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Medical abbreviations in criminal law.

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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.

ABBREV.MEANING
#Denotes a bone fracture, e.g., # femur, # rib
YDenotes psychological/psychiatric (e.g., R/V by Y = reviewed by psych unit)
ABAntibiotic(s)
ABG, ABGsArterial Blood Gases – indicator of oxygen uptake and exchange in the body
AE L=RAir entry (to lungs) is the same on both sides, indicating normality
AKAAbove Knee Amputation
BDTwice daily
BKABelow Knee Amputation
BMBowel Motion/Movement
BPBlood Pressure
BS PRESENTBowel sounds present – indicates (usually) a functioning intestinal tract
BSLBlood Sugar Level – indicative of pancreatic function (important for diabetics)
CaCancer
CHF, CCFCongestive Heart Failure, Congestive Cardiac Failure – the inability of the heart to supply sufficient blood flow to meet the needs of the body
CHIClosed Head Injury – a traumatic head injury in which the skull remains intact
CT/CATComputerised (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, ATSPCalled 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)
CXRChest 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, H2Presence of normal heart sounds
HbHaemoglobin – portion of red blood cells that carries oxygen; level is indicative of loss of blood
HRHeart Rate
HxHistory
IA, I/AIntra-arterial – denotes the administration of drugs or the insertion of medical devices via this route (i.e., into an artery)
ICCIntercostal 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
IDCIndwelling catheter, used to drain urine directly from the bladder
IMIntramuscular – denotes the administration of drugs via this route (i.e., into a muscle)
IV, I/VIntravenous – denotes (usually) the administration of drugs or fluids via this route (i.e., into a vein)
IVTIntravenous Therapy (usually administration of IV fluids)
LFTsLiver Function Tests – indicative of liver function
LOCLoss of Consciousness
LRTILower Respiratory Tract Infection (more serious than URTI)
MANEIn the morning
MRIMagnetic 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, MCAMotor Vehicle Accident, Motor Car Accident
NADNo Abnormalities Detected
NBMNil By Mouth – patient is/was not allowed to take food/fluid orally
NGTNasogastric Tube, used to deliver nutritional supplements via a tube from nose to stomach
NKANil Known Allergies (to medications usually)
NOCTEAt night
NSAIDsNon-Steroidal Anti-Inflammatory Drugs
O/EOn examination – e.g., “O/E AE L < R”
PEARLPupils Equal And Reactive to Light – an indicator of brain function (unequal pupils and non-reactivity suggests brain injury)
POPer oral (to be administered orally)
PRPer rectum (to be administered rectally)
PTAPost-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
PVPer vagina (to be administered vaginally)
q 6/24Every 6 hours (medical intervals are frequently expressed as a fraction of the whole, e.g., 6/12 = 6 months, 4/7 = 4 days)
QIDFour times a day
R/VReview
RRRespiratory (breath) Rate
RxTreatment
SAHSubarachnoid 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/CSubcutaneous – denotes the administration of drugs or fluids via this route (i.e., under the surface of the skin)
SDHSubdural 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
SOBShort(ness) of breath
SOBOEShort(ness) of breath on exertion
TTemperature
TBITraumatic 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
TDSThree times a day
U/AUrinalysis – 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
URTIUpper Respiratory Tract Infection (less serious than LRTI; not to be confused with UTI)
US, U/SUltrasound – 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)
UTIUrinary Tract Infection

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