Medterm - a list of medical terminology that can be used for studying PDF

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a list of medical terminology that can be used for studying...

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Medical Terminology Information Sheet: Medical Chart Organization: • Demographics and insurance • Flow sheets • Physician Orders • Visit notes • Laboratory results • Radiology results • Consultant notes • Other communications Types of Patient Encounter Notes: • History and Physical o PE Physical Exam o Lab Laboratory Studies o Radiology y x-rays y CT and MRI scans y ultrasounds o AssessmentDx (diagnosis) or DDx (differential diagnosis) if diagnosis is unclear o R/O = rule out (if diagnosis is unclear) o Plan- Further tests, consultations, treatment, recommendations • The “SOAP” Note o S = Subjective (what the patient tells you) o O = Objective (info from PE, labs, radiology) o A = Assessment (Dx and DDx) 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 Medical History Terms: • CC Chief Complaint of Patient • HPI History of Present Illness • ROS Review of Systems • PMHx Past Medical History • PSHx Past Surgical History • SHx & FHx Social & Family History • Medications and medication allergies • NKDA = no known drug allergies Physical Examination Terms: • PE= Physical Exam • (+) = present • (-) = Ф = negative or absent • nl = normal • wnl = within normal limits Laboratory Terminology: • CBC = complete blood count • Chem 7 (or Chem 8, 14, 20) = chemistry panels of 7,8,14,or 20 chemistry tests • BMP = basic Metabolic Panel • CMP = complete Metabolic Panel • LFTs = liver function tests • ABG = arterial blood gas • UA = urine analysis • HbA1C= diabetes blood test 1 Medical Terms by Body System HEENT – Head, Ears, Eyes, Nose & Throat: • Occipital – back of the head • Photophobia – intolerant of light • Phonophobia – intolerant of sounds • Diplopia – double vision • Epistaxis– nosebleed • Rhinorrhea – runny nose or nasal discharge • Otorrhea – discharge from the ear • Tinnitus – ringing noise in the ear • NCAT = normocephalic, atraumatic • PERRL = Pupils Equal Round and Reactive to Light • Erythema = redness • Exudate (tonsilar) = most commonly white spots on the tonsils, but can be any fluid or cellular matter deposited on any tissue • Purulent = consisting of pus • Injected = blood vessel congestion, such as red eye Coronary & Pulmonary: • Cor – Coronary (the heart) • Pulm – Pulmonary (respiratory/breathing system) • CTAB no rrw = Lungs are “Clear to auscultation bilaterally, no rales, rhonchi or wheezes” • SOB Shortness of Breath = Dyspnea • Productive cough = phlegm producing • Hemoptysis = coughing up blood • Pleuritic = worse with deep inspiration/breathing • Retractions = visible skin retractions with inspiration • Tachypnea = rapid breathing Breathing sounds: • Rales = crackles = crackling sounds like velcro being pulled • Rhonchi = wheezes = whistling sounds • Wheezing = high pitched sounds Abdomen (Abd) or Gastrointestinal (GI): • Anorexia – loss or lack of appetite • Post-prandial – after eating • Emesis – vomiting • NBNB = non-bloody, non-bilious • Hematemesis = bloody emesis • Hematochezia – bloody stool • BRBPR – Bright Red Blood per Rectum • Melena – tarry black stool • BS = bowel sounds – normoactive, hyperactive, hypoactive, absent • TTP = Abdomen tender to palpation, often in a single quadrant/area • Guarding = involuntary or voluntary guarding of painful area. • Rebound pain = worse pain as examining hand is quickly pulled away Genitourinary (GU): • GenitoUrinary (GU) • Dysuria = painful urination • Hematuria = blood in the urine Musculoskeletal & Extremities: • Musculoskeletal (MS) • Extremities (Ext) • Myalgias = Muscle Aches • Arthralgias = Joint Aches • Edema = swelling Peripheral Pulmonary Skin: • Dermatologic (Derm) • Pruritic and nonpruritic = itchy and non-itchy • Spot Macule - flat discoloration 5mm • Plaque – raised area • Sacs Vesicle – fluid filled sac 5mm Pustule – sac filled with pus • Erosion – superficial loss of skin • Ulcer – deeper loss of skin • Scale – dry, flaky areas of skin • Erythema – redness Other: • Neurologic (Neuro) • Paresthesias = tingling sensation 2 Common Medical Abbreviations O2 oxygen (R) refused A before (ante) a fib. atrial fibrillation a. tach. atrial tachycardia a.c. or a/c before meals A.D.L. Activities of Daily Living A.S.A.P. as soon as possible A.T. Activity Therapy Aa of each AA Alcoholics Anonymous Ab abortion Abd abdomen ABG arterial blood gases ABP arterial blood pressure AD Right ear ad lib As desired ADA American Diabetic Association Adm. admitted (admission) Alc alcohol Alt alternate AM morning AMA against medical advise amb ambulatory Amt amount angio

angiogram Ant anterior APC Aspirin - Phenacetin - Caffeine approx. approximately appt. appointment aq. water (aqueous) art. artery as tol as tollerated ASA acetylsalicylic acid (aspirin) AWOL absent without leave Ax axilla b.i.d. (BID) twice a day B/P blood pressure BE barium enema blad bladder BM bowel movement BUN blood urea nitrogen Bx behavior C centigrade C with C.S. central service c/o complains of Ca cancer Ca. or Calc. calcium CABG coronary artery bypass & graft cal calorie cap. capsule card. computerized axial tomography CAT (CT scan) complete blood count CC chief complaint cc cubic centimeter chol. cholesteral CL chloride clav. clavicle cm centimeter CNS central nervous system CO2 carbon dioxide comf comfortable conc concentrate cons consultation cont continued contrib contributary COPD chronic obstructive pulmonary disease COR 0 acute heart stoppage cpd compound CPR cardio-pulmonary resuscitation cran cranial CSF cerebral spinal fluid CVA cerebrovascular accident (stroke) D & C dilatation & curettage D.C. Doctor of Chiropractic D.O. Doctor of Osteopathy D/C discharge d/c discontinue D5W dextrose 5% in water DD date dictated decr decreased defib defibrillation depr depressed Diff differential dil Dilute dis disease dist distal dk drunk dl deciliters DOA dead on arrival DOB date of birth dr dram Dr. doctor DS discharge summary 3 DTR's deep tendon reflexes DT's delerium tremens Dx diagnosis ECT electroconvulsive therapy EEG electroencephalogram EENT eyes, ears, nose & throat EKG electrocardiogram Elev elevate ENT ears, nose & throat EOM Extraoccular muscles (movements) ER emergency room EST electric shock treatment EtOH alcohol etx. external extr extremeties f/u Follow up Fa Father FBS fasting blood sugar Fl fluids ft. foot FUO fever of unknown origin Fx fracture g or gm gm GB gall bladder Gen general genit genitalia GI gastrointestinal gluc glucose Gp group gr. grain grav. gravid GSW gun shot wound GTT glucose toloerance test gtt. drop Gtts. drops GU genitourinary Gyn gynecology H hour H20 water H202 hydrogen peroxide HA headache Hb husband Hbg hemoglobin Hct hematocrit HCVD hypertensive cardiovascular disease Hd. head HEENT head, eyes, ears, nose and throat hern herniated HR heart rate hr hour HS hour of sleep ht height hx history hyst hysterectomy I & D Incision and drained I & O intake and output I.C. initial contact id in diem (during the day) IM intramuscular inj injured inpt. inpatient int internal IPPB intermittent positive pressure breathing irreg irregular irrig irrigate IV intravenous IVP intravenous pyelogram K+ potassium kg kilogram KUB kidneys, ureters, and bladder L Left L & A light and accomodation L.P.N. licensed practical nurse lab laboratory lac laceration lap laparotomy or laporoscopy lat lateral lb pound LE lower extremities or Lupus Erythematosus Leuc leucocytes Lg large or leg lig ligament liq liquid LLQ lower left quadrant LOA leave of absence LP Lumbar puncture LUQ Left upper quadrant lymphs Lymphocytes M.D. Physician m.s. multiple sclerosis, morphine sulphate M.T. movement therapy max maximum MCH mean corpuscular hemoglobin MCHC mean corpuscular hemoglobin concentration MCV mean corpuscular volume med medical, medid meds medicines 4 mEq/1 milliequivalent per liter Mg milligram MI myocardial infarction (heart attack) Mm millimeter Mo mother MR mental retardation MR# medical record number NA not available Na+ no applicable NBS no bowel sounds Neg negative Ng nasogastric NKA no known allergies NMR nuclear magnetic resonance No. number Noct night norm normal NPN non-protein nitrogen NPO nothing by mouth nullip nulleparous (no pregnancies) o.d. once a day O.T. occupational therapy OB obstetrics OBS organic brain syndrome OD Right eye Od over dose Opd out-patient department Ops operations OR operating room Orth orthopedic OS Left eye OU Both eyes outpt outpatient Oz ounce P after P & A percussion & auscultation P.E. physical examination P.I.D. pelvic inflammatory disease p.o. by mouth PA postero-anterior palp palpated PBI protein bound iodine Pc after meals Pdr powder Ped pediatrics Pen penicillin Per by PERLA pupils equal reactive to light and accomodation pH measure of acidity or alkalinity Ph.D Doctor of philosophy phys physical PM afternoon PN progress note pneu pneumonia pos positive post posterior postop postoperative, after surgery PPD purified protein derivative preop preoperative, before surgery prep prepare for prev previous prn whenever necessary pros prostate prox proximal Psy. Ser. psychological services PT physical therapy pt patient pvc preventricular contraction pwd

powder q every q.__h every ___ hour q.d. every day q.h. every hour q.i.d. Four times a day q.n. every night q.o.d. every other day QA quality assurance QAC quality Assurance Coordinator QAP quality Assurance Program QAR quality Assurance Review qns quantity not sufficient R right R.D. registered dietician R.N. registered nurse R.O. reality orientation R.T.P. recreational Therapeutic Pass R/O rule out rad radial RBC red blood count rbc Red blood cells rect rectal Rh rhesus blood factor RLQ right lower quadrant ROS review of systems RR respiratory rate RUQ right upper quadrant Rx prescription, take s without S.H. state hospital S/A sugar and acetone Sa saline 5 Schiz. schizophrenia Sed rate erythrocycte sedimentation rate serol serology SGOT serum glutomie oxalacetic transaminase SGPT serum glutamic pyruvic transaminase Sibs siblings SIDS sudden infant death syndrome Sig to write , to take Sl slight SOAPE subjective, objective, assessment, plan, evaluation SOB shortness of breath Soc. hx social history Soc. Ser. social service Sol solution Sos when necessary Sp spine sp. cd. spinal cord sp. fl. spinal fluid sp. gr. specific gravity Spec. specimen SQ subcutaneous Staph staphylococcus Stat immediately Strep streptococcus subcut subcutaneous Sup superior 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 tuberculosis Tbsp. tablespoon temp. temperature thor thorax thromb thrombosis TLC tender loving care TM tympanic membrane (eardrum) TP treatment plan TPR temperature, pulse, respiration tsp. teaspoon Tx treatment U.O. urinary output u/o under observation UA urinanalysis UGI upper gastrointestinal series (X-ray) UNK unknown URI upper respiratory infection UTI urinary tract infection v. fib. ventricular fibrillation v. tach. ventricular tachycardia V.O. verbal order Vag vaginal VC vital capacity VD veneral disease VDRL Serological test for syphilis vit. vitamin vol volume VS vital signs WBC white blood count wbc white blood cell wd well developed wf wife wk week wn well nourished WNL within normal limits wt. weight x times x-ray radiology y/o year old yrs years...