Med terms Ch 2

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mkpfister
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238235
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Med terms Ch 2
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2013-10-03 01:38:09
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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 illness
  10. Hx
    History
  11. IMP
    impression
  12. L&W
    living and well
  13. NAD
    no acute distress
  14. NKA, NKDA
    no know 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 accommodation
  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. progress notes
    • are used to document the pts continued care
    • SOAP
    • Subjective
    • Objective
    • Assessment
    • Plan
  25. SH
    social history
  26. Sx
    symptom
  27. UCHD
    unusual childhood diseases
  28. WNL
    within normal limits
  29. history and physical
    the first document entered into the patient's hospital recored and is commonly required before elective admission for surgery
  30. physician's orders
    list the directives for care prescribed by the doctor who is attending to the patient
  31. nurse's and physician's progress notes
    chronicle the the care throughout the patients stay
  32. ionizing
    a process that changes the electrical charge of atoms and has a possible effect on body cells
  33. radiology
    • ionizing modalities :
    • radiography (x ray) 
    • computed tomography ( CT)
    • nuclear medicine 
    • non ionizing modalities: 
    • magnetic resonance imaging (MRI)
    • sonography (US)
  34. radiography
    • X-RAY
    • imaging modality that uses x-rays (ionizing radiation) to produce body images of thebody's anatomy   for the diagnosis of a condition or impairement 
    • an image is created when a small amount of radiation is passed through the body to expose a sensitive film 
    • image called a radiograph
  35. computed tomography (CT)
    CAT- a radiologic procedure that uses a machine (scanner) to examine a body site by taking a series of cross-sectional (tomographic) x-ray films in a full-circle rotation. A computer then calculates and converts the rates of absorption and density of the x-rays into a 3-D picture on the screen
  36. Nuclear medicine imaging or radionuclide organ imaging
    • uses an injected or ingested radioactive isotope (radionuclide) or a chemical that has been tagged with radioactive compounds that emit gamma rays 
    • a gamma camera detects and produces an image of the distributed gamma rays in the body
    • a technique is useful in determining the size, shape, location, and function of body organs, such as the brain, lungs, bones, and heart
  37. Magnetic Resonance Imaging
    • MRI
    • a non-ionizing imaging technique using magnetic fields and radiofrequency waves to visualize anatomic structures with the body
    • a large magnet surrounds the pt as a scanner subjects the body to a radio signal that temporarily alters the alignment of the H atoms in the pts tissue
    • as the radio signal is turned off, the atoms realign, and the energy produced is absorbed by detectors and then interpreted using computers to provide detailed anatomic images of the body part
    • this modality is particulary useful in examining soft tissues, joints, and the brain and spinal cord
  38. Magnetic Resonance Angiopgraphy
    • MRA
    • applies magnetic resonance technology is the study of blood flow
  39. sonogrpahy
    • diagnostic ultra sound
    • U/S or US
    • the use of high-frequency sound waves (ultrasound) to visualize body tissues 
    • ultrasound waves are sent trough a scanning device (transducer) are reflected off structures within the body and then analyzed by a computer to produce moving images on the monitor 
    • used to examine abdomen, male and female reproduction organs, thyroid and parathyroid glands, and the cardiovascular system
  40. contrast medium
    • used to enhance anatomic structures 
    • barium, iodinated compounds, gases 
    • maybe injected, swallowed, or introduced through an enema or catheter
  41. acute
    • sharp
    • having intense, often severe symptoms and a short course
  42. chronic
    a condition that develops slowly and persists over a period of time
  43. benign
    mild or noncancerous
  44. malignant
    harmful or cancerous
  45. degeneration
    gradual deterioration of normal cells and body functions
  46. degenerative disease
    any disease in which deterioration of the structure or function of tissue occurs
  47. diagnosis
    • determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results)
    • dia= through
    • gnosis= knowing
  48. etiology
    • study of the cause of the disease
    • etio = cause
  49. exacerbation
    • increase in the severity of a disease, with aggravation of symptoms
    • ex= out
    • acerbo= harsh
  50. remission
    a period in which symptoms and signs stop or abate
  51. febrile
    relating to a fever (elevated temperature)
  52. idiopathic
    • a condition occuring without a clearly identified cause
    • idio = one's own
  53. localized
    limited to a definite area or part
  54. systemic
    relating to the whole body rather than to only a part
  55. malaise
    • feeling of uneasiness or discomfort
    • often the first indication of illness
  56. marked
    significant
  57. morbidity
    • sick
    • a diseased state
  58. mortality
    the state of being subject to death
  59. prognosis
    • foreknowledge
    • prediction of the likely outcome of a disease based on the general health status of the pt along with knowledge of the usual course of the disease
    • often noted in one word (prognosis = good)
  60. progessive
    pertaining to the advance of a condition as the signs and symptoms increase in severity
  61. prophylaxis
    • a process or measure that prevents disease
    • pro= before
    • phylassein = guard
  62. recurrent
    • to occur again
    • describes a return of symptoms and signs after a period of quiescence (rest or inactivity)
  63. sequela
    a disorder or condition usually resulting from a previous disease or injury
  64. sign
    • a mark
    • objective evidence of disease that can be seen or verified by an examiner
  65. symptom
    subjective evidence of disease that is perceived by the pt and often noted in his or her owns words
  66. syndrome
    • a running together
    • combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease (menopausal syndrome)
  67. noncontributory
    not involved in bringing on the condition or result
  68. unremarkable
    • common
    • not out of the ordinary or significant
  69. CCU
    coronary (cardiac) care unit
  70. ECU
    emergency care unit
  71. ER
    emergency room
  72. ICU
    intensive care unit
  73. IP
    • inpatient
    • a registered bed pt
  74. OP
    out patient
  75. OR
    operating room
  76. PACU
    postanesthetic care unit
  77. PAR
    postanesthetic recovery
  78. post-op 
    postop
    postoperative (after surgery)
  79. pre-op
    preop
    preoperative (before surgery)
  80. RTC
    return to clinic
  81. RTO
    return to office
  82. bilateral
  83. BRP
    bathroom privileges
  84. CP
    chest pain
  85. DC or D/C
    discharge, discontinue
  86. ETOH
    ethyl alcohol
  87. left
  88. right
  89. murmur
  90. pt
    patient
  91. RRR
    regular rate and rhythm
  92. SOB
    shortness of breath
  93. Tr
    treatment
  94. Tx
    treatment or traction
  95. VS
    vital signs
  96. T
    temperature
  97. P
    pulse
  98. R
    respiration
  99. BP
    blood pressure
  100. Ht
    height
  101. Wt
    weight
  102. WDWN
    well-developed and well-nourished
  103. y/o or y.o.
    year old
  104. #
    • number or pound
    • before a number: number
    • after the number: pound
  105. C
    celsius, centigrade
  106. F
    fahrenheit
  107. standing
  108. sitting
  109. lying
  110. cc
    • cubic centimeter
    • 1cc = 1 mL
  111. cm
    • centimeter
    • 2.5 cm = 1 inch
  112. g or gm
    gram
  113. NPO
    nothing by mouth
  114. PR
    through rectum
  115. PV
    through vagina
  116. without
  117. one half
  118. A
    assessment
  119. ad lib.
    as desired
  120. amt
    amount
  121. aq
    water
  122. A&W
    alive and well
  123. CBC
    complete blood count
  124. CCU
    coronary (cardiac) care unit
  125. c/o
    complains of
  126. ID
    intradermal
  127. IMP
    impression
  128. JCAHO
    joint commission on accreditation of healthcare organizations
  129. NAD
    no acute distress
  130. noc.
    night
  131. OH
    occupational history
  132. a.m.
    before noon
  133. p.m.
    afternoon
  134. WNL
    within normal levels

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