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Med Terminology
Chapter 2 terms and abbreviations
| Question | Answer |
|---|---|
| HR | Heart Rate or Pulse |
| RR | Respiratory Rate |
| BP | Blood Pressure |
| T | Temperature |
| Ht | Height |
| Wt | Weight |
| BMI | Body Mass Index |
| SOAP | Subjective, Objective, Assessment, Plan |
| Discharge | to send home or fluid coming out of a part of the body |
| Prophylaxis | Preventative Treatment |
| acute | started recently; short term illness |
| chronic | Long term or ongoing illness |
| abrupt | all of a suddent |
| exacerbation | It's getting worse |
| febrile | fever |
| afebrile | does not have fever |
| malaise | not feeling well |
| progressive | increases more and more each day |
| symptom (sx) | how a patient says they feel |
| Noncontributory | not related to a specific problem |
| lethargic | a decrease in level of consciousness; feeling of no energy |
| genetic/hereditary | it runs in the family |
| Alert | Able to answer questions; responsive |
| Oriented x3 | Aware of who they are, where they are and the current time/day |
| Marked | Something stands out (such as on an x-ray or MRI) |
| Unremarkable | Normal results or no findings on images |
| Auscultation | "to listen" (ex. listening with stethoscope) |
| Percussion | to hit something and listen to resulting sound or feel for vibration |
| Palpation | "to feel" (ex. Doctor may feel abdomen to see if tenderness occurs.) |
| Impression | a.k.a. "assessment" |
| Diagnosis (Dx) | What the health care provider had decided is wrong with the patient. |
| Differential Diagnosis (DDx) | Based on symptoms and test results, more than diagnosis is possible; |
| Benign | safe or not cancerous |
| Malignant | Danger or it is Cancer |
| Degeneration | It's getting worse |
| Remission | Most often used to discuss cancer. It does not mean the cancer has been completely cured, but not currently having symptoms |
| Idiopathic | No known specific cause of illness |
| Localized | In a particular part of the body |
| Systemic/Generalized | Over most or all of the body |
| Prognosis | The changes for things getting better or worse. |
| Occult | means "hidden" |
| Lesion | Diseased tissue |
| Recurrent | to have again |
| Sequela | a problem resulting from a disease of injury |
| Pathogen | the organism that caused the illness |
| morbidity | the risk for being sick |
| Mortality | the risk for dying |
| etiology | the cause of the disease or pathogen |
| Disposition | what happened to the patient at the end of the visit (used mostly in ER visits) |
| Palliative | Treating the symptoms, but not a cure. (Making the patent comfortable.) |
| Sterile | Germ free conditions |
| Chief Complaint (CC) | Main reason for patient's visit. Goes under Subjective section; also describes how the patients says they feel. See also HPI |
| History of Present Illness (HPI) | Same as "Chief Complaint" |
| Review of Systems (ROS) | A review of the individual body systems to determine if any are related to the main problem. |
| Past medical history (PMHx) | Anything the patient has previously been diagnosed with or treated for. |
| Past Surgical history | Any previous surgeries are documented here. |
| Family history (FHx) | Usually contains information about immediate family members; documents significant illnesses that could run in the patient's family. |
| Social history | A record of history of smoking, drinking, drug abuse, or sexual practices that could impact health |
| Tx | Treatment |
| Rx | Prescription |
| H & P | History and Physical |
| Hx | History |
| NKDA | No Known Drug Allergies |
| NKA | No Known Allergies (food or drug) |
| PE | Physical Exam |
| Pt | Patient |
| y/o | years old |
| PCP | Primary Care Provider |
| f/u | follow up |
| SOB | Shortness of Breath |
| HEENT | Head, eyes, ears, nose, and throat |
| CV | Cardiovascular |
| RRR | Regular Rate Rhythm |
| NOS | Not otherwise specified |
| NEC | Not elsewhere classified |
| PO | By mouth |
| NPO | Nothing by mouth |
| IM | Intramuscular |
| IV | Intravenous |
| PICC | Peripherally inserted central catheter |
| Sig | Instructions short for signa; "label" |
| BID | Twice daily |
| TID | Three times daily |
| QD | daily or each day |
| QID | Four times daily |
| QHS | at night or at bedtime |
| AC | before meals |
| PC | after meals |
| prn | as needed |
| Sub q | Subcutaneous |
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