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207 Cards in this Set
- Front
- Back
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CC
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chief complaint
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c/o
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complains of
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Dx
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diagnosis
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FH
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family history
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HEENT
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head, eyes, ears, nose, and throat
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H&P
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history and physical
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HPI, PI
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history of present illness, present illness
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Hx
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history
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IMP
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impression
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L&W
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living and well
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NAD
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no acute distress
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NKA, NKDA
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no known allergies, no known drug allergies
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O
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objective information
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OH
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occupational history
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P
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plan (recommendation, disposition)
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PE, Px
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physical examination
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PERRLA
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pupils equal, round, and reactive to light and accommodation
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PH, PMH
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past history, past medical history
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R/O
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rule out
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ROS, SR
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review of systems, system review
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S
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subjective information
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SH
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social history
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Sx
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symptom
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UCHD
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usual childhood diseases
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WNL
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within normal limits
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A
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assessment
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A&W
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alive and well
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h&p is called ______ when patient is to have surgery
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preoperative H&P
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after h&p is recorded ____ are used to document patients continued care
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progress notes
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most common method of documenting patient progress
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SOAP
(subjective, objective, assessment, plan) |
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first document entered into patients hospital record& commonly required before elective admission for surgery
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history and physical
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list the directives for care prescribed by the doctor who is attend to the patient
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physicians orders
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chronicle the care throughout patients stay (2)
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nurses notes & physicians progress notes
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in a difficult case specialist called in by attending physician and _____ is filed
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consultation report
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detailed account of operation (incision, techniques, instruments, suture, method of closure, patients response)
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operative report
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covers anesthesia details filed by anesthesiologist in charge of life support during surgery
(amesthesia details, drugs used, dose, time) |
anesthesiologists report
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must be signed by patient when surgery or procedure involves reasonable risk
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informed consent
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note any additional procedures or therapies such as diagnostic tests and pathalogy reports
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ancillary reports
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final hospital document recorded at time of discharge, summary of patients hospital care (date of admission/discharge, diagnosis)
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discharge summary
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other names for discharge summary (3)
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clinical resume
clinical summary discharge abstract |
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discovered xrays in 1885
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wilhelm roentgen
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a process that changes the electrical charge of atoms & has a possible effect on body cells
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ionizing
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nonionizing modalities presenting no apparent risk
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MRI
sonography |
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imaging modality uses xrays to produce images of bodys anatomy for diagnosis of condition
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radiography
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small amount of radiation passed through body to expose a sensitive film
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radiograph
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uses scanner to examine body site by taking series of cross sectional (tomographic) xray films in full circle rotation
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computed tomography (CT)
computed axial tomography (CAT) |
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nonionizing imaging technique using magnetic fields & radio frequency waves to visualize anatomical structures
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magnetic resonance imaging (MRI)
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applies magnetic resonance technology in study of blood flow
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magnetic resonance angiography
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use of high frequency sound waves to visualize body tissues
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sonography (diagnostic ultra sound)
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increase visual clarity (barium, iodinated compounds, gases)
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contrast medium
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CT
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computed tomography
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another name for nuclear medicine imaging
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radionuclide organ imaging
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acute
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sharp; intense severe symptoms & a short course
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chronic
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condition develops slowly & persists over a period of time
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benign
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mild/ non cancerous
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malignant
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harmful/ cancerous
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degeneration
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gradual deterioration of normal cells & body functions
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degenerative disease
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any disease in which deterioration of structure or function of tissue occurs
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diagnosis
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determination of presence of disease based on evaluation of symptoms/ signs/ test findings
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etiology
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study of the cause of a disease
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etio
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cause
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exacerbation
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increase in severity of a disease with aggravation of symptoms
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remission
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period in which symptoms and signs stop or abate
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febrile
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relating to a fever
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idiopathic
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condition occuring w/o clearly identified cause
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localized
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limited to a definite area or part
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systemic
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relating to whole body rather than only a part
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malaise
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feeling of uneasiness or discomfort (1st indication of illness)
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marked
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significant
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morbidity
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sick, diseased state
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mortality
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state of being subject to death
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prognosis
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foreknowledge. prediction of likely outcome of disease based on general health status of patient along with knowledge of usual course of disease
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progressive
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advance of a condition as the signs and symptoms increase in severity
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prophylaxis
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process or measures that prevents disease
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CCU
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coronary (cardiac) care unit
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ECU
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emergency care unit
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ER
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emergency room
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ICU
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intensive care unit
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IP
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inpatient (a registered bed patient)
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OP
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outpatient
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OR
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operating room
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PACU
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post anesthestic care unit
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PAR
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post anesthestic recovery
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postop
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postoperative
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preop
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preoperative
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RTC
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return to clinic
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RTO
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return to office
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BRP
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bathroom privileges
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CP
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chest pain
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DC
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discharge
discontinue |
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ETOH
|
ethyl alcohol
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L enclosed by circle
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left
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R enclosed by circle
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right
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m enclosed by circle
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murmur
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b enclosed by circle
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bilateral
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pt
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patient
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RRR
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regular rate and rythm
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SOB
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shortness of breath
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Tr
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treatment
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Tx
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treatment of traction
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VS
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vital signs
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T
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temperature
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P
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pulse
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R
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respiration
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BP
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blood pressure
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Ht
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height
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Wt
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weight
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WDWN
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well developed and well nourished
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y/o
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year old
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# used before a numeral means
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number
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# used after numeral
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pound (150#)
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C
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Celsius, centigrade
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F
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Fahrenheit
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2 systems used to express pharmaceutical units of measure
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metric & apothecary
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most commonly used system of measurement in health care
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metric
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method of liquid and weight used by earliest chemists and pharmacists
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apothecary system
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meter measures
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length (39.37 inches)
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liter measures
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volume (1.0567 quarts)
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gram measures
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weight (15.432 grains)
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cc
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cubic centimeter (1cc=1mL)
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cm
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centimeter (2.5 cm=1 inch)
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g
gm |
gram
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kg
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kilogram (1000 grams or 2.2 lbs)
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L
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liter
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mg
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milligram (one thousandth of a gram)
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mL
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milliliter (one thousandth of a liter)
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mm
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millimeter (one thousandth of a meter)
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cu mm
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cubic millimeter
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fl oz
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fluid ounce
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gr
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grain
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gt
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drop (gutta=drop)
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gtt
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drops
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dr
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dram (1/8 oz)
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oz
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ounce
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lb or #
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pound (16 oz)
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qt
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quart (32 oz)
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one thousandth
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milli-
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kilo-
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one thousand
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centi-
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one hundred
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diameter of a lesion commonly measured in
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centimeters (cm)
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oral
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by mouth
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sublingual (SL)
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under tongue
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buccal
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in cheek
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vaginal
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inserted in vagina
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rectal
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inserted in rectum
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aerosol
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spray
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nebulizer
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fine spray or mist
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intradermal (ID)
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within skin
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intramuscular (IM)
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within muscle
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intravenous (IV)
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within vein
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subcutaneous
(SC SQ sub-Q |
under the skin
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topical
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applied to surface of skin
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transdermal
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absorption of drug through unbroken skin
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implant
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drug imbedded in body to provide continual infusion of medication (insulin pump)
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p.o.
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by mouth
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by or through
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per
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parental route of administration
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injection
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pr
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Through rectum
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pv
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through vagina
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suppositories are inserted (2)
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pr (rectum) or pv (vagina)
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written direction by a physician for dispensing or administering a medication to a patient
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prescription
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formula for drug written exactly according to its chemical structure
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chemical name
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generic name
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official non proprietary name given to a drug
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trade or brand
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manufacturers name for a drug
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label that provides specific instructions for administration
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sig:
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most pharmacy organizations promote the use of _____ numerals only
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arabic
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ā
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before
(ante) |
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a.c.
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before meals
(ante cibum) |
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a.m.
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before noon
(ante meridiem) |
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b.i.d.
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twice a day
(bis in die) |
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d
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day
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h
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hour
(hora) |
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h.s.
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at the hour of sleep/ bedtime
(hora somni) |
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noc.
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night
(noctis) |
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p
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after
(post) |
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p.c.
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after meals
(post cibum) |
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p.m.
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after noon
(post meridiem) |
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p.r.n.
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as needed
(pro re nata) |
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q
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every
(quaque) |
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q.d.
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every day
(quaque die) |
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qh
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every hour
(quaque hora) |
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q2h
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every two hours
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q.i.d.
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four times daily
(quarter in die) |
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q.o.d.
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every other day
(quaque altera die) |
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STAT
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immediately
(statium) |
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t.i.d.
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three times daily
(ter in die) |
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wk
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week
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yr
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year
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AD
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right ear
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ad lib.
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as desired
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amt
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amount
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aq
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water
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AS
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left ear
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AU
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both ears
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ć
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with
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NPO
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Nothing by mouth
(non per os) |
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OD
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right eye
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OS
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left eye
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OU
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both eyes
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per
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by or through
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p.o.
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by mouth
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Rx
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prescription
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wa
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while awake
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x
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times or for
(x6= six times) (x2d= for two days) |
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>
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greater than
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<
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less than
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error prone abbreviations that should NEVER be used are on this list provided by JCAHO
|
"do not use" list
|
