Medical Terminology Information Sheet:

Medical Chart Organization: • Demographics and insurance • Flow sheets • Orders Terms: • Visit notes • CC of • Laboratory results • HPI History of Present Illness • results • ROS • Consultant notes • PMHx • Other communications • PSHx Past Surgical History • SHx & FHx Social & Family History Types of Patient Encounter Notes: • and • History and Physical • NKDA = no known allergies o PE Physical Exam o Lab Laboratory Studies Terms: o Radiology • PE= Physical Exam y x-rays • (+) = present y CT and MRI scans • (-) = Ф = negative or absent y • nl = normal o Assessment- Dx (diagnosis) or • wnl = within normal limits DDx () if diagnosis is unclear o R/O = rule out (if diagnosis is Laboratory Terminology: unclear) • CBC = complete 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 = function tests o O = Objective (info from PE, • ABG = arterial blood gas labs, radiology) • UA = analysis o A = Assessment (Dx and DDx) • HbA1C= blood test o P = Plan (treatment, further tests, etc.) • Discharge Summary o Narrative in format o Summarizes the events of a stay o Subjective terminology is used in the history section (CC, HPI, etc.) o Physical examination terminology


Medical Terms by Body System

HEENT – Head, , , & : • BRBPR – Bright Red Blood per • Occipital – back of the head Rectum • Photophobia – intolerant of – tarry black stool • Phonophobia – intolerant of sounds • BS = bowel sounds – normoactive, • Diplopia – double vision hyperactive, hypoactive, absent • Epistaxis– • TTP = tender to , • – runny nose or nasal often in a single quadrant/area discharge • Guarding = involuntary or voluntary • Otorrhea – discharge from the 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 deposited on any tissue Musculoskeletal & Extremities: • Purulent = consisting of pus • Musculoskeletal (MS) • Injected = blood vessel congestion, • Extremities (Ext) such as red • Myalgias = Muscle Aches • Arthralgias = Aches Coronary & Pulmonary: • Edema = swelling • Cor – Coronary (the ) Peripheral • Pulm – Pulmonary Pulmonary (respiratory/ system) • CTAB no rrw = are “Clear to : bilaterally, no rales, rhonchi or • Dermatologic (Derm) ” • Pruritic and non-pruritic = itchy and • SOB = Dyspnea non-itchy • Productive = producing • Spot • = 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 • = rapid breathing • Plaque – raised area Breathing sounds: • Sacs • Rales = = 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 – Other: • NBNB = non-bloody, non-bilious • Neurologic (Neuro) • Hematemesis = bloody emesis • Paresthesias = tingling sensation • Hematochezia – bloody stool


Common Medical Abbreviations

O2 cal calorie (R) refused cap. capsule A before (ante) card. computerized axial a fib. atrial fibrillation a. tach. atrial tachycardia (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 chol. cholesteral Aa of each CL chloride AA Alcoholics Anonymous clav. Ab cm centimeter Abd abdomen CNS ABG arterial blood gases CO2 carbon dioxide ABP arterial 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 COPD chronic obstructive pulmonary 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 - Phenacetin - Caffeine CVA cerebrovascular accident () approx. approximately appt. appointment D & C dilatation & curettage aq. (aqueous) D.C. Doctor of . 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 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 dr dram Ca. or Calc. calcium Dr. doctor CABG coronary artery bypass & graft DS discharge summary


DTR's deep tendon reflexes hr hour DT's delerium tremens HS hour of 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 Fl fluids K+ ft. kg kilogram FUO fever of unknown origin KUB kidneys, , 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 laparotomy or laporoscopy gluc glucose lat lateral Gp group lb pound gr. grain lower extremities or LE grav. gravid Erythematosus GSW gun shot wound Leuc leucocytes GTT glucose toloerance test Lg large or leg gtt. drop lig Gtts. drops liq liquid GU genitourinary LLQ lower left quadrant Gyn gynecology LOA leave of absence H hour LP H20 water LUQ Left upper quadrant H202 hydrogen peroxide lymphs Lymphocytes HA M.D. Physician Hb husband multiple sclerosis, m.s. Hbg hemoglobin morphine sulphate Hct hematocrit M.T. movement therapy max maximum HCVD hypertensive 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 meds


mEq/1 milliequivalent per liter Ph.D Doctor of philosophy Mg milligram phys physical PM afternoon MI myocardial infarction (heart attack) PN Mm millimeter pneu Mo mother pos positive MR mental retardation post posterior MR# number postop postoperative, after NA not available PPD purified 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 norm normal pt patient NPN non-protein nitrogen pvc preventricular contraction NPO nothing by pwd powder nullip nulleparous (no ) q every o.d. once a day q.__h every ___ hour O.T. q.d. every day OB q.h. every hour OBS organic 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 & 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 red blood count PA postero-anterior rbc Red blood cells palp palpated rect rectal PBI protein bound iodine Rh rhesus blood factor Pc after meals RLQ right lower quadrant Pdr powder ROS review of systems Ped RR Pen penicillin RUQ right upper quadrant Per by Rx prescription, take pupils equal reactive to light s without PERLA and accomodation S.H. state hospital S/A sugar and acetone pH measure of acidity or alkalinity Sa saline


Schiz. schizophrenia U.O. urinary output u/o under observation Sed rate erythrocycte sedimentation rate UA urinanalysis serol serology UGI upper gastrointestinal series (X-ray) SGOT glutomie oxalacetic transaminase UNK unknown URI upper respiratory SGPT serum glutamic pyruvic transaminase UTI urinary tract infection Sibs siblings v. fib. ventricular fibrillation SIDS sudden infant death syndrome v. tach. ventricular tachycardia Sig to write , to take V.O. verbal order Sl slight Vag vaginal subjective, objective, assessment, VC vital capacity SOAPE plan, evaluation VD veneral disease SOB shortness of breath VDRL Serological test for syphilis Soc. hx social history vit. Soc. Ser. social service vol volume Sol solution VS Sos when necessary WBC white blood count Sp spine wbc white blood sp. cd. wd well developed sp. fl. spinal fluid wf wife sp. gr. specific gravity wk week Spec. specimen wn well nourished SQ subcutaneous WNL within normal limits Staph staphylococcus wt. weight Stat immediately x times Strep streptococcus x-ray radiology subcut subcutaneous y/o year old Sup superior yrs years Surg surgery Sx symptoms Sys system T & A tonsillectomy and adenoidectomy T.A. therapeutic assignment t.i.d. three times a day T.O. telephone order Tab tablet TB Tbsp. tablespoon temp. thor thromb TLC tender loving care TM tympanic membrane (eardrum) TP treatment plan TPR temperature, , respiration tsp. teaspoon Tx treatment