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HLHS Chap 2

TermDefinition
malaise not feeling well
alert able to answer questions; responsive; interactive
oriented being aware of who her/she is, where he/she is, and the current time; a patient who is aware of all three is "oriented x3"
marked really stands out
unremarkable another way of saying normal
auscultation to listen
percussion to hit something and listen to resulting sound or feel for the resulting vibration
palpation to feel
impression another way of saying assessment
differential diagnosis a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
degeneration getting worse
idiopathic no known specific cause; just happens
prognosis the chances for things getting better or worse
occult hidden
lesion diseased tissue
sequela a problem resulting from a disease or injury
pathogen organism that causes the problem
morbidity the risk for being sick
mortality the risk for dying
etiology the cause
disposition what happens to the patient at the end of the visit
discharge literally, to unload; it has two meanings: 1. to send home 2. fluid coming out of a part of the body
palliative treating the symptoms, but not actually getting rid of the cause
supportive care to treat the symptoms and make the patient feel better
prophylaxis preventive treatment
proximal closer to the center
distal farther away from the center
lateral out to the side
medial toward the middle
ventral the front
antral the front
anterior the front
dorsal the back
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
dorsum the top of the hand or foot
plantar the sole of the foot
palmar the palm of the hand
sagittal divides the body along a hypothetical plane from right to left
coronal divides the body along a hypothetical plane from front to back
transverse divides the body from top to bottom
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 and delivery
OR operating room
(R) right
(L) left
(B) bilateral
VS vital signs
T temperature
BP blood pressure
HR heart rate
RR respiratory rate
Ht height
Wt weight
I/O intake/output: the amount of fluids a patient has taken in and produced
Dx diagnosis
DDx differential diagnosis
Tx treatment
Rx prescription
H&P history and physical
Hx history
CC chief complaint
HPI history of present illness
ROS review of systems
PMHx past medical history
FHx family history
NKDA no known drug allergies
PE physical exam
Pt patient
h/o history of
SOB shortness of breath
HEENT head, eyes, ears, nose, and throat
PERRLA pupils are equal, round, and reactive to light and accommodation
NAD no acute distress
CV cardiovascular
RRR regular rate and rhythm
CTA clear to auscultation
WDWN well developed, well nourished
A&O alert and 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
IM intramuscular
SC subcutaneous
IV intravenous
CVL central venous line
PICC peripherally inserted central catheter
Sig instruction short for signa
BID twice daily
TID three times daily
Q every x, Q4hr means every 4 hours
QD daily
QID four times daily
QHS at night
AC before meals
PC after meals
prn as needed
ad lib as desired
Created by: qclemenz
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