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Chapter 1

Learning Terminology

Pericolonic Around the colon
Dentalgia Toothpain
Dysmenorrhea Abnormal Menses
Hepatomegaly enlarged liver
vasculitis inflammation of the blood vessels
hypotension abnormally low blood pressure
epigastric area above the stomach
phlebotomy incision (or going into) the vein
a before
ac before meals
AMI Acute myocardial infarction
bid twice a day
BP blood pressure
c/o Complaining of
Ca Cancer/carcinoma
CC Chief Complaint
CHF Congestive Heart Failure
COPD Chronic Obstructive pulmonary disease (emphysema, chronic bronchitis)
CXR chest x-ray
DOB Date of Birth
Dx Diagnosis
ECG, EKG Electrocardiogram
GI Gastrointestinal
HEENT Head, ears, eyes, nose, throat
h/o History of
HTN Hypertension
Hx History
IM Intramuscular
LAC Laceration
LOC Level of consciousness
mcg Micrograms
NKDA No known drug allergies
npo Nothing by mouth
po By mouth
PRN as needed
qid Four times a day
Rx or Tx Treatment
SOB shortness of breath
tid three times a day
w/o or s without
WNL within normal limits
Medical Record created with a patient's phone call or visit to a physician's office
CBC Complete Blood Count
BID Twice a Day
SNOMED Systematized Nomenclature Medicine
Pharmacology Dispensing medication to treat ailments
EMR Electronic Health Record
ICD International Classification of Diseases
A (blank) is creataed with a patient's phone call or visit to a physician Office Medical Record
The medical record must be (blank) each time there is a communication (blank ) or (blank) a patient documented; with, about
The format of the documentation and () may (). The medical () will typically be the same to avoid () Medical record, vary, terminology, mistakes
() Procedures are treatments that require invasive cutting into the body to repair or remove a diseased part. () is the diagnosis of the disease or condition. Surgical; Pathology
SNOMED is a medical terminology standard developed for use in () medical records electronic
Implementation of SNOMED will not take place until some time int he future because most US hospital and physicians use () medical records paper
ICD is the current standard for () coding diagnosis
Created by: dkeller4150ob