Med Term Ch 2 Health Care Records

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chrastini
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172508
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Med Term Ch 2 Health Care Records
Updated:
2012-09-22 11:13:06
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willis medical terminology
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Medical Terminology Ch 2
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  1. A
    Assessment
  2. A&W
    alive and well
  3. CC
    chief complaint
  4. c/o
    complains of
  5. Dx
    diagnosis
  6. FH
    family history
  7. HEENT
    Head, eyes, ears, nose, and throat
  8. H&P
    history and physical
  9. HPI, PI
    history of present illness, present illnes
  10. Hx
    history
  11. IMP
    impression
  12. L&W
    living and well
  13. NAD
    no acute distress
  14. NKA, NKDA
    no known allergies, no known drug allergies
  15. O
    objective information
  16. OH
    occupational history
  17. P
    plan (recommendation, disposition)
  18. PE, Px
    physical examination
  19. PERRLA
    pupils equal, round, and reactive to light and accomodation
  20. PH, PMH
    past history, past medical history
  21. R/O
    rule out
  22. ROS, SR
    review of systems, systems review
  23. S
    subjective information
  24. SH
    social history
  25. Sx
    symptom
  26. UCHD
    usual childhood diseases
  27. WNL
    within normal limits
  28. acute
    sharp; having intense, often severe symptoms and a short course
  29. chronic
    a condition that develops slowly and persists over a period of time
  30. benign
    mild or noncancerous
  31. malignant
    harmful or cancerous
  32. degeneration
    gradual deterioration of normal cells and body functions
  33. degenerative disease 
    any disease in which deterioration of the structure or function of tissue occurs
  34. diagnosis
    determination of the presence of a diseases based on an evaluation of symptoms, signs and test findings
  35. etiology
    study of the cause of a disease (etio= cause)
  36. exacerbation
    increase in the severity of disease, with aggravtion of symptoms (ex=out; acerbo=harsh)
  37. remission
    a period in which symptoms and signs stop or abate
  38. febrile
    relating to a fever (Elevated temperature)
  39. idiopathic
    a condition occurring without a clearly identified cause (idio= one's own)
  40. localized
    limited to a definite area or part
  41. systemic 
    relating to the whole body rather than one part
  42. malaise
    a feeling of uneasiness or discomfort; often the first indiciation of illness
  43. marked
    significant
  44. morbidity
    sick; a diseased state
  45. mortality
    the state of being subject to death
  46. prognosis
    foreknowledge; prediction of the likely outcome of a disease based on general health status of patient along with disease knowledge; often one-word (eg: prognosis: good)
  47. progressive
    pertaining to the advance of the condition as the signs and symptoms increase in severity
  48. prophylaxis
    a process or measure that prevents disease (pro=before, phylassein = guard)
  49. recurrent
    to occur again; return of symptoms after period of quiescence (rest or inactivity)
  50. sequela
    a disorder or condition usually resulting from a previous disease or injury
  51. sign
    a mark
  52. symptom
    subjective evidence of disease that is perceived by patient
  53. syndrome
    a running together; combination of symptoms and signs that give a distince clinical picture indicating a particular con./disease
  54. noncontributory
    not involved in bringing on the condition or result
  55. unremarkable
    common
  56. CCU
    coronary (cardiac) care unit
  57. ECU
    Emergency care unit
  58. ER
    emergency room
  59. ICU
    intensive care unit
  60. IP
    inpatient (a registered bed patient)
  61. OP
    outpatient
  62. OR
    operating room
  63. PACU
    postanesthetic care unit
  64. PAR
    postanesthetic recovery
  65. post-op, postop
    after surgery
  66. pre-op, preop
    before surgery
  67. RTC
    return to clinic
  68. RTO
    return to office
  69. (B)
    bilateral
  70. BRP
    bathroom privileges
  71. CP
    chest pain
  72. DC , D/C
    discharge, discontinue (spell out discharge or discontinue)
  73. ETOH
    ethyl alcohol
  74. (L)
    left
  75. (R)
    right
  76. (m)
    murmur
  77. pt
    patient
  78. RRR
    regular rate and rhythm
  79. SOB
    shortness of breath
  80. Tr
    treatment
  81. Tx
    treatment or traction
  82. VS
    vital signs
  83. T
    temperature
  84. P
    pulse
  85. R
    respiration
  86. BP
    blood pressure
  87. Ht
    height
  88. Wt
    weight
  89. WDWN
    well-developed and well-nourished
  90. y/o, y.o.
    year old
  91. #
    number or pound
  92. C
    celsius
  93. F
    fahrenheit
  94. female
  95. male
  96. °
    degree or hour
  97. increased
  98. decreased
  99. Ø 
    none or negative
  100. O
     |
    standing
  101. O
     L
    sitting
  102. O--
    lying
  103.  cc
    cubic centimeter (1 cc= 1 mL)
  104. cm
    centimeter
  105. g or gm
    gram
  106. kg
    kilogram
  107. L
    liter
  108. mg
    milligram (1/1000 of g)
  109. mL, ml
    milliliter (1/1000 of L)
  110. mm
    millimeter (1/1000 of meter)
  111. cu mm or mm³
    cubic millimeter
  112. fl oz
    fluid ounce
  113. gr
    grain
  114. gt
    drop (gutta = drop)
  115. gtt
    drops
  116. dr
    dram (1/8 ounce)
  117. qt
    quart
  118. tablet or capsule (route of administration)
    oral (p.o.), sublingual (SL), buccal
  119. suppository (route of administration)
    vaginal (PV), rectal (PR)
  120. fluid (route of administration)
    inhalation: aerosol (spray) or nebulizer (fine spray or mist)
  121. parenteral (route of administration)
    • by injection:
    • intradermal (ID) 
    • intramuscular (IM)
    • intravenous (IV)
    • subcutaneous (SC, SQ, or sub-Q)
  122. cream, lotion or ointment (route of administration)
    topical
  123. transdermal
    absorption of drug through unbroken skin
  124. implant
    a drug resorvoir imbedded in the body to provide continual infusion of a medication 
  125. ā
    before
  126. a.c.
    before meals
  127. a.m.
    before noon
  128. b.i.d.
    2x a day
  129. d
    day
  130. h
    hour
  131. h.s.
    hour of sleep (bedtime)
  132. noc.
    night
  133. _
    P
    after
  134. p.c.
    after meal
  135. p.r.n.
    as needed
  136. p.m.
    after noon
  137. q
    every
  138. q.d.
    every day (spell out every day or daily)
  139. qh
    every hour
  140. q2h
    every 2 hours
  141. q.i.d.
    4x a day
  142. q.o.d.
    every other day (spell out)
  143. STAT
    immediately
  144. t.i.d.
    3x a day
  145. wk
    week
  146. yr
    year
  147. AD
    right ear (spell out)
  148. ad lib.
    as desired
  149. amt
    amount
  150. aq
    water
  151. AS
    left ear (spell out)
  152. AU
    both ears (spell out)
  153. _
    c
    with
  154. NPO
    nothing by mouth
  155. OD
    right eye (spell out)
  156. OS
    left eye (spell out)
  157. OU
    both eyes (spell out)
  158. per
    by or through
  159. p.o.
    by mouth
  160. PR
    through rectum
  161. PV
    through vagina
  162. Rx
    recipe, prescription
  163. _
    s
    without
  164. Sig
    label, instruction to patient
  165. __
     ss
    one-half (spell out)
  166. wa
    while awake
  167. x
    time or for (ex: x6 means six times or x2d means for two days)
  168. >
    greater than (spell out)
  169. <
    less than (spell out)
  170. T with a dot over
    modified lower case numerals

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