Transcription
Medical Terminology Information Sheet:Medical Chart Organization: Demographics and insurance Flow sheets Physician Orders Visit notes Laboratory results Radiology results Consultant notes Other communicationsMedical History Terms: CCChief 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 allergiesTypes of Patient Encounter Notes: History and Physicalo PEPhysical Examo Lab Laboratory Studieso Radiologyy x-raysy CT and MRI scansy ultrasoundso Assessment- Dx (diagnosis) orDDx (differential diagnosis)if diagnosis is unclearo R/O rule out (if diagnosis isunclear)o Plan- Further tests,consultations, treatment,recommendations The “SOAP” Noteo S Subjective (what thepatient tells you)o O Objective (info from PE,labs, radiology)o A Assessment (Dx and DDx)o P Plan (treatment, furthertests, etc.) Discharge Summaryo Narrative in formato Summarizes the events of ahospital stayo Subjective terminology is usedin the history section (CC, HPI,etc.)o Physical examinationterminologyPhysical Examination Terms: PE Physical Exam ( ) present (-) Ф negative or absent nl normal wnl within normal limitsLaboratory Terminology: CBC complete blood count Chem 7 (or Chem 8, 14, 20) chemistry panels of 7,8,14,or 20chemistry tests BMP basic Metabolic Panel CMP complete Metabolic Panel LFTs liver function tests ABG arterial blood gas UA urine analysis HbA1C diabetes blood test1
Medical Terms by Body System BRBPR – Bright Red Blood perRectum 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 voluntaryguarding of painful area. Rebound pain worse pain asexamining hand is quickly pulled awayHEENT – 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 nasaldischarge Otorrhea – discharge from the ear Tinnitus – ringing noise in the ear NCAT normocephalic, atraumatic PERRL Pupils Equal Round andReactive to Light Erythema redness Exudate (tonsilar) most commonlywhite spots on the tonsils, but can beany fluid or cellular matter depositedon any tissue Purulent consisting of pus Injected blood vessel congestion,such as red eyeGenitourinary (GU): GenitoUrinary (GU) Dysuria painful urination Hematuria blood in the urineMusculoskeletal & Extremities: Musculoskeletal (MS) Extremities (Ext) Myalgias Muscle Aches Arthralgias Joint Aches Edema swellingPeripheralPulmonaryCoronary & Pulmonary: Cor – Coronary (the heart) Pulm – Pulmonary(respiratory/breathing system) CTAB no rrw Lungs are “Clear toauscultation bilaterally, no rales, rhonchi orwheezes” SOB Shortness of Breath Dyspnea Productive cough phlegm producing Hemoptysis coughing up blood Pleuritic worse with deepinspiration/breathing Retractions visible skin retractionswith inspiration Tachypnea rapid breathingBreathing sounds: Rales crackles crackling soundslike velcro being pulled Rhonchi wheezes whistling sounds Wheezing high pitched soundsSkin: Dermatologic (Derm)Pruritic and non-pruritic itchy andnon-itchySpotMacule - flat discoloration 10mm indiameterBumpsPapule – bump 5mm or lessNodule – well defined bump 5mmPlaque – raised areaSacsVesicle – fluid filled sac 5mmBulla – fluid filled sac 5mmPustule – sac filled with pusErosion – superficial loss of skinUlcer – deeper loss of skinScale – dry, flaky areas of skinErythema – 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 stoolOther:2
Common Medical AbbreviationsO2(R)Aa fib.a. tach.a.c. or a/cA.D.L.A.S.A.P.A.T.AaAAAbAbdABGABPADad aq.art.as tolASAAWOLAxb.i.d.B/PBEbladBMBUNBxCCC.S.c/oCaCa. or Calc.CABGoxygenrefusedbefore (ante)atrial fibrillationatrial tachycardiabefore mealsActivities of Daily Livingas soon as possibleActivity Therapyof eachAlcoholics Anonymousabortionabdomenarterial blood gasesarterial blood pressureRight earAs desiredAmerican Diabetic Associationadmitted (admission)alcoholalternatemorningagainst medical adviseambulatoryamountangiogramanteriorAspirin - Phenacetin - Caffeineapproximatelyappointmentwater (aqueous)arteryas tolleratedacetylsalicylic acid (aspirin)absent without leaveaxilla(BID) twice a dayblood pressurebarium enemabladderbowel movementblood urea nitrogenbehaviorcentigradewithcentral servicecomplains ofcancercalciumcoronary artery bypass & graft3calcap.caloriecapsulecard.computerized axial tomographyCAT(CT scan) complete blood ibchief complaintcubic tral nervous systemcarbon contributaryCOPDchronic obstructive pulmonary diseaseCOR 0cpdacute heart stoppagecompoundCPRcardio-pulmonary resuscitationcranCSFcranialcerebral spinal fluidCVAcerebrovascular accident disdistdkdlDOADOBdrDr.DSdilatation & curettageDoctor of ChiropracticDoctor of Osteopathydischargediscontinuedextrose 5% in waterdate alDilutediseasedistaldrunkdecilitersdead on arrivaldate of birthdramdoctordischarge summary
DTR'sDT'sDxECTEEGEENTEKGElevENTdeep tendon reflexesdelerium tremensdiagnosiselectroconvulsive therapyelectroencephalogrameyes, ears, nose & throatelectrocardiogramelevateears, nose & throatEOMExtraoccular muscles (movements)ERESTEtOHetx.extrf/uFaFBSFlft.FUOFxg or 20H202HAHbHbgHctemergency roomelectric shock treatmentalcoholexternalextremetiesFollow upFatherfasting blood sugarfluidsfootfever of unknown originfracturegmgall pgraingravidgun shot woundglucose toloerance gen ertensive cardiovascular diseaseHd.headHEENThead, eyes, ears, nose and throathernHRherniatedheart ratehrHShthxhystI&DI&OI.C.idIMinjinpt.inthourhour of sleepheighthistoryhysterectomyIncision and drainedintake and outputinitial contactin diem (during the mittent positive pressure breathingirregirrigIVIVPK avenousintravenous pyelogrampotassiumkilogramkidneys, ureters, and bladderLeftlight and accomodationlicensed practical nurselaboratorylacerationlaparotomy or laporoscopylateralpoundlower extremities or LupusErythematosusleucocyteslarge or legligamentliquidlower left quadrantleave of absenceLumbar punctureLeft upper quadrantLymphocytesPhysicianmultiple sclerosis,morphine sulphatemovement therapymaximummean corpuscular hemoglobinmean corpuscular hemoglobinconcentrationmean corpuscular volumemedical, .s.M.T.maxMCHMCHCMCVmedmeds4
mEq/1Mgmilliequivalent per litermilligramMImyocardial infarction (heart attack)MmMoMRMR#NANa pPBIPcPdrPedPenPermillimetermothermental retardationmedical record numbernot availableno applicableno bowel soundsnegativenaso-gastricno known allergiesnuclear magnetic resonancenumbernightnormalnon-protein nitrogennothing by mouthnulleparous (no pregnancies)once a dayoccupational therapyobstetricsorganic brain syndromeRight eyeover doseout-patient departmentoperationsoperating roomorthopedicLeft eyeBoth eyesoutpatientounceafterpercussion & auscultationphysical examinationpelvic inflammatory diseaseby mouthpostero-anteriorpalpatedprotein bound iodineafter mealspowderpediatricspenicillinbypupils equal reactive to lightand DpreopprepprevprnprosproxPsy. Ser.PTptpvcpwdqq. easure of acidity or alkalinity5Doctor of philosophyphysicalafternoonprogress notepneumoniapositiveposteriorpostoperative, after surgerypurified protein derivativepreoperative, before surgeryprepare forpreviouswhenever necessaryprostateproximalpsychological servicesphysical therapypatientpreventricular contractionpowdereveryevery hourevery dayevery hourFour times a dayevery nightevery other dayquality assurancequality Assurance Coordinatorquality Assurance Programquality Assurance Reviewquantity not sufficientrightregistered dieticianregistered nursereality orientationrecreational Therapeutic Passrule outradialred blood countRed blood cellsrectalrhesus blood factorright lower quadrantreview of systemsrespiratory rateright upper quadrantprescription, takewithoutstate hospitalsugar and acetonesaline
Schiz.schizophreniaSed rateerythrocycte sedimentation rateserolserologySGOTserum glutomie oxalacetic transaminaseSGPTserum glutamic pyruvic transaminaseSibsSIDSSigSlSOBSoc. hxSoc. Ser.SolSosSpsp. cd.sp. fl.sp. sudden infant death syndrometo write , to takeslightsubjective, objective, assessment,plan, evaluationshortness of breathsocial historysocial servicesolutionwhen necessaryspinespinal cordspinal fluidspecific systemT&Atonsillectomy and mbTLCtherapeutic assignmentthree times a daytelephone thrombosistender loving careTMtympanic membrane (eardrum)TPtreatment planTPRtemperature, pulse, rinary outputunder observationurinanalysisUGIupper gastrointestinal series (X-ray)UNKURIUTIv. fib.v. x-rayy/oyrsunknownupper respiratory infectionurinary tract infectionventricular fibrillationventricular tachycardiaverbal ordervaginalvital capacityveneral diseaseSerological test for syphilisvitaminvolumevital signswhite blood countwhite blood cellwell developedwifeweekwell nourishedwithin normal limitsweighttimesradiologyyear oldyears
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 File Size: 200KBPage Count: 6
