Medical Terminology Chapter 2 Health Records

Front 1

Acute

Back 1

Sharp; having intense, often severe symptoms and a short course.

Front 2

Chronic

Back 2

a condition that develops slowly and persists over a period of time.

Front 3

Benign

Back 3

mild or noncancerous.

Front 4

Malignant

Back 4

harmful or cancerous.

Front 5

Degeneration

Back 5

gradual deterioration of normal cells and body functions.

Front 6

Degenerative Disease

Back 6

any disease in which deterioration of the structure or function of tissue occurs.

Front 7

Diagnosis

Back 7

determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results) (dia = through; gnosis = knowing).

Front 8

Etiology

Back 8

study of the cause of a disease. (etio = cause).

Front 9

Exacerbation

Back 9

increase in the severity of a disease, with aggravation of symptoms (ex = out; acerbo = harsh).

Front 10

Remission

Back 10

a period in which symptoms and signs stop or abate.

Front 11

Febrile

Back 11

relating to a fever (elevated temperature).

Front 12

Idiopathic

Back 12

a condition occurring without a clearly identified cause (ido = one's own).

Front 13

Localized

Back 13

limited to a definite area or part.

Front 14

Systemic

Back 14

relating to the whole body rather than to only a part.

Front 15

Malaise

Back 15

a feeling of uneasiness or discomfort; often the first indication of illness.

Front 16

Marked

Back 16

significant.

Front 17

Morbidity

Back 17

sick; a diseased state.

Front 18

Mortality

Back 18

the state of being subject to death.

Front 19

Prognosis

Back 19

foreknowledge; prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease; often noted in one word (e.g, "Prognosis: good").

Front 20

Progressive

Back 20

pertaining to the advance of a condition as the signs and symptoms increase in severity.

Front 21

Prophylaxis

Back 21

a process or measure that prevents disease (pro = before; phylassein = guard).

Front 22

Recurrent

Back 22

to occur again; describes a return of symptoms and signs after a period of quiescence (rest or inactivity).

Front 23

Sequela

Back 23

a disorder or condition usually resulting from a previous disease or injury.

Front 24

Sign

Back 24

a mark; objective evidence of disease that can be seen or verified by an examiner.

Front 25

Symptom

Back 25

subjective evidence of disease that is perceived by the patient and often noted in his or her own words.

Front 26

Syndrome

Back 26

a running together; combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease (e.g, menopausal syndrome).

Front 27

Noncontributory

Back 27

not involved in bringing on the condition or result.

Front 28

Unremarkable

Back 28

common; not out of the ordinary or significant.

Front 29

CCU

Back 29

coronary (cardiac) care unit

Front 30

ECU

Back 30

emergency care unit

Front 31

ER

Back 31

Emergency Room

Front 32

ICU

Back 32

Intensive care unit

Front 33

IP

Back 33

inpatient (a registered bed patient)

Front 34

OP

Back 34

outpatient

Front 35

OR

Back 35

operating room

Front 36

PACU

Back 36

postanesthetic care unit

Front 37

PAR

Back 37

postanesthetic recovery

Front 38

Post-op or Postop

Back 38

postoperative (after surgery)

Front 39

Pre-op or preop

Back 39

preoperative (before surgery)

Front 40

RTC

Back 40

return to clinic

Front 41

RTO

Back 41

return to office

Front 42

B

Back 42

bilateral

Front 43

BRP

Back 43

bathroom privileges

Front 44

CP

Back 44

chest pain

Front 45

DC or D/C

Back 45

discharge, discontinue

Front 46

ETOH

Back 46

ethyl alcohol

Front 47

L

Back 47

left

Front 48

R

Back 48

right

Front 49

m

Back 49

murmur

Front 50

pt

Back 50

patient

Front 51

RRR

Back 51

regular rate and rhythm

Front 52

SOB

Back 52

shortness of breath

Front 53

Tr

Back 53

treatment

Front 54

Tx

Back 54

treatment or traction

Front 55

VS

Back 55

vital signs

Front 56

T

Back 56

temperature

Front 57

P

Back 57

pulse

Front 58

R

Back 58

respiration

Front 59

BP

Back 59

blood pressure

Front 60

Ht

Back 60

height

Front 61

Wt

Back 61

weight

Front 62

WDWN

Back 62

well-developed and well-nourished.

Front 63

y/o or y.o.

Back 63

year old

Front 64

#

Back 64

number or pound; if used before a numeral, it means number (e.g, #2 = number 2); if used after a numeral, it means pound (e.g, 150# = 150 pounds).

Front 65

C

Back 65

Celsius, centigrade

Front 66

F

Back 66

Fahrenheit

Front 67

cc

Back 67

cubic centimeter; 1 cc = 1 mL (use the metric equivalent mL.)

Front 68

cm

Back 68

centimeter; 2.5 cm = 1 inch

Front 69

g or gm

Back 69

gram

Front 70

kg

Back 70

kilogram; equal to 1,000 grams or 2.2 pounds.

Front 71

L

Back 71

liter

Front 72

mg

Back 72

milligram; equal to one-thousandth (0.001) of a gram.

Front 73

mL, ml

Back 73

millileter; equal to one-thousandth (0.001) of a liter.

Front 74

mm

Back 74

millimeter; equal to one-thousandth (0.001) of a meter.

Front 75

cu, mm, mm^3

Back 75

cubic millimeter.

Front 76

fl oz

Back 76

fluid ounce

Front 77

gr

Back 77

grain

Front 78

gt

Back 78

drop (gutta = drop)

Front 79

gtt

Back 79

drops

Front 80

dr

Back 80

dram; equal to 1/8 ounce

Front 81

oz

Back 81

ounce

Front 82

lb or #

Back 82

pound; equal to 16 ounces

Front 83

qt

Back 83

quart; equal to 32 ounces.

Front 84

tablet (tab)

Back 84

by mouth.

Front 85

capsule (cap)

Back 85

(sublingual)- under the tongue

(buccal)- in the cheek

Front 86

Suppository (suppos)

Back 86

(vaginal)- inserted in the vagina

(rectal)- inserted in the rectum

Front 87

fluid

Back 87

(inhalation)- inhaled through the nose or mouth.

(aerosol)- spray

(nebulizer)- device used to produce a fine spray or mist, often in a metered dose.

Front 88

Parenteral

Back 88

{by injection}
ID (intradermal)- within the skin
IM (instramuscular)-within muscle
IV (Intravenous)- within the vein
SC,SQ (subcutaneous)- under
the skin
(write out subcut)

Front 89

Cream, lotion, ointment

Back 89

(topical)- applied to the surface of the skin

Front 90

Other delivery systems

Back 90

(transdermal)- absorption of drug through broken skin.

(implant)- a drug reservoir imbedded in the body to provide continual infusion of a medication (e.g, insulin pump).

Front 91

a.c.

Back 91

before meals

Front 92

a.m.

Back 92

before noon

Front 93

b.i.d.

Back 93

twice a day

Front 94

h

Back 94

hour

Front 95

h.s.

Back 95

at the hour of sleep (bedtime) [spell out bedtime]

Front 96

noc.

Back 96

night

Front 97

p.c.

Back 97

after meals

Front 98

p.m.

Back 98

after noon

Front 99

p.r.n.

Back 99

as needed

Front 100

q

Back 100

every

Front 101

q.d.

Back 101

everday [NEVER USE: spell out every day or daily]

Front 102

qh

Back 102

every hour

Front 103

q2h

Back 103

every 2 hours

Front 104

q.i.d.

Back 104

four times a day

Front 105

q.o.d.

Back 105

every other day [NEVER USE: spell out every other day]

Front 106

STAT

Back 106

immediately

Front 107

t.i.d.

Back 107

three times a day

Front 108

wk

Back 108

week

Front 109

yr

Back 109

year

Front 110

ad lib.

Back 110

right ear [spell out right ear]

Front 111

amt

Back 111

as desired

Front 112

aq

Back 112

water

Front 113

AS

Back 113

left ear [spell out left ear]

Front 114

AU

Back 114

both ears [ spell out both ears ]

Front 115

NPO

Back 115

nothing by mouth

Front 116

OD

Back 116

right eye [spell out right eye]

Front 117

OS

Back 117

left eye [spell out left eye]

Front 118

OU

Back 118

both eyes [spell out both eyes]

Front 119

per

Back 119

by or through

Front 120

p.o.

Back 120

by mouth

Front 121

PR

Back 121

through rectum

Front 122

PV

Back 122

through vagina

Front 123

Rx

Back 123

recipe; prescription

Front 124

Sig

Back 124

label; instruction to the patient

Front 125

wa

Back 125

while awake

Front 126

x

Back 126

times or for; x6 means six times while x2d means for two days

Front 127

>

Back 127

greater than (spell out greater than)

Front 128

<

Back 128

less than (spell out less than)

Front 129

i

Back 129

one (modified lowercase Roman numeral i)

Front 130

ii

Back 130

two (modified lowercase Roman numeral ii)

Front 131

iii

Back 131

three (modified lowercase Roman numeral iii)

Front 132

iv

Back 132

four (modified lowercase Roman numeral iv).

Front 133

I,II,III,IV,V,VI,VII,VIII,IX,X

Back 133

uppercase Roman numerals from 1 to 10.