System

Abbreviation
Term Definition Example
(written)
Cerebral
(brain) CVA can be caused by a
Impaired brain function resulting from
CVA vascular blood clot in the brain or
decrease of blood flow to the brain
(vessel) brain vessel rupture.
accident
My patient suffered a TIA
Transient A temporary reduction in the blood with slurring of speech and
TIA Ischemic supply and adequate oxygen to brain weakness of his right face
Attack cells and arm lasting about 10
hours.
The young man suffered a
Occurs when an external force injures
Traumatic TBI when his head hit the
TBI the brain. Common causes are falls,
brain injury windshield during a car
vehicular accidents, and violence.
accident.
ALS damages motor
Amyotrophic A progressive and fatal degenerative
neurons causing muscle
ALS lateral disease of the nerves that control
weakness and loss of
sclerosis voluntary muscle function.
muscle tissue or atrophy.
 A degenerative disease affecting the
myelin covering of neurons of the
Multiple brain and spinal cord causing diffuse
MS
Sclerosis deficits including balance problems
(ataxia), spasticity of muscles, tremor
and visual disturbances
She was 27 when she
developed inflammation of
the optic nerve (optic
neuritis) and trouble feeling
steady when walking; a
neurologist diagnosed MS.

Musculoskeletal System
Abbreviation
Term Definition Example
(Written)
Mr. Johnson who has OA has
Osteoarthritis noticed a slow onset of
and bone of the joints often
-or- stiffness in his knees and
OA -or- DJD causing pain and disability more
Degenerative now has some pain but no
prevalent with aging
Joint Disease heat or redness in his right
knee.
A chronic systemic autoimmune Because she has RA, Mrs.
disease that causes inflammation Silkowski is experiencing
Rheumatoid of connective tissue, primarily swollen painful joints of both
RA
Arthritis affecting the small joints of the hands and wrists even
wrists, hands, feet and cervical though she is just 30 years
spine old.

Cardiovascular System
Abbreviation
Term Definition Example
(written)
Mr. Marks complains of
chest discomfort radiating to
Destruction of heart muscle cells as
Myocardial his left shoulder and jaw. His
MI a result of an interruption of blood
infarction pulse feels weak. He may be
supply muscle
having a MI. We need a 12
lead ECG, stat.
Mr. Conway’s father died of
an MI in his forties. So Mr.
A narrowing or blockage of the
Coronary Conway has become
CAD arteries that provide oxygen and
artery disease educated about changes in
nutrients to the cells of heart
life style that can help
prevent CAD.
A surgical procedure in which one
CABG can restore blood
Coronary or more blocked coronary arteries
supply to affected heart
CABG artery bypass are bypassed by a blood vessel
muscle through a grafted
graft graft to restore blood flow to the
vessel.
heart tissue.
Occurs when the heart is unable to
Mr. Lee developed edema or
Congestive provide sufficient pump action to
CHF swelling in his lower legs
heart failure maintain blood flow to meet the
because of his CHF disease.
body needs
A DVT may be causing Mr.
A blood clot in a major vein that
Deep vein Jensen’s complaints of pain
DVT usually develops in the legs and/or
thrombosis in the back of his calf when
pelvis
walking.
 An abnormal dilation of the Mr. Joe complains of severe
Abdominal
abdominal aorta, often abdominal pain with low
AAA aortic
asymptomatic. May require repair blood pressure. Triple A is a
aneurysm
to prevent or treat rupture. likely diagnosis.
Extra or additional heart beats
The EKG was consistently
originating from one of the
Premature detecting more than six
ventricles of the heart. These
PVC Ventricular PVC’s a minute so the
abnormal beats are usually
Contractions physician decided to do
harmless and are felt as palpation
more testing.
or “skipped beat.”
A common cardiac arrhythmia
He was 82 when he noticed
produced by rapid unsynchronized
irregularities in his pulse. His
Atrial movement of the atria and
A-fib -or- AF doctor diagnosed A-fib and
Fibrillation consequent irregular pulse. Often
placed him on a drug to help
asymptomatic. Known to increase
prevent stroke.
risk of CVA or stroke.
Abnormal fatal arrhythmia usually
caused by lack of oxygen to heart
The physician said, “He’s in
Ventricular muscle. The ventricles quiver rather
V-fib -or- VF VF. Stand back I must
Fibrillation than contract, cardiac output stops,
defibrillate now.”
and unless circulation is restored,
the person dies.

Respiratory System
Abbreviation
Term Definition Example
(Written)
An autosomal recessive
disorder affecting epithelial This young girl has been suffering
Cystic cells of organs, particularly from CF for many years with
CF
fibrosis respiratory and GI. recurrent pneumonia, exercise
Characterized by abnormal intolerance, and chronic cough.
secretion and organ failure
Chronic
Chronic narrowed airway Mr. Smith who has been a cigarette
obstructive
COPD with occurrences of smoker for 20 years was diagnosed
pulmonary
bronchitis and emphysema with COPD.
disease
Six hours after his return from the
Is the obstruction of the
Pulmonary OR, Mr. Smith complained of severe
PE pulmonary artery by a blood
embolism SOB and dyspnea. He said he felt he
clot or thrombus
was dying. We suspected a PE.
Cessation of breathing
Mr. Miller is obese and has chronic
Obstructive during sleep caused by
OSA fatigue. He has been diagnosed with
sleep apnea repetitive upper airway
obstructive sleep apnea.
obstruction
My patient was being treated for
Acute A life threatening syndrome pneumonia when her condition
respiratory of lung inflammation suddenly worsened. Within 4 hours
ARDS
distress generally caused by she developed SOB and confusion.
syndrome infection or trauma ARDS was diagnosed and she was
transferred to the ICU.
Gastrointestinal System
Abbreviation
Term Definition Example
(written)
The backward flowing of gastric
This patient has classic
contents from the stomach into the
GERD; he has heartburn
Gastroesophageal esophagus. Symptoms are
GERD after meals, especially if
Reflux Disease epigastric burning sensation
he lies down to rest after
(heartburn) and acidic
a meal.
regurgitation.
A digestion problem affecting the Mr. Simpson, a 30 young
large intestine (colon). Symptoms man, with IBS is
Irritable bowel are abdominal pain, bloating gas experiencing abdominal
IBS
syndrome (flatus), stomach cramps and cramping and disabling
alternating bouts of diarrhea and diarrhea that interfere
constipation with his work.

Genitourinary System
Abbreviation
Term Definition Example
(written)
Slow progressive loss of
Written nursing note: Long term
Chronic kidney kidney or renal function
CKD CKD. Being considered for
disease most often associated with
transplantation of a kidney
HTN or diabetes
 End stage
Untreated chronic kidney disease
ESRD -or- renal disease - The final stage of CKD,
can result in end stage renal
ESRF or- End stage also called renal failure
disease.
renal failure
Benign Enlargement of the Mr. Lee suffers from difficulty
BPH prostatic prostate gland common in urination (dysuria) because of his
hyperplasia older men BPH disease.
My patient complained of frequency
An infection of one or more
Urinary tract and difficulty for urination. We did
UTI structures in the urinary
infection some simple tests and confirmed
system
that she had a UTI.

Endocrine System
Abbreviation
Term Definition Example
(written)
A group of metabolic diseases characterized by Mr. Simpson
Diabetes lack of effective processing of glucose and needs to inject
DM
mellitus consequent development of elevated blood insulin for his DM
glucose levels disease.
Insulin
dependent
IDDM
diabetes
mellitus
General
Abbreviation
Term Definition Example
(written)
Uncontrolled growth of CA can affect any body tissue
abnormal cells in various when normal cells mutate,
CA Cancer
organs or the body. Formal becoming abnormal and
name carcinoma having uncontrolled growth.
Disease characterized by The patient said that he had
progressive deterioration of an HIV test a year ago and it
Human
the immune system and was negative. He knew he
Immunodeficiency
occurrence of opportunistic had a possible exposure
HIV/AIDS Virus / Acquired
infections and cancers. when he learned that a
Immunodeficiency
Contracted from transfer of former lover he was with six
Syndrome
blood, semen, vaginal fluid, months ago was recently
pre-ejaculate or breast milk. diagnosed with AIDS.
The patient suffered a GSW
A form of physical trauma
to the chest. Bring me a
GSW Gunshot wound from the discharge of a type of
thoracotomy or chest tube
ammunition
tray.
A collision of two or more MVA’s are a major cause of
Motor vehicle
MVA motor vehicles resulting in morbidity in industrialized
accident
personal injuries or death. countries.