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Med. Lang. & Records
Chapters 1-2
| Term | Definition |
|---|---|
| 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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