Medical Terminology and Abbreviations

  1. Abrasion
    Scrape of the skin due to something abrasive
  2. Abscess
    Collection of pus underneath the skin
  3. Antipyretic
    Medication used to reduce a fever
  4. Acute
    New, usually of rapid onset and of concern, opposite of chronic
  5. Afebrile
    Without a fever (Temperature of less than 100.4)
  6. Anterior
    Located towards the front of the body
  7. Appendicitis
    Dangerous infection of the appendix
  8. Auscultation
    Listening to sounds arising within organs (as the lungs)
  9. Benign
    Normal, of no danger to health
  10. Bradycardia
    Slow heart-rate (HR<60bpm)
  11. Bronchitis
    Infection of the bronchi (upper airway)
  12. Bronchiolitis
    Infection of the bronchioles (smaller air-tubes in the lungs)
  13. Catheter
    Tube inserted into vessels or body cavities to permit injection or withdrawal of fluids or to keep a passage open
  14. Chronic
    • Long-standing, constant
    • Opposite of acute
  15. Cellulitis
    Infection of skin cells
  16. Conjunctivitis
    Infection of the outer layer of the eye
  17. Dialysis
    Process for removing waste from the blood for people with renal failure
  18. Diaphoresis
  19. Diffuse
    Spread out (not localized)
  20. Distal
    Farther from the trunk of the body
  21. Dyspnea
    Difficulty breathing
  22. Dysuria
    Painful urination
  23. Ecchymosis
    A bruise
  24. -ectomy (suffix)
    • Surgical removal
    • e.g. tonsillectomy
  25. Edema
  26. Emesis
  27. Epilepsy
    Seizure disorder
  28. Epistaxis
    Nose bleed
  29. Erythema/Erythematous
  30. Exudates (tonsillar)
    Pus-pockets on the tonsils
  31. Febrile
    The state of having a fever (Temperature of more than 100.4)
  32. Grossly
    Obviously; a lot; wholly
  33. Hematemesis
    Gross amounts of blood in the vomit
  34. Hematuria
    Blood in the urine
  35. Hemoptysis
    Coughing up gross amounts of blood
  36. Hemorrhage
    Excessive or profuse bleeding
  37. Hepatomegaly
    Enlarged liver
  38. Hernia
    Protrusion of an organ through the wall of the cavity that normally contains it
  39. Hyperlipidemia
    High cholesterol
  40. Hypertension
    High blood pressure
  41. Hypotension
    Low blood pressure
  42. Hypoxia
    Low oxygen saturation of the body, not enough oxygen in the blood
  43. ICD-10
    A system to classify and code diagnoses, symptoms, and procedures
  44. Infarct
    Area of dead tissue after a lack of blood supply
  45. Inferior
    Lower on the body, farther from the head
  46. Ischemia
    Lack of blood supply
  47. -itis (suffix)
    • Inflammation
    • e.g. appendicitis
  48. Laceration
    • Splitting of the skin due to trauma
    • a cut due to something sharp
  49. Lateral
    • Farther from the midline
    • a line that can be traced from nose to belly-button
  50. Lethargic
    • Septic
    • Very sick
    • About to die
  51. Medial
    Nearer to the midline
  52. Meningitis
    Dangerous infection of the outer lining of the brain
  53. Otitis Externa
    Infection of the outer ear (ear canal)
  54. Otitis Media
    Infection inner ear (behind the eardrum)
  55. Melena
    Black tarry stool
  56. Myalgia
    Muscular pain, ?muscle aches?
  57. Pallor
    Pale skin
  58. Palpation
    Examine by touch
  59. Palpitation
    To beat rapidly, irregularly, or forcibly (usually relating to the heart)
  60. Peritoneal signs
    Guarding/Rebound/Rigidity: PE findings indicating a rupture in the abdomen
  61. Pharyngitis
    Throat infection
  62. Pneumonia
    Bacterial infection of the lungs
  63. Posterior/Dorsal
    Rear or backside of the body
  64. Prone
    Body position lying flat, face down
  65. Proximal
    Nearer to the trunk of the body
  66. Pulmonary
    Relating to the lungs
  67. Purulence/Purulent
  68. Rales
    • Crackles
    • Wet crackling noise in lungs
  69. Rhinorrhea
    Clear nasal discharge, "runny nose"
  70. Rhonchi
    Rattling noise of mucous in the lungs
  71. -scopy (suffix)
    • Viewing with a scope
    • e.g. colonoscopy
  72. Sepsis
    Dangerous infection of the blood
  73. Sinusitis
    Infection/inflammation of the nasal sinuses
  74. Small Bowel Obstruction
    Physical blockage of the small intestines
  75. Streptococcal Pharyngitis
    Strep throat
  76. Superior
    Higher on the body, nearer to the head
  77. Supine
    Body position lying face up
  78. Syncope
    • "Passing out"
    • Loss of consciousness or fainting
  79. Tachycardia
    • Fast heart rate
    • HR>100bpm
  80. Trismus
    Inability to open the jaw due to pain
  81. Tachypnea
    Increased breathing rate
  82. Ulcerations
    Blisters or open-sores
  83. Vertigo
    Room-spinning dizziness (not light-headed)
  84. Wheezing
    High pitched sound heard in the lungs with asthmatics or lung disease
  85. Abd
    • Abdomen
    • Abdominal
  86. Abx
  87. A fib
    Atrial fibrillation
  88. AOM
    • Acute Otitis Media
    • (new ear infection)
  89. A/P
    Assessment and Plan
  90. ASA
    Acetylsalicylic Acid (Aspirin)
  91. BID
    Twice Daily
  92. Bilat LE
    Bilateral Lower Extremities
  93. BM
    Bowel Movement
  94. BP
    Blood Pressure
  95. c (with line on top)
  96. CA
    • Cancer
    • Carcinoma
  97. CABG
    Coronary Artery Bypass Graft
  98. CAD
    Coronary Artery Disease
  99. CBC
    • Complete Blood Count
    • (bloodwork to look for infection or anemia)
  100. CHF
    Congestive Heart Failure
  101. CP
    Chest Pain
  102. c/o
    Complains of
  103. COPD
    Chronic Obstructive Pulmonary Disease
  104. CRF
    Chronic Renal Failure
  105. C-section
    Caesarean Section
  106. C-Spine Cervical spine
  107. CT or CAT
    Computerized Assisted Tomography
  108. CTA
    Clear to auscultation
  109. CV
  110. CVA
    Cerebrovascular Accident
  111. CXR
    Chest X-Ray
  112. DM
    Diabetes Mellitus
  113. DOE
    Dyspnea on Exertion
  114. DP /PT (pulse)
    Dorsalis Pedis / Posterior Tibialis
  115. DVT
    Deep Vein Thrombosis
  116. Dx
  117. EKG/ECG
  118. EOMI
    Extraocular Movements Intact
  119. EtOH
  120. FHx
    Family History
  121. F/U
    • Follow-up
    • (i.e. Follow-up in 3 days for a re-evaluation)
  122. Fx
  123. GERD
    Gastroesophageal Reflux Disease
  124. GI
  125. G/P/Ab
  126. GU
  127. HA
  128. HEENT
    Head, Ears, Eyes, Nose, Throat
  129. HIPAA
    Health Insurance Portability and Accountability Act
  130. HLD
  131. HPI
    History of Present Illness
  132. HTN
    Hypertension (high blood pressure)
  133. Hx
  134. H&H
    Hemoglobin and Hematocrit
  135. I&D
    Incision and Drainage
  136. IDDM
    Insulin Dependent Diabetes Mellitus
  137. IUP
    Intrauterine Pregnancy
  138. IVDA
    Intravenous Drug Abuse
  139. LLE
    Left Lower Extremity
  140. LLQ
    Left Lower Quadrant
  141. LNMP
    Last Normal Menstrual Period
  142. LOC
    Loss of Consciousness
  143. L-spine
    Lumbar spine
  144. LUE
    Left Upper Extremity
  145. LUQ
    Left Upper Quadrant
  146. MI
    Myocardial Infarction
  147. N/A
    Not Applicable
  148. NAD
    • No Acute Distress
    • No Acute Disease
  149. NIDDM
    Non-Insulin Dependent Diabetes Mellitus
  150. NKDA
    No Known Drug Allergies
  151. nl/nml
  152. NSAID
    Non Steroidal Anti-Inflammatory Drug
  153. NSR
    Normal Sinus Rhythm
  154. N/V/D
  155. O2 Sat
    • Oxygen Saturation
    • (a.k.a. SaO2 or SpO2 or Pulse Ox or Sat)
  156. OB/GYN
    Obstetrics and gynecology
  157. OD
  158. OM
    • Otitis Media
    • (inner ear infection)
  159. OP
    • Oropharynx
    • (mouth and throat)
  160. ORIF
    Open Reduction and Internal Fixation (orthopedic surgery)
  161. PCP/PMD
    Primary Care Physician/Primary Medical Doctor
  162. PE
    Physical exam/Pulmonary Embolism
  163. PERRL
    Pupils are Equal, Round, and Reactive, to Light
  164. PO
    • Per Os
    • (by mouth)
  165. prn
    As needed
  166. Pt
  167. PTA
    • Prior To Arrival
    • -OR-
    • Peritonsillar Abscess
  168. PVD
    Peripheral Vascular Disease
  169. q
  170. QD
    Every Day
  171. QHS
    At Every Bedtime
  172. QID
    Four Times a Day
  173. RLE
    Right Lower Extremity
  174. RLQ
    Right Lower Quadrant
  175. ROM
    Range of Motion
  176. ROS
    Review of System
  177. RRR
    Regular rate and rhythm (normal heart sounds)
  178. RUE
    Right Upper Extremity
  179. RUQ
    Right Upper Quadrant
  180. Rx
  181. r/o
    Rule Out
  182. SOB
    Shortness of Breath
  183. SOAP
    Subjective, Objective, Assessment, and Plan
  184. s/p
    Status Post (after)
  185. Sx
  186. STEMI
    S/T Elevation Myocardial Infarction
  187. T&A
    • Tonsillectomy & Adenoidectomy
    • (tonsils and adenoids removal surgery)
  188. TIA
    Transient Ischemic Attack
  189. TID
    Three Times a Day
  190. TM
    Tympanic Membrane (Ear drum)
  191. Tx
  192. T-Spine
    Thoracic spine
  193. UA
  194. URI
    Upper Respiratory Infection
  195. US
  196. UTD
    Up to Date
  197. UTI
    Urinary Tract Infection
  198. WNL
    Within Normal Limits (normal, not of concern)
  199. y/o
    Year(s) Old
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Medical Terminology and Abbreviations
Medical Terminology and Abbreviations for Scribe Job