For illustrative purposes, below is an excerpt from a hypothetical patient chart note:
“58 yr old well-nourished male patient, very poor historian, impressive chest X-ray, a fib, occult blood in the urine, +BS, dizzy, +++ SOB needs CABG and F/U.”
It occurs to us that if this hypothetical patient were to read such a note, he might reasonably misinterpret it and take offense. So, let’s break it down and explain what each of these commonly used phrases means:
- Well-nourished means not malnourished. It does not mean fat.
- Poor historian means the patient cannot remember important details of his history. It does not mean that he was/is a poor student of history.
- Impressive chest X-ray means the X-ray is worrying not that it is good.
- Occult does not mean that the patient practices sorcery but that the problem, in this case blood in the urine, is present in tiny amounts and, therefore, undetectable by the naked eye.
- BS refers to bowel sounds not a patient who is full of it.
- Dizzy describes that the patient felt lightheaded not that he was/is scatterbrained.
- A fib describes an irregular heart rhythm, not a lie.
- +++ SOB means that the patient was extremely short of breath, not that he is a son of a you know what.
- Needs CABG refers not to cabbage the vegetable but to a coronary artery bypass graft.
- F/U stands for follow-up not a middle finger insult.
Be warned that ophthalmologists always use the abbreviation OD, which stands not for overdose but for “oculus dexter” or right eye. 👁️
If at this point you were to throw up your hands in frustration and declare that all this medical jargon is total BS 💩, we would perfectly understand what you mean, no translation necessary.