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Medical Terminology Information Sheet

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Medical Terminology Information Sheet Medical Terminology Information Sheet: Medical Chart Organization: • Demographics and insurance • Flow sheets • Physician Orders Medical History Terms: • Visit notes • CC Chief Complaint of Patient • Laboratory results • HPI History of Present Illness • Radiology results • ROS Review of Systems • Consultant notes • PMHx Past Medical History • Other communications • PSHx Past Surgical History • SHx & FHx Social & Family History Types of Patient Encounter Notes: • Medications and medication allergies • History and Physical • NKDA = no known drug allergies o PE Physical Exam o Lab Laboratory Studies Physical Examination Terms: o Radiology • PE= Physical Exam y x-rays • (+) = present y CT and MRI scans • (-) = Ф = negative or absent y ultrasounds • nl = normal o Assessment- Dx (diagnosis) or • wnl = within normal limits DDx (differential diagnosis) if diagnosis is unclear o R/O = rule out (if diagnosis is Laboratory Terminology: unclear) • CBC = complete blood count o Plan- Further tests, • Chem 7 (or Chem 8, 14, 20) = consultations, treatment, chemistry panels of 7,8,14,or 20 recommendations chemistry tests • The “SOAP” Note • BMP = basic Metabolic Panel o S = Subjective (what the • CMP = complete Metabolic Panel patient tells you) • LFTs = liver function tests o O = Objective (info from PE, • ABG = arterial blood gas labs, radiology) • UA = urine analysis o A = Assessment (Dx and DDx) • HbA1C= diabetes blood test o P = Plan (treatment, further tests, etc.) • Discharge Summary o Narrative in format o Summarizes the events of a hospital stay o Subjective terminology is used in the history section (CC, HPI, etc.) o Physical examination terminology 1 Medical Terms by Body System HEENT – Head, Ears, Eyes, Nose & Throat: • BRBPR – Bright Red Blood per • Occipital – back of the head Rectum • Photophobia – intolerant of light • Melena – tarry black stool • Phonophobia – intolerant of sounds • BS = bowel sounds – normoactive, • Diplopia – double vision hyperactive, hypoactive, absent • Epistaxis– nosebleed • TTP = Abdomen tender to palpation, • Rhinorrhea – runny nose or nasal often in a single quadrant/area discharge • Guarding = involuntary or voluntary • Otorrhea – discharge from the ear guarding of painful area. • Tinnitus – ringing noise in the ear • Rebound pain = worse pain as • NCAT = normocephalic, atraumatic examining hand is quickly pulled away • PERRL = Pupils Equal Round and Reactive to Light Genitourinary (GU): • Erythema = redness • GenitoUrinary (GU) • Exudate (tonsilar) = most commonly • Dysuria = painful urination white spots on the tonsils, but can be • Hematuria = blood in the urine any fluid or cellular matter deposited on any tissue Musculoskeletal & Extremities: • Purulent = consisting of pus • Musculoskeletal (MS) • Injected = blood vessel congestion, • Extremities (Ext) such as red eye • Myalgias = Muscle Aches • Arthralgias = Joint Aches Coronary & Pulmonary: • Edema = swelling • Cor – Coronary (the heart) Peripheral • Pulm – Pulmonary Pulmonary (respiratory/breathing system) • CTAB no rrw = Lungs are “Clear to Skin: auscultation bilaterally, no rales, rhonchi or • Dermatologic (Derm) wheezes” • Pruritic and non-pruritic = itchy and • SOB Shortness of Breath = Dyspnea non-itchy • Productive cough = phlegm producing • Spot • Hemoptysis = coughing up blood Macule - flat discoloration <10mm in • Pleuritic = worse with deep diameter inspiration/breathing • Bumps • Retractions = visible skin retractions Papule – bump 5mm or less with inspiration Nodule – well defined bump > 5mm • Tachypnea = rapid breathing • Plaque – raised area Breathing sounds: • Sacs • Rales = crackles = crackling sounds Vesicle – fluid filled sac <5mm like velcro being pulled Bulla – fluid filled sac >5mm • Rhonchi = wheezes = whistling sounds Pustule – sac filled with pus • Wheezing = high pitched sounds • Erosion – superficial loss of skin • Ulcer – deeper loss of skin Abdomen (Abd) or Gastrointestinal (GI): • Scale – dry, flaky areas of skin • Anorexia – loss or lack of appetite • Erythema – redness • Post-prandial – after eating • Emesis – vomiting Other: • NBNB = non-bloody, non-bilious • Neurologic (Neuro) • Hematemesis = bloody emesis • Paresthesias = tingling sensation • Hematochezia – bloody stool 2 Common Medical Abbreviations O2 oxygen cal calorie (R) refused cap. capsule A before (ante) card. computerized axial tomography a fib. atrial fibrillation a. tach. atrial tachycardia CAT (CT scan) complete blood count a.c. or a/c before meals A.D.L. Activities of Daily Living CC chief complaint A.S.A.P. as soon as possible cc cubic centimeter A.T. Activity Therapy chol. cholesteral Aa of each CL chloride AA Alcoholics Anonymous clav. clavicle Ab abortion cm centimeter Abd abdomen CNS central nervous system ABG arterial blood gases CO2 carbon dioxide ABP arterial blood pressure comf comfortable AD Right ear conc concentrate ad lib As desired cons consultation ADA American Diabetic Association cont continued Adm. admitted (admission) contrib contributary Alc alcohol COPD chronic obstructive pulmonary disease Alt alternate AM morning COR 0 acute heart stoppage AMA against medical advise cpd compound amb ambulatory CPR cardio-pulmonary resuscitation Amt amount angio angiogram cran cranial Ant anterior CSF cerebral spinal fluid APC Aspirin - Phenacetin - Caffeine CVA cerebrovascular accident (stroke) approx. approximately appt. appointment D & C dilatation & curettage aq. water (aqueous) D.C. Doctor of Chiropractic art. artery D.O. Doctor of Osteopathy as tol as tollerated D/C discharge ASA acetylsalicylic acid (aspirin) d/c discontinue AWOL absent without leave D5W dextrose 5% in water Ax axilla DD date dictated b.i.d. (BID) twice a day decr decreased B/P blood pressure defib defibrillation BE barium enema depr depressed blad bladder Diff differential BM bowel movement dil Dilute BUN blood urea nitrogen dis disease Bx behavior dist distal C centigrade dk drunk C with dl deciliters C.S. central service DOA dead on arrival c/o complains of DOB date of birth Ca cancer dr dram Ca. or Calc. calcium Dr. doctor CABG coronary artery bypass & graft DS discharge summary 3 DTR's deep tendon reflexes hr hour DT's delerium tremens HS hour of sleep Dx diagnosis ht height ECT electroconvulsive therapy hx history EEG electroencephalogram hyst hysterectomy EENT eyes, ears, nose & throat I & D Incision and drained EKG electrocardiogram I & O intake and output Elev elevate I.C. initial contact ENT ears, nose & throat id in diem (during the day) IM intramuscular EOM Extraoccular muscles (movements) inj injured ER emergency room inpt. inpatient EST electric shock treatment int internal EtOH alcohol IPPB intermittent positive pressure breathing etx. external extr extremeties irreg irregular f/u Follow up irrig irrigate Fa Father IV intravenous FBS fasting blood sugar IVP intravenous pyelogram Fl fluids K+ potassium ft. foot kg kilogram FUO fever of unknown origin KUB kidneys, ureters, and bladder Fx fracture L Left g or gm gm L & A light and accomodation GB gall bladder L.P.N. licensed practical nurse Gen general lab laboratory genit genitalia lac laceration GI gastrointestinal lap laparotomy or laporoscopy gluc glucose lat lateral Gp group lb pound gr. grain lower extremities or Lupus LE grav. gravid Erythematosus GSW gun shot wound Leuc leucocytes GTT glucose toloerance test Lg large or leg gtt. drop lig ligament Gtts. drops liq liquid GU genitourinary LLQ lower left quadrant Gyn gynecology LOA leave of absence H hour LP Lumbar puncture H20 water LUQ Left upper quadrant H202 hydrogen peroxide lymphs Lymphocytes HA headache M.D. Physician Hb husband multiple sclerosis, m.s. Hbg hemoglobin morphine sulphate Hct hematocrit M.T. movement therapy max maximum HCVD hypertensive cardiovascular disease MCH mean corpuscular hemoglobin Hd. head mean corpuscular hemoglobin MCHC concentration HEENT head, eyes, ears, nose and throat MCV mean corpuscular volume hern herniated med medical, medid HR heart rate meds medicines 4 mEq/1 milliequivalent per liter Ph.D Doctor of philosophy Mg milligram phys physical PM afternoon MI myocardial infarction (heart attack) PN progress note Mm millimeter pneu pneumonia Mo mother pos positive MR mental retardation post posterior MR# medical record number postop postoperative, after surgery NA not available PPD purified protein derivative Na+ no applicable preop preoperative, before surgery NBS no bowel sounds prep prepare for Neg negative prev previous Ng naso-gastric prn whenever necessary NKA no known allergies pros prostate NMR nuclear magnetic resonance prox proximal No. number Psy. Ser. psychological services Noct night PT physical therapy norm normal pt patient NPN non-protein nitrogen pvc preventricular contraction NPO nothing by mouth pwd powder nullip nulleparous (no pregnancies) q every o.d. once a day q.__h every ___ hour O.T. occupational therapy q.d. every day OB obstetrics q.h. every hour OBS organic brain syndrome q.i.d. Four times a day OD Right eye q.n. every night Od over dose q.o.d. every other day Opd out-patient department QA quality assurance Ops operations QAC quality Assurance Coordinator OR operating room QAP quality Assurance Program Orth orthopedic QAR quality Assurance Review OS Left eye qns quantity not sufficient OU Both eyes R right outpt outpatient R.D. registered dietician Oz ounce R.N. registered nurse P after R.O. reality orientation P & A percussion & auscultation R.T.P. recreational Therapeutic Pass P.E. physical examination R/O rule out P.I.D. pelvic inflammatory disease rad radial p.o. by mouth RBC
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