Medical abbreviations in criminal law

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Doogue + GeorgeThe article Medical abbreviations in criminal law is written by Doogue + George Defence Lawyers.

Doogue + George are experts in criminal law and have been involved in thousands of criminal matters and defended clients in hundreds of jury trials and thousands of other criminal cases. Our experienced lawyers have unparalleled experience in criminal law.

Brain ScansIt’s so common… that thing that starts from when you are an embryo. The interchangeable requisite that our elders hold in their hearts that after being born healthy, their offspring will forge their way in the world and become either a) a doctor or b) a lawyer.

So trite, but so true. You know it, I know it. Those two professions hold this unyielding clout that impress simply by reputation. At very opposite ends of the vocational spectrum there is not much else that bonds these disciplines. They are simply put in that box together.

Then again, as a lawyer, there are times when reading client files and reports requires you to have all of this medical knowledge tucked away in that (ostensibly gifted) brain to decipher abbreviations and jargon.
For anyone in the field of criminal law who a) determined their vocational path in less steps than I did or b) has no desire to empty a bed-pan, I have compiled for you a ready-reckoner of medical terms that might help you all when you are deciphering those pesky medical reports and hospital files.

I hope that this helps, whether you are a student of law or one of medicine who is required to know all this but have just forgotten.

# Denotes a bone fracture, e.g., # femur, # rib
Y Denotes psychological/psychiatric (e.g., R/V by Y = reviewed by psych unit)
AB Antibiotic(s)
ABG, ABGs Arterial Blood Gases – indicator of oxygen uptake and exchange in the body
AE L=R Air entry (to lungs) is the same on both sides, indicating normality
AKA Above Knee Amputation
BD Twice daily
BKA Below Knee Amputation
BM Bowel Motion/Movement
BP Blood Pressure
BS PRESENT Bowel sounds present – indicates (usually) a functioning intestinal tract
BSL Blood Sugar Level – indicative of pancreatic function (important for diabetics)
Ca Cancer
CHF, CCF Congestive Heart Failure, Congestive Cardiac Failure – the inability of the heart to supply sufficient blood flow to meet the needs of the body
CHI Closed Head Injury – a traumatic head injury in which the skull remains intact
CT/CAT Computerised (Axial) Tomography – scans of internal organs, bones, soft tissue and blood vessels that provide greater clarity and reveal more details than regular X-ray
CTSP, ATSP Called To See Patient, Asked To See Patient – written by a doctor or allied health professional when asked to medically review a patient (usually by a nurse or other medical professional)
CXR Chest X-ray – used to diagnose many conditions involving the chest wall, bones of the thorax, and structures contained within the thoracic cavity including the lungs, heart
H1, H2 Presence of normal heart sounds
Hb Haemoglobin – portion of red blood cells that carries oxygen; level is indicative of loss of blood
HR Heart Rate
Hx History
IA, I/A Intra-arterial – denotes the administration of drugs or the insertion of medical devices via this route (i.e., into an artery)
ICC Intercostal Catheter – a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural effusion, blood), or pus (empyema) from the intrathoracic space
IDC Indwelling catheter, used to drain urine directly from the bladder
IM Intramuscular – denotes the administration of drugs via this route (i.e., into a muscle)
IV, I/V Intravenous – denotes (usually) the administration of drugs or fluids via this route (i.e., into a vein)
IVT Intravenous Therapy (usually administration of IV fluids)
LFTs Liver Function Tests – indicative of liver function
LOC Loss of Consciousness
LRTI Lower Respiratory Tract Infection (more serious than URTI)
MANE In the morning
MRI Magnetic Resonance Imaging – provides good contrast between the different soft tissues of the body, which makes it especially useful in imaging the brain, muscles, the heart, and cancers compared with other medical imaging techniques such as computed tomography (CT) or X-rays
MVA, MCA Motor Vehicle Accident, Motor Car Accident
NAD No Abnormalities Detected
NBM Nil By Mouth – patient is/was not allowed to take food/fluid orally
NGT Nasogastric Tube, used to deliver nutritional supplements via a tube from nose to stomach
NKA Nil Known Allergies (to medications usually)
NOCTE At night
NSAIDs Non-Steroidal Anti-Inflammatory Drugs
O/E On examination – e.g., “O/E AE L < R”
PEARL Pupils Equal And Reactive to Light – an indicator of brain function (unequal pupils and non-reactivity suggests brain injury)
PO Per oral (to be administered orally)
PR Per rectum (to be administered rectally)
PTA Post-Traumatic Amnesia – a state of confusion that occurs immediately following a traumatic brain injury (TBI) in which the injured person is disoriented and unable to remember events that occur after the injury
PV Per vagina (to be administered vaginally)
q 6/24 Every 6 hours (medical intervals are frequently expressed as a fraction of the whole, e.g., 6/12 = 6 months, 4/7 = 4 days)
QID Four times a day
R/V Review
RR Respiratory (breath) Rate
Rx Treatment
SAH Subarachnoid Haemorrhage – bleeding into the subarachnoid space between the arachnoid membrane and the pia mater surrounding the brain; this may occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head injury following trauma
SC, S/C Subcutaneous – denotes the administration of drugs or fluids via this route (i.e., under the surface of the skin)
SDH Subdural Haemorrhage/Haematoma – a type of haematoma (traumatic brain injury) where blood gathers within the outermost meningeal layer, between the dura mater, which adheres to the skull, and the arachnoid mater, which envelops the brain; usually resulting from tears in bridging veins which cross the subdural space, subdural hemorrhages may cause an increase in intracranial pressure(ICP), which can cause compression of and damage to brain tissue
SOB Short(ness) of breath
SOBOE Short(ness) of breath on exertion
T Temperature
TBI Traumatic Brain Injury – when an external force traumatically injures the brain; can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area); see also PTA
TDS Three times a day
U/A Urinalysis – an array of tests performed on urine, most commonly performed using a test strip to analyse for the presence of abnormal substances (e.g., blood) in the urine that are indicative of disease or injury to the urinary tract
URTI Upper Respiratory Tract Infection (less serious than LRTI; not to be confused with UTI)
US, U/S Ultrasound – exposes part of the body to high-frequency sound waves to produce pictures of the inside of the body (e.g., U/S bladder = ultrasound of bladder)
UTI Urinary Tract Infection

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Date Published: 19 April 2012

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