Medical Terminology and Abbreviations

Scrape of the skin due to something abrasive

Collection of pus underneath the skin

Medication used to reduce a fever

New, usually of rapid onset and of concern, opposite of chronic

Without a fever (Temperature of less than 100.4)

Located towards the front of the body

Dangerous infection of the appendix

Listening to sounds arising within organs (as the lungs)

Normal, of no danger to health

Slow heart-rate (HR<60bpm)

Infection of the bronchi (upper airway)

Infection of the bronchioles (smaller air-tubes in the lungs)

Tube inserted into vessels or body cavities to permit injection or withdrawal of fluids or to keep a passage open

• Long-standing, constant
• Opposite of acute

Infection of skin cells

Infection of the outer layer of the eye

Process for removing waste from the blood for people with renal failure

Sweating

Spread out (not localized)

Farther from the trunk of the body

Difficulty breathing

Painful urination

A bruise

• Surgical removal
• e.g. tonsillectomy

Swelling

Vomiting

Seizure disorder

Nose bleed

Redness/Red

Pus-pockets on the tonsils

The state of having a fever (Temperature of more than 100.4)

Obviously; a lot; wholly

Gross amounts of blood in the vomit

Blood in the urine

Coughing up gross amounts of blood

Excessive or profuse bleeding

Enlarged liver

Protrusion of an organ through the wall of the cavity that normally contains it

High cholesterol

High blood pressure

Low blood pressure

Low oxygen saturation of the body, not enough oxygen in the blood

A system to classify and code diagnoses, symptoms, and procedures

Area of dead tissue after a lack of blood supply

Lower on the body, farther from the head

Lack of blood supply

• Inflammation
• e.g. appendicitis

• Splitting of the skin due to trauma
• a cut due to something sharp

• Farther from the midline
• a line that can be traced from nose to belly-button

• Septic
• Very sick
• About to die

Nearer to the midline

Dangerous infection of the outer lining of the brain

Infection of the outer ear (ear canal)

Infection inner ear (behind the eardrum)

Black tarry stool

Muscular pain, ?muscle aches?

Pale skin

Examine by touch

To beat rapidly, irregularly, or forcibly (usually relating to the heart)

Guarding/Rebound/Rigidity: PE findings indicating a rupture in the abdomen

Throat infection

Bacterial infection of the lungs

Rear or backside of the body

Body position lying flat, face down

Nearer to the trunk of the body

Relating to the lungs

Pus/Pus-like

• Crackles
• Wet crackling noise in lungs

Clear nasal discharge, "runny nose"

Rattling noise of mucous in the lungs

• Viewing with a scope
• e.g. colonoscopy

Dangerous infection of the blood

Infection/inflammation of the nasal sinuses

Physical blockage of the small intestines

Strep throat

Higher on the body, nearer to the head

Body position lying face up

• "Passing out"
• Loss of consciousness or fainting

• Fast heart rate
• HR>100bpm

Inability to open the jaw due to pain

Increased breathing rate

Blisters or open-sores

Room-spinning dizziness (not light-headed)

High pitched sound heard in the lungs with asthmatics or lung disease

• Abdomen
• Abdominal

Antibiotics

Atrial fibrillation

• Acute Otitis Media
• (new ear infection)

Assessment and Plan

Acetylsalicylic Acid (Aspirin)

Twice Daily

Bilateral Lower Extremities

Bowel Movement

Blood Pressure

With

• Cancer
• Carcinoma

Coronary Artery Bypass Graft

Coronary Artery Disease

• Complete Blood Count
• (bloodwork to look for infection or anemia)

Congestive Heart Failure

Chest Pain

Complains of

Chronic Obstructive Pulmonary Disease

Chronic Renal Failure

Caesarean Section

Computerized Assisted Tomography

Clear to auscultation

Cardiovascular

Cerebrovascular Accident

Chest X-Ray

Diabetes Mellitus

Dyspnea on Exertion

Dorsalis Pedis / Posterior Tibialis

Deep Vein Thrombosis

Diagnosis

Electrocardiogram

Extraocular Movements Intact

Alcohol

Family History

• Follow-up
• (i.e. Follow-up in 3 days for a re-evaluation)

Fracture

Gastroesophageal Reflux Disease

Gastrointestinal

Gravida/Para/Abortion

Genitourinary

Headache

Head, Ears, Eyes, Nose, Throat

Health Insurance Portability and Accountability Act

Hyperlipidemia

History of Present Illness

Hypertension (high blood pressure)

History

Hemoglobin and Hematocrit

Incision and Drainage

Insulin Dependent Diabetes Mellitus

Intrauterine Pregnancy

Intravenous Drug Abuse

Left Lower Extremity

Left Lower Quadrant

Last Normal Menstrual Period

Loss of Consciousness

Lumbar spine

Left Upper Extremity

Left Upper Quadrant

Myocardial Infarction

Not Applicable

• No Acute Distress
• No Acute Disease

Non-Insulin Dependent Diabetes Mellitus

No Known Drug Allergies

Normal

Non Steroidal Anti-Inflammatory Drug

Normal Sinus Rhythm

Nausea/Vomiting/Diarrhea

• Oxygen Saturation
• (a.k.a. SaO2 or SpO2 or Pulse Ox or Sat)

Obstetrics and gynecology

Overdose

• Otitis Media
• (inner ear infection)

• Oropharynx
• (mouth and throat)

Open Reduction and Internal Fixation (orthopedic surgery)

Primary Care Physician/Primary Medical Doctor

Physical exam/Pulmonary Embolism

Pupils are Equal, Round, and Reactive, to Light

• Per Os
• (by mouth)

As needed

Patient

• Prior To Arrival
• -OR-
• Peritonsillar Abscess

Peripheral Vascular Disease

Every

Every Day

At Every Bedtime

Four Times a Day

Right Lower Extremity

Right Lower Quadrant

Range of Motion

Review of System

Regular rate and rhythm (normal heart sounds)

Right Upper Extremity

Right Upper Quadrant

Prescription

Rule Out

Shortness of Breath

Subjective, Objective, Assessment, and Plan

Status Post (after)

Symptoms

S/T Elevation Myocardial Infarction

• Tonsillectomy & Adenoidectomy
• (tonsils and adenoids removal surgery)

Transient Ischemic Attack

Three Times a Day

Tympanic Membrane (Ear drum)

Treatment

Thoracic spine

Urinalysis

Upper Respiratory Infection

Ultrasound

Up to Date

Urinary Tract Infection

Within Normal Limits (normal, not of concern)

Year(s) Old