ALOC
Altered level of consciousness
Ambulatory
Can walk
Amoxicillin
A common antibiotic given to kids
AMS
Altered mental status
Aneurysm
Any abnormal widening of a blood vessel
Angina
Chest pain due to lack of blood flow to heart muscle
Angioplasty
Opening of an artery (usually in heart) with a wire dilator, usually followed by stent placement to keep it open
Anion gap
A blood test that suggests and unmeasured acid is in the blood
Anisocoria
Unequal pupil sizes
Anterior
Front
Appendectomy
Surgical removal of the appendix
Arrhythmia
Abnormal heart rhythm
Artery
Blood vessel carrying blood away from heart
Arthralgia
Pain in the joint without swelling or wrmth
Articulation
Connection between bones
ASA
Asprin
Atelectasis
Partial collapse of the small airways in the lungs
Atrial flutter/fibrillation
A very fast regular arrhythmia of the heart, needs slowing or conversion
Augmentin
A common antibiotic for ears, bites, skin
Avulsion
A forcible tearing away of a part or structure
Axilla
Underarm
Azithromycin
A common antibiotic for lung infection
BCP
Birth control pill
Beta blocker
Group of drugs that slow heart rate and lower BP
BIB
Brought in by
BID
Twice per day (refers to Rx)
BLE
Bilateral lower extremities
Bradycardia
Abnormally slow heart beat
Bradypnea
Abnormally slow breathing
Brudzinski's sign
Sign of meningitis; positive when a patient's legs lift involuntarily when lifting a patient's head
Bruit
A murmur or sound heard in auscultation indicating narrowing of a vessel
BSO
Bilateral salpingo-oophorectomy
BTL
Bilateral tubal ligation
BUE
Bilateral upper extremities
C/O
Complains of
C/w
Consistent with
CA
Cancer
CABG or CABS (cardiac bypass)
Open heart surgery involving arterial bypass using a transplanted vein
CAD (coronary artery disease)
Abnormal narrowing of the blood vessels of the heart, predisposing to heart attacks
Cardiac catheterization (angiogram)
Passage of a catheter into the heart through an artery usually done to evaluate coronary artery blood flow
Cardiomegaly
Enlargement of the heart
Carotid bruit
Noise from carotid artery narrowing heard with stethoscope
c-dif
Clostridium difficile
Cellulitis
Infection of the skin characterized by erythema, warmth, tenderness
Cerumen
Earwax
Cervical
Pertaining to the neck or to the cervix of the uterus (same word!!!)
Cholecystectomy
Surgical removal of the gallbladder
Cholecystitis
Inflammation of the gallbladder
Cholelithiasis
Gallstone formation in the gallbladder
Cipro
A common antibiotic, especially for lung, urine, kids
Cirrhosis
Inflammation of an liver resulting in scarring and loss of function
Clubbing
Swelling and softening of the nailbed indicating chronic lung problem
CMT
Cervical Motion Tenderness
Colectomy
Surgical removal of part or all of the large intestine
Colostomy
Surgical procedure that provides an opening between the colon and abdominal wall
Conjunctiva
White part of eye and inside lining of eyelids
COPD
Lung problem resulting in shortness of breath, usually from smoking (chronic obstructive pulmonary disease or emphysema)
Cornea
Transparent coat of the eyeball that covers the iris and pupil,
Costovetebral angle tenderness (CVA tenderness)
Tenderness posteriorly at the lower rib
CP
chest pain
Creatinine
blood test measuring kidney function
Crepitus
A crackling or grating sound, usually of bones
CSF
Cerebrospinal fluid
AAA
Abdominal aortic aneurysm
Abd
Abdomen
Abduction
Movement away from the midline
Accessory muscle use
Struggling for breath using muscles in the neck
Adduction
Movement toward the midline
Adenopathy
Enlargement of lymph nodes
Adnexa
Ovaries and fallopian tubes
AED
Automatic External Defibrillator
Afebrile
Without fever
A fib
Atrial fibrillation
Albuterol
An inhaled or oral medication to relieve asthma
CVA (cerebral vascular accident or stroke)
Death of brain matter from loss of blood supply
CW
Chest wall
Cyanosis
Blue skin due to lack of oxygen
Cyanotic
Bluish skin color due to lack of oxygenation
D&C
Dilation and curettage
D5W
An IV solution that has only 5% sugar in it
DDD
Degenerative disk disease
Debridement
Removal of dead or contaminated tissue from a wound
Decubitus
pressure sore on skin
Deep
Farther from the surface
Dentition
The condition of the teeth
Dermis
True skin, beneath the epidermis
Diabetes Mellitus
Disease characterized by abnormally high blood sugar
Diaphoresis
Sweaty
Diaphoresis
Excessive or profuse sweating or perspiration
Differential Diagnosis
A list of possible diagnoses to explain a set of symptoms
Dilaudid
A common narcotic used iv
Diltiazem
A common medication used to slow heart rate
Distal
Farther from the limb root
DJD
Degenerative joint disease
DKA
Diabetes Ketoacidosis
Dopamine
Drug to raise blood pressure in shock
Dorsiflexion
Upward flexion of the foot
Dullness on percussion
Sign of solid fluid or mass under area being "tapped
DVT (deep venous thrombosis)
Clot in the deep veins of the leg or arm
Dysmenorrhea
Painful menstruation
Dyspareunia
Painful intercourse
Dyspepsia
Indigestion
Ecchymosis
Bruising
EF
ejection fraction
EGD
Upper endoscopy
EMS
emergency medical services
Endometriosis
Presence of functioning endometrial tissue outside of the uterus
EOMI
extraocular movements intact
Everted
Rolled outward
Exopthalmus
bulging eyes, often from thyroid disease
Extension
Straightening out
External
Outside
Extrasystoles
Extra beats of the heart
f/u
follow up
FHR
fetal heart rate
FHT
fetal heart tones
Flexion
Bending or angulation
Friction rub
Abnormal heart or lung sound
Funduscopic
exam of back of the eye
G_P_A_
grava (pregnancies), para (live births), abortions (spontaneous or induced)
Gallop
Extra heart sound heard common in CHF
GCS
Glasgow Coma Scale
GIB
Gastrointestinal bleed
Gravid
Being pregnant
GSW
Gun Shot Wound
Guarding
Involuntary tightening of stomach muscles when pushed on - patient cannot control this - due to irritation of lining of abdominal cavity
HCTZ
Hydrochlorothiazide
Hemangioma
Tumor consisting of blood vessels
Hematemesis
Vomiting of blood
Hematochezia
Bright red blood in the stool
Hematoma
Swelling of blood which occurs in an organ or tissue
Hematuria
Blood in the urine
Heme negative
No blood detected by chemical test, usually referring to stool or urine
Hemiparesis
Weakness on one half of body
Hemiplegia
Paralysis on one half of body
Hemoptysis
Coughing up blood
Hemorrhage
Excessive or profuse bleeding
Hemothorax
Blood fluid present in the pleural cavity (outside lung but in chest cavity)
Hepatomegaly
Enlarged liver
Hepatosplenomegaly
Enlargement of the liver and spleen
HH
Hiatal Hernia
Hyperlipidemia
Elevation of cholesterol and or triglycerides in the blood
Hypertension
Persistently high or arterial blood pressure
Hypotension
Persistently low arterial blood pressure
Hysterectomy
Surgical removal of the uterus
IBS
Irritable Bowel Syndrome
ICH
Intracranial hemorrhage
Ileus
Bowel lacks normal contractions, usually shows as air fluid levels on xrays
Induration
Hardened tissue, often from infection
Infarct
Cessation of the blood fl own causing tissue death
Inferior
Lower, farther from head
Inguinal
Pertaining to the groin region
Internal
Inside
Intervertebral disc
Structure lying between the bony vertebral bodies
Inverted
Rolled inward
Irregularly irregular rhythm
No consistent pattern to the heart rhythm, usually implying atrial fibrillation
Ischemia
Temporary and localized lack of blood flow
IUP
Intrauterine pregnancy
IVC
Inferior vena cava
Jaundice
Yellow discoloration of the skin
Joint
Articulation or junction between two or more bones or cartilage
JVD
Jugular vein distention
Keloid
Scar formation consisting of dense tissue
Kernig's sign
Sign of meningitis; positive when the leg is fully bent at the hip and knee, and subsequent extension of the knee leads to pain
Lacrimal
Pertaining to tears
LAFB
Left anterior fascicular block
Lateral
Farther from the midline
LBBB
Left bundle branch block
Leukocyte esterase
Chemical test to detect possible infection in urine
Ligament
Fibrous tissue, binding bones together
Lingual
Pertaining to the tongue
Lipase
Blood test measuring pancreas activity
LLE
Left lower extremity
LLQ
Left lower quadrant
LNMP
Last normal menstrual period
LOC
Loss of consciousness
LUE
Left upper extremity
LUQ
Left upper quadrant
LVH
Left ventricular hypertrophy
Lymphadenopathy
Enlargement of lymph nodes
Lymphangitis
Infection traveling up lymphatic system
Macule
Small colored spot on the skin
Malaise
Generalized discomfort or weakness
Malleolus
Projections on either side of the ankle joint from the lower leg bones
Malocclusion
Teeth don't fit together
Mass
Any firm abnormality seen or palpated on physical exam
Mastectomy
Surgical excision of the breast
Maxalt
A migraine medication
Maxilla
Cheek, or structures near cheek
MCA or MCC
Motorcycle accident
Medial
Nearer to the midline
Melena
Black tarry stool
Meningismus
Stiff neck
MI
Myocardial infarction
Morphine
A common narcotic used IV
MRA
Magnetic resonance angiogram
MRSA/VRSA
two types of very resistant bacteria
Murmur
Abnormal heart sound rated on 1 to 6 scales, 6 being the loudest
MVA
Motor vehicle accident
Myalgia
Muscular pain
Myocardial infarction
heart attack (coronary artery occluded)
Nares
Nostrils
Neuralgia
Sharp pain along the course of a nerve
Nitroglycerine
Dilates blood vessels, used with heart pain
NL
normal
Norco
An oral narcotic, identical to Vicodin
Normal saline
An IV fluid that is equimolar to blood
NSAID
non-steroidal anti-inflammatory
NSR
normal sinus rhythm
NSVD
normal spontaneous delivery
NTG
nitroglycerine
Nystagmus
Involuntary rapid eye movements
Occiput
Back part of the skull
Olecranon
Bony projection of the ulna forming the point of the elbow
Oophorectomy
Surgical removal of ovaries
OOT/OOA
out of town/area
Organomegaly
Enlargement of the abdominal organs, usually spleen, liver or kidneys
Os
Mouth, orifice
OTC
Over the counter
Pallor
Paleness of the skin
Palmar or Volar
Palm side of hand or body
Palpable
Able to be touched or easily perceived
Paresthesia
Abnormal tactile sensation often described as burning, tingling, or numbness
PAT
Paroxysmal atrial tachycardia
PE (pulmonary embolus)
clot in the lung, often arising from leg veins or pelvis
Pedal edema
Water retention in the foot/ankle area
Peritonsillar abscess
Abscess that forms behind the tonsil
Petechia
Tiny red spot occurring on the skin caused by a small amount of subcutaneous bleeding from the capillaries
Pharynx
back of the throat extending up to the nose and down to the vocal cords
Photophobia
Abnormal intolerance to light
Plantar
Sole side of foot
Plantar flexion
Downward flexion of the foot
PMD/PCP
primary care doctor
PMI displaced laterally
Sign of enlarged heart
Pneumothorax
Abnormal presence of air in the pleural space (chest cavity) and outside of the lung, causing the lung to collapse
Posterior or Dorsal
Back of body
PRN
As needed (refers to Rx)
Prolonged expirations
Indicates airway narrowing on expiration, common in asthma
Prominent abdominal aortic pulsation
Possible abdominal aortic aneurysm
Prone
Face down
Proximal
Nearer to the limb root
PSVT
Paroxysmal supraventricular tachycardia
Pt
Patient
Pulmonary
Related to lung
Purulent
Consisting of pus
PVC
Premature ventricular contraction
PVD
peripheral vascular disease
q
Every (refers to Rx)
Q4H
Every 4 hours (refers to Rx)
qd
Everyday (refers to Rx)
RA
Rheumatoid arthritis
Rales
Clicking, rattling, or crackling noises heard in the lungs on inhalation, indicating fluid in the alveoli (sign of pneumonia or heart failure)
RBBB
Right bundle branch block
Rebound
Pain when releasing hand from abdominal palpation or from other movement
Retractions
Sucking in between ribs or sternum, during inspiration - usually children
Rhinorrhea
Thin, watery discharge from the nose
Rhonchi
A coarse sound in the lungs that indicates the presence of thick fluid
Rhonchi
Abnormal respiratory sound heard on auscultation
RLE
Right lower extremity
RLQ
Right lower quadrant
Rocephin
A common IV antibiotic
ROM
Range of motion
Romberg's sign
Falling to one sign standing with eyes closed
RUE
Right upper extremity
RUQ
Right upper quadrant
RVR
Rapid ventricular response
S/P
Status post (after)
SAB
Spontaneous abortion
SAH
Subarachnoid hemorrhage
Sclera
The layer under the white part of the eye
SDH
Subdural hemorrhage
Sepsis
Severe systemic infection; toxins in the blood
Shaft
Long, slender portion of a long bone
SNF
Skilled nursing facility
SOB
Shortness of breath
Splenectomy
Surgical removal of the spleen
Splenomegaly
Enlarged spleen
Splinting
Not moving because of pain
Sputum
Spittle, any mixed matter with saliva that is expectorated through the mouth
Status epilepticus
Continuous seizure activity
Stellate
Star-Shaped
Stenosis
Narrowing of a body opening or passage
Stridor
Harsh or high-pitched respiratory sound, caused by obstruction of upper airway passages
Stridor
High pitched sound heard on inspiration that is indicative of airway obstruction
Superficial
Nearer to the surface
Superior
Upper, nearer to head
Supine
Face up
Supraventricular
Arising from the atria of the heart
SVT
Supraventricular tachycardia
Syncope
Loss of consciousness
T&A
Tonsillectomy and adenoidectomy
TAB
Therapeutic abortion
Tachycardia
Abnormal rapid heart beat
Tachycardia
Fast heart rate
Tachypnea
Extremely rapid respiration
TAH
Total abdominal hysterectomy
Thoracotomy
Surgical opening of the chest cavity
Thyroid
Gland in front of the windpipe that makes thyroid hormones
Thyromegaly
Enlarged thyroid
TIA (transient ischemic attack)
Minor stroke", neurological function is regained with time
Tinea
Superficial fungal infection of the skin
Tinnitis
Ringing in the ears
Tonsillectomy
Surgical excision of the tonsils
Torsion
The twisting of a bodily organ on its own axis (usually pertaining to an ovary or testicle)
TPA - tissue plasminogen activator
Drug that immediately dissolves clots
Troponin
Test done to indicate recent heart attack
TTP
Tenderness to palpation
Turgor
Condition of being distended or swollen
TURP (transurethral resection of prostate)
Procedure to remove prostatic tissue preformed using an endoscope passed through the urethra
URI
Upper respiratory infection
Urinary retention
Large bladder due to obstruction
Urticaria
Hives or wheals, either redder or paler than the surrounding area and are often itchy
Vancomycin
A common IV antibiotic given for skin infections
Vein
Vessel carrying deoxygenated blood back to the heart
Vertebral point
Tenderness: Tenderness directly over the spine
Vertigo
A spinning sensation caused by an inner ear problem
Vestibulitis
Inflammation of balance mechanism in the inner ear causing dizziness
Vicodin
An oral narcotic, identical to Norco
VSS
Vital signs stable
w/
With
w/o
Without
w/u
Work up
WBC
White blood cells including leukocytes, monocytes, and others
Wheal
Round, localized area of edema on the skin attended by severe itching
Wheezing
High: pitched whistling sound of air moving through narrowed airways
Xopenex
An inhaled medication to releive asthma
Zofran
A common anti-nausea medication
Mandible
Jaw bone
PQRST
provocative/palliative, quality, region/radiation, severity, timing
HTN
hypertension
DM
diabetes mellitus
GERD
gastroesophageal reflux disease
PNA
pneumonia
Diverticulitis
common digestive disease involving formation of pouches (diverticula) on the outside of the colon
BPH
benign prostatic hyperplasia
Icterus
sclera is yellow (jaundice)
Diplopia
double vision
Orthopnea
difficulty breathing when lying down
Nocturia
frequent urination at nighttime
Claudication
blood clotting
Myalgias
body ache
Polydypsia
excessive thirst
Otalgia
ear pain
PND
paroxysmal nocturnal dyspnea
PERRLA
pupils equal, round, reactive to light and accommodation
FAST
focused assessment with sonography for trauma
CHF
congestive heart failure
STEMI
ST elevation MI (myocardial infarction)
Effusion
abnormal collection of fluid in a body cavity or space
Edema
abnormal accumulation of fluid beneath the skin or in the cavities of the body
Erythema
redness of skin
Pronator Drift
patient has eyes closed and both arms extended and supinated. If one arm drifts down and pronates, this may indicate a neurological problem
Nuchal Rigidity
neck stiffness, possibly signifying meningitis
Tongue Deviation
tongue points to one side when patient extends it, may indicate neurological problem
Rovsing's Sign
positive when deep palpation of the left iliac fossa causes pain in the right iliac fossa, may indicate acute appendicitis
Psoas Sign
positive when RLQ abdominal pain is reproduced when the patient lies on his or her left side and the hip is subsequently extended, may indicate appendicitis
Obturator Sign
positive when the obturator muscles spasms when the patient's hip is flexed and internally rotated, may indicate appendicitis
McBurney's Point
area over the right side of abdomen that is 1/3 the distance from the right iliac spine to the umbilicus, pain when palpated may indicate acute appendicitis