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Med. Lang. & Records

Chapters 1-2

a not
ab away
ad toward
an not
ante before
anti against
bi two
brady slow
circum around
con with, together
contra against
de down, away from
dia through
dys bad
e out
ec out
ecto outside
en in, inside
endo in, inside
epi upon
eu good
ex out
exo ouside
extra outside
hemi half
hyper over
hypo under
inter between
angio blood vessel
arthro joint
cardio heart
dermo, dermato skin
entero small intestine
gastro stomach
geno generation, cause
hemo, hemato blood
hepato liver
hydro water
morpho change
musculo muscle
myo muscle
myco fungus
necro death
neuro nerve
ortho straight
patho suffering, disease
phago eat
plaso formation
pneumo, pneumono lung
pulmono lung
pyo pus
sclero hard
steno narrowing
tropho nourishment, development
vaso, vasculo blood vessel
xeno foreign
-ac pertaining to
-al pertaining to
-algia pain
-ar, -ary pertaining to
-cele hernia
-centesis puncture
-desis binding
-dynia pain
-eal pertaining to
-ectomy removal
-emia blood condition
-gram written record
-graph instrument used to produce a record
-graphy writing procedure
-ia condition
-iasis presence of
-iatrics medical science
-iatrist specialist in medicine of
-iatry medical science
-ic pertaining to
-icle small
-ism condition
-ist specialist
-ium tissue, structure
-logist specialist in the study of
-logy study of
-lysis loosen, break down
intra in, inside
macro large
micro small
mono one
multi many
oligo few
pan all
peri around
poly many
post after
pre before
pro before, on behalf of
re again
semi half
sub beneath
sym with, together
syn with, together
tachy fast
trans through
uni one
-malacia abnormal softening
-megaly enlargement
-meter instrument used to measure
-metry process of measuring
-old resembling
-ole small
-oma tumor
-osis condition
-ous pertaining to
-pathy disease
-penia deficency
-pexy surfical fixation
-plasty reconstruction
-ptosis drooping
-rrhage, -rrhagia excessive flow
-rrhaphy suture
-rrhea flow
-rrhexis rupture
-scope instrument used to look
-scopy process of looking
-spasm involuntary contraction
-stomy creation of an opening
-tic pertaining to
-tomy incision
-ula small
-y condition, process
VS vital signs
T temperature
BP blood pressure
HR heart rate
RR respiratory rate
Ht height
Wt weight
BMI body mass index (based on height & weight)
I/O intake/output
Dx diagnosis
DDx differential diagnosis
Tx treatment
Rx prescription
H&P history & physical
Hx history
CC chief complaint
HPI history of present illness
ROS review of symptoms
PMHx past medical history
FHx family history
NKDA no know drug allergies
PE physical exam
Pt patient
y/o years old
h/o history of
PCP primary care provider
f/u follow up
SOB shortness of breath
HEENT head, eyes, ears, nose, & throat
PERRLA pupils are equal, round, & reactive to light & accomidation
NAD no acute distress
CV cardiovascular
RRR regular rate & rhythm (heart rate)
CTA clear to auscultation (lungs)
WDWN well developed, well nourished
A&O alert & oriented
WNL within normal limits
NOS not otherwise specified
NEC not elsewhere classified
PO per os (by mouth)
NPO nil per os (nothing by mouth)
PR per rectum (anal)
IM intramuscular
SC subcutaneous (under the skin)
IV intravenous
CVL central venous line
PICC peripherally inserted central catheter
Sig instructions short for signa, from Latin for "label"
BID twice daily
TID three times daily
Q every
QD daily
QID for times daily
QHS at night
AC before meals
PC after meals
prn as needed
ad lib as desired
S in SOAP subjective
O in SOAP objective
A in SOAP assessment
P in SOAP plan
acute it just started recently or is a sharp, severe symptom
chronic it has been going on for a while now
exacerbation it is getting worse
abrupt all of a sudden
febrile to have a fever
afebrile to not have a fever
malaise not feeling well
progressive more and more each day
symptom something a patient feels
noncontributory net related to this specific problem
lethargic a decrease in level of consciousness; in a medical record, this is generally
genetic, hereditary it runs in the family
alert able to answer questions; responsive, interactive
oriented being aware of who he or she is, where he or she is, & the current time; a patient who is aware of all three is "oriented x3"
marked it really stands out
unremarkable another way of saying normal
auscultation to listen
percussion to hit something & listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument
palpation to feel
impression another way of saying assessment
diagnosis what the health care professional things the patient has
differential diagnosis a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
benign safe
malignant dangerous; a problem
degeneration to be getting worse
etiology the cause
remission to get better or improve; most often used when discussing cancer; remission does not mean cure
idiopathic no known specific cause; it just happens
localized stays in a certain part of the body
systemic, generalized all over the body (or most of it)
morbidity the risk for dying
prognosis the chances for things getting better or worse
occult hidden
pathogen the organism that causes the problem
lesion diseased tissue
recurrent to have again
sequelae a problem resulting from a disease or injury
pending waiting for
disposition what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU, normal hospital bed)
discharge to unload-to send home, fluid coming out of a part of the body
prophylaxis preventative treatment
palliative treating the symptoms, but not actually getting rid of the cause
observation watch, keep an eye on
reassurance to tell the patient that the problem is not serious or dangerous
supportive care to treat the symptoms and make the patient feel better
sterile extremely clean, germ-free conditions; especially important during medical procedures and surgery
proximal closer to the center
distal farther away from the center
lateral out to the side
medial toward the midline
ventral, antral, anterior the front
dorsal, posterior the back
cranial toward the top
caudal toward the bottom
superior above
inferior below
prone lying down on belly
supine lying down on back
contralateral opposite side
ipsilateral same side
unilateral one side
bilateral both sides
dorsum the top of the hand or foot
plantar the sole of the foot
palmar the palm of the hand
sagital divides the body in slices right to left
coronal divides the body in slices from front to back
transverse divides the body from tom to bottom
physician (MD or DO) a skilled health care provider who attended and graduated medical school
pediatrician a physician with special training in caring for children
surgeon a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure
anesthesiologist a physician with special training in pain sedation and pain control
physician assistant (PA) a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training
nurse practitioner (NP) a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician
emergency medical technician (EMT) specially trained in the emergency care of a patient before and/or during transport to medical facility
speech therapist specially trained in evaluating & treating problems with speech and/or swallowing
occupational therapist specially trained in evaluating & treating problems with performing daily activities at home, school or work
physical therapist specially trained in evaluating & treating physical impairments including disabilities or recovery from an injury
respiratory therapist specially trained in evaluating & treating patient's respiratory issued under the guidance of a health care provider
dietician specially trained in evaluating the nutritional status of a patient & developing an appropriate diet plan
licensed practical nurse (LPN) or licensed vocational nurse (LVN) trained & certified to provide basic care to a patient
registered nurse (RN) an advanced level nurse who has completed an associate's or bachelor's degree; often assists with patience care planning & patient education
medical assistant (MA) trained to carry our basic administrative & clinical tasks under the guidance of a health care provider
pathologist a physician with special training in both evaluating the causes and effects of disease & in laboratory medicine
medical laboratory technician trained in performing laboratory testing on bodily fluids
phlebotomist trained in the removal of blood from the body for diagnostic or therapeutic purposes
radiology a physician specifically trained in evaluating images of the body to diagnose illness or injury
radiology technician trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
ultrasonagrapher trained in performing ultrasound imaging on a patient
pharmacist trained & licensed in preparing & dispensing medicine
pharmacy technician trained to assist a pharmacist with pharmacy-related tasks
patient service coordinator handles administrative tasks & coordinates patient care
medical transcriptionist trained in converting the voice-recored dictations of health care providers into text format
CCU coronary care unit
ECU emergency care unit
ER emergency room
ED emergency department
ICU intensive care unit
PICU pediatric intensive care unit
NICU neonatal intensive care unit
SICU surgical intensive care unit
PACU post-anesthesia care unit
L&D labor & delivery
OR operating room
post-op after surgery
pre-op before surgery
Created by: cknapp27
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