Medical Terminology Information Sheet:

Medical Terminology Information Sheet:
Medical Chart Organization:
• Demographics and insurance
• Flow sheets
• Physician Orders
• Visit notes
• Laboratory results
• Radiology results
• Consultant notes
• Other communications
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
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 Assessment- Dx (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
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
• 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
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
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
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
Skin:
•
•
•
•
•
•
Dermatologic (Derm)
Pruritic and non-pruritic = itchy and
non-itchy
Spot
Macule - flat discoloration <10mm in
diameter
Bumps
Papule – bump 5mm or less
Nodule – well defined bump > 5mm
Plaque – raised area
Sacs
Vesicle – fluid filled sac <5mm
Bulla – 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
•
•
Neurologic (Neuro)
Paresthesias = tingling sensation
•
•
•
•
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
Other:
2
Common Medical Abbreviations
O2
(R)
A
a fib.
a. tach.
a.c. or a/c
A.D.L.
A.S.A.P.
A.T.
Aa
AA
Ab
Abd
ABG
ABP
AD
ad lib
ADA
Adm.
Alc
Alt
AM
AMA
amb
Amt
angio
Ant
APC
approx.
appt.
aq.
art.
as tol
ASA
AWOL
Ax
b.i.d.
B/P
BE
blad
BM
BUN
Bx
C
C
C.S.
c/o
Ca
Ca. or Calc.
CABG
oxygen
refused
before (ante)
atrial fibrillation
atrial tachycardia
before meals
Activities of Daily Living
as soon as possible
Activity Therapy
of each
Alcoholics Anonymous
abortion
abdomen
arterial blood gases
arterial blood pressure
Right ear
As desired
American Diabetic Association
admitted (admission)
alcohol
alternate
morning
against medical advise
ambulatory
amount
angiogram
anterior
Aspirin - Phenacetin - Caffeine
approximately
appointment
water (aqueous)
artery
as tollerated
acetylsalicylic acid (aspirin)
absent without leave
axilla
(BID) twice a day
blood pressure
barium enema
bladder
bowel movement
blood urea nitrogen
behavior
centigrade
with
central service
complains of
cancer
calcium
coronary artery bypass & graft
3
cal
cap.
calorie
capsule
card.
computerized axial tomography
CAT
(CT scan) complete blood count
CC
cc
chol.
CL
clav.
cm
CNS
CO2
comf
conc
cons
cont
contrib
chief complaint
cubic centimeter
cholesteral
chloride
clavicle
centimeter
central nervous system
carbon dioxide
comfortable
concentrate
consultation
continued
contributary
COPD
chronic obstructive pulmonary disease
COR 0
cpd
acute heart stoppage
compound
CPR
cardio-pulmonary resuscitation
cran
CSF
cranial
cerebral spinal fluid
CVA
cerebrovascular accident (stroke)
D&C
D.C.
D.O.
D/C
d/c
D5W
DD
decr
defib
depr
Diff
dil
dis
dist
dk
dl
DOA
DOB
dr
Dr.
DS
dilatation & curettage
Doctor of Chiropractic
Doctor of Osteopathy
discharge
discontinue
dextrose 5% in water
date dictated
decreased
defibrillation
depressed
differential
Dilute
disease
distal
drunk
deciliters
dead on arrival
date of birth
dram
doctor
discharge summary
DTR's
DT's
Dx
ECT
EEG
EENT
EKG
Elev
ENT
deep tendon reflexes
delerium tremens
diagnosis
electroconvulsive therapy
electroencephalogram
eyes, ears, nose & throat
electrocardiogram
elevate
ears, nose & throat
EOM
Extraoccular muscles (movements)
ER
EST
EtOH
etx.
extr
f/u
Fa
FBS
Fl
ft.
FUO
Fx
g or gm
GB
Gen
genit
GI
gluc
Gp
gr.
grav.
GSW
GTT
gtt.
Gtts.
GU
Gyn
H
H20
H202
HA
Hb
Hbg
Hct
emergency room
electric shock treatment
alcohol
external
extremeties
Follow up
Father
fasting blood sugar
fluids
foot
fever of unknown origin
fracture
gm
gall bladder
general
genitalia
gastrointestinal
glucose
group
grain
gravid
gun shot wound
glucose toloerance test
drop
drops
genitourinary
gynecology
hour
water
hydrogen peroxide
headache
husband
hemoglobin
hematocrit
HCVD
hypertensive cardiovascular disease
Hd.
head
HEENT
head, eyes, ears, nose and throat
hern
HR
herniated
heart rate
hr
HS
ht
hx
hyst
I&D
I&O
I.C.
id
IM
inj
inpt.
int
hour
hour of sleep
height
history
hysterectomy
Incision and drained
intake and output
initial contact
in diem (during the day)
intramuscular
injured
inpatient
internal
IPPB
intermittent positive pressure breathing
irreg
irrig
IV
IVP
K+
kg
KUB
L
L&A
L.P.N.
lab
lac
lap
lat
lb
irregular
irrigate
intravenous
intravenous pyelogram
potassium
kilogram
kidneys, ureters, and bladder
Left
light and accomodation
licensed practical nurse
laboratory
laceration
laparotomy or laporoscopy
lateral
pound
lower extremities or Lupus
Erythematosus
leucocytes
large or leg
ligament
liquid
lower left quadrant
leave of absence
Lumbar puncture
Left upper quadrant
Lymphocytes
Physician
multiple sclerosis,
morphine sulphate
movement therapy
maximum
mean corpuscular hemoglobin
mean corpuscular hemoglobin
concentration
mean corpuscular volume
medical, medid
medicines
LE
Leuc
Lg
lig
liq
LLQ
LOA
LP
LUQ
lymphs
M.D.
m.s.
M.T.
max
MCH
MCHC
MCV
med
meds
4
mEq/1
Mg
milliequivalent per liter
milligram
MI
myocardial infarction (heart attack)
Mm
Mo
MR
MR#
NA
Na+
NBS
Neg
Ng
NKA
NMR
No.
Noct
norm
NPN
NPO
nullip
o.d.
O.T.
OB
OBS
OD
Od
Opd
Ops
OR
Orth
OS
OU
outpt
Oz
P
P&A
P.E.
P.I.D.
p.o.
PA
palp
PBI
Pc
Pdr
Ped
Pen
Per
millimeter
mother
mental retardation
medical record number
not available
no applicable
no bowel sounds
negative
naso-gastric
no known allergies
nuclear magnetic resonance
number
night
normal
non-protein nitrogen
nothing by mouth
nulleparous (no pregnancies)
once a day
occupational therapy
obstetrics
organic brain syndrome
Right eye
over dose
out-patient department
operations
operating room
orthopedic
Left eye
Both eyes
outpatient
ounce
after
percussion & auscultation
physical examination
pelvic inflammatory disease
by mouth
postero-anterior
palpated
protein bound iodine
after meals
powder
pediatrics
penicillin
by
pupils equal reactive to light
and accomodation
PERLA
pH
Ph.D
phys
PM
PN
pneu
pos
post
postop
PPD
preop
prep
prev
prn
pros
prox
Psy. Ser.
PT
pt
pvc
pwd
q
q.__h
q.d.
q.h.
q.i.d.
q.n.
q.o.d.
QA
QAC
QAP
QAR
qns
R
R.D.
R.N.
R.O.
R.T.P.
R/O
rad
RBC
rbc
rect
Rh
RLQ
ROS
RR
RUQ
Rx
s
S.H.
S/A
Sa
measure of acidity or alkalinity
5
Doctor of philosophy
physical
afternoon
progress note
pneumonia
positive
posterior
postoperative, after surgery
purified protein derivative
preoperative, before surgery
prepare for
previous
whenever necessary
prostate
proximal
psychological services
physical therapy
patient
preventricular contraction
powder
every
every ___ hour
every day
every hour
Four times a day
every night
every other day
quality assurance
quality Assurance Coordinator
quality Assurance Program
quality Assurance Review
quantity not sufficient
right
registered dietician
registered nurse
reality orientation
recreational Therapeutic Pass
rule out
radial
red blood count
Red blood cells
rectal
rhesus blood factor
right lower quadrant
review of systems
respiratory rate
right upper quadrant
prescription, take
without
state hospital
sugar and acetone
saline
Schiz.
schizophrenia
Sed rate
erythrocycte sedimentation rate
serol
serology
SGOT
serum glutomie oxalacetic transaminase
SGPT
serum glutamic pyruvic transaminase
Sibs
SIDS
Sig
Sl
SOB
Soc. hx
Soc. Ser.
Sol
Sos
Sp
sp. cd.
sp. fl.
sp. gr.
Spec.
SQ
Staph
Stat
Strep
subcut
Sup
Surg
Sx
Sys
siblings
sudden infant death syndrome
to write , to take
slight
subjective, objective, assessment,
plan, evaluation
shortness of breath
social history
social service
solution
when necessary
spine
spinal cord
spinal fluid
specific gravity
specimen
subcutaneous
staphylococcus
immediately
streptococcus
subcutaneous
superior
surgery
symptoms
system
T&A
tonsillectomy and adenoidectomy
T.A.
t.i.d.
T.O.
Tab
TB
Tbsp.
temp.
thor
thromb
TLC
therapeutic assignment
three times a day
telephone order
tablet
tuberculosis
tablespoon
temperature
thorax
thrombosis
tender loving care
TM
tympanic membrane (eardrum)
TP
treatment plan
TPR
temperature, pulse, respiration
tsp.
Tx
teaspoon
treatment
SOAPE
6
U.O.
u/o
UA
urinary output
under observation
urinanalysis
UGI
upper gastrointestinal series (X-ray)
UNK
URI
UTI
v. fib.
v. tach.
V.O.
Vag
VC
VD
VDRL
vit.
vol
VS
WBC
wbc
wd
wf
wk
wn
WNL
wt.
x
x-ray
y/o
yrs
unknown
upper respiratory infection
urinary tract infection
ventricular fibrillation
ventricular tachycardia
verbal order
vaginal
vital capacity
veneral disease
Serological test for syphilis
vitamin
volume
vital signs
white blood count
white blood cell
well developed
wife
week
well nourished
within normal limits
weight
times
radiology
year old
years
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