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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 |