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