Transcription of Medical Terminology Information Sheet
1 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).
2 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.)
3 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).
4 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.
5 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.
6 Atrial fibrillation a. tach. atrial tachycardia CAT (CT scan) complete blood count or a/c before meals Activities of Daily Living CC chief complaint as soon as possible cc cubic centimeter 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).
7 Approx. approximately appt. appointment D&C dilatation & curettage aq. water (aqueous) Doctor of Chiropractic art. artery 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 (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 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.
8 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 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.
9 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 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 Physician Hb husband multiple sclerosis, Hbg hemoglobin morphine sulphate Hct hematocrit movement therapy max maximum HCVD hypertensive cardiovascular disease MCH mean corpuscular hemoglobin Hd.
10 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 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.
