Medical Terminology and Abbreviations
Amy Sayle, PhD, MPH
This presentation by Brad Torok, MD, gives you an overview of medical
terminology and abbreviations one might encounter when reviewing medical
records.
SLIDE 1
Medical Terminology and Abbreviations or How to Decipher the Secret Code in a
Medical Record. This presentation explains some of the commonly seen types of
medical chart notes and the terminology in them.
SLIDE 2
The objectives of this presentation are to first, understand the organization of a medical
chart; second, to recognize the three most common types of patient notes found in
medical charts; third, to recognize common clinical terms used to describe symptoms in
the major body systems and finally, recognize common clinical terms used to describe
examination findings in the major body systems.
SLIDE 3
Topics to be presented include medical chart organization, types of patient encounter
notes, medical history terms and abbreviations, physical examination terms and
abbreviations, and laboratory and chest x-ray terms and abbreviations.
SLIDE 4
Medical charts are a highly-specialized, technical document. They are predominantly
paper-based, although some are computerized, and many are hand-written. Like any
technical document, medical charts are difficult to interpret; however, there is a great
deal of standard formatting and terminology. Chart interpretation can sometimes be
made more difficulty by physicians' notoriously illegible handwriting, but for the purposes
of this exercise, we will assume any notes we encounter are typed.
SLIDE 5
Chart organization. Most patient records are still composed of paper in a manila folder,
usually divided into several sections. They are often close to this order if not identical,
the first section consisting of patient demographic and insurance information. Flow
sheets are used to concisely keep track of preventive care, medications, allergies,
medical problems, surgeries, and other useful information. These are often followed by
the patient's actual visit notes and then laboratory results, radiology results, consultant
notes and letters, and other reports and communications. The exact format of charts
and their organization can very quite a bit, depending on whether the patient is in a
hospital, another institution, or in an outpatient setting.
SLIDE 6
The three most commonly encountered types of patient notes are the history and
physical, the SOAP note, and the discharge summary.
SLIDE 7
First, we will review the history and physical. The history and physical note is usually a
very in-depth note performed on the first visit or consultation with a patient or for routine,
physical examinations. These begin with a section on the patient's history, which
includes the following components. The CC or Chief Complaint, otherwise known as
the reason for the visit, the HPI, or History of Present Illness, which is the history around
the reason for the visit, the ROS or Review of Systems, which consists of asking the
patient about the presence or absence of symptoms by body area. This is followed by
the patient's prior history, including their past medical history, abbreviated PMHx, and
past surgical history, abbreviated PSHx.
SLIDE 8
The social history can include information regarding smoking, drinking, drug use,
education, employment, the living situation, the sexual preference, and the marital
status of the patient. The family history will usually pertain to illnesses present in the
immediate family, such as parents and siblings. The final component is often
medications, including medications the patient is currently taking and any medication
allergies. A very commonly encountered abbreviation is NKDA, which is short for No
Known Drug Allergies. You may also see just NKA for No Known Allergies.
SLIDE 9
All of the objective or examination findings are after the subjective findings. This
includes a section on physical examination findings, followed by a section on laboratory
studies, and finally, other studies, such as radiologic studies like x-rays, CT scans, MRI
scans, and ultrasounds.
SLIDE 10
The history and physical concludes with an assessment consisting of either a Dx, the
abbreviation for diagnosis, or DDx, the abbreviation for differential diagnosis. A
differential diagnosis is a list of possible diagnoses when the diagnosis is unclear. For
each diagnosis, a plan is laid out for treatment. If the diagnosis is unclear, a plan is laid
out for determining the diagnosis. The full history and physical will often be dictated in
narrative form and when typed, can cover two or more pages.
SLIDE 11
Another commonly encountered note format is called the SOAP note.
SLIDE 12
The SOAP note format is very brief and is usually used when a patient already has a
more complete history and physical in their chart to refer back to. The SOAP note
includes four basic sections. S stands for Subjective, meaning anything collected by
verbal means rather than examination and testing. The subjective component includes
the complaints the patient is being seen for and the surrounding information the provider
collects verbally. Subjective includes the chief complaint or CC, the history of present
illness, or HPI, and the review of systems, or ROS, from the more comprehensive
history and physical note discussed above. The O is for Objective and includes any
objectively obtain information, including the vital signs, physical examination findings,
and laboratory and radiological results. The A is for Assessment and is usually a brief
section where the provider notes the diagnosis or diagnoses or several potential
diagnoses if the provider is unsure. P is for Plan where the further diagnostic testing to
be done is noted, as well as any treatment plans and instructions for the patient are
noted.
SLIDE 13
The final type of note we'll discuss is the Hospital Discharge Summary.
SLIDE 14
The Discharge Summary is a long history and physical format narrative summarizing a
patient's hospital stay. It condenses the large amount of information from a hospital
stay into one note, starting with the events surrounding the hospital admission and
includes the course of events in the hospital, such as important test results, major
diagnoses, and major treatments. It concludes with a summary of the patient's
diagnoses, the condition of the patient at the time of discharge, and any treatment
recommendations and follow up required once discharged. The format can be easily
followed when you understand the format of the history and physical.
SLIDE 15
The following section will present subjective terminology, which is encountered in the
history section of a history and physical or the S section of a SOAP note.
SLIDE 16
We will review these terms by body system. We will begin with HEENT, which stands
for head, eyes, ears, nose, and throat. Some commonly encountered terms referring to
these areas include occipital, meaning back of the head, photophobia, meaning literally
fear of light but more commonly meaning light worsening a patient's head or eye pain,
phonophobia, meaning again literally fear of sound but more commonly used to mean
sound making a headache worse, and also diplopia, which is double vision or seeing
double.
SLIDE 17
Epistaxis is a term meaning nose bleed. Rhinorrhea is nasal drainage or runny nose.
Otorrhea is discharge or drainage from the ear. Tinnitus means a constant ringing in
one or both ears.
SLIDE 18
Moving on from the HEENT system, the cor or coronary refers to the heart. Other than
pain in the chest, the most common description patients may have regarding their heart
is the sensation of palpitations, which is a fluttering sensation or the feeling of a skipped
or extra beat. Next is pulm, which is short for pulmonary and refers to the lungs.
Patients with SOB feel short of breath. A more concise term for short of breath is
dyspnea. Those who cough up phlegm have a productive cough, whereas a dry cough
is nonproductive.
SLIDE 19
Wheezing is a high-pitched whistling sound when breathing, most often heard in
patients with asthma. Hemoptysis is coughing up blood. Pleuritic is a symptom, usually
pain that gets worse with deep breathing, such as a pleuritic chest pain.
SLIDE 20
The abdomen is abbreviated Abd or GI, which is short for gastrointestinal. Patients with
abdominal complaints often have pain in one area of the abdomen. The abdomen is
divided into four sections or quadrants, as you see in the diagram, using the naval as
the center of the dividing lines. The abbreviations used are right upper quadrant, right
lower quadrant, left upper quadrant, and left lower quadrant.
SLIDE 21
Sometimes pain is in the upper center, which is epigastric or near the stomach around
the bellybutton, termed periumbilical, or in the low central abdomen, which can be called
suprapubic, meaning above the pubic bone.
SLIDE 22
Patients who have no appetite have anorexia. Post-prandial means after eating. An
example would be post-prandial stomach pain. Emesis is the medical term for vomiting.
If emesis is not green or bloody, it is NBNB emesis, which is short for non-bloody, nonbilious. Bilious means bile-like or green tinted. If one vomits blood, it's called
hematemesis, he meaning blood.
SLIDE 23
If one has a bloody stool, it is termed hematochezia. Black, tar-like stool is called
melena and usually indicates old blood in the stool coming from somewhere higher in
the gastrointestinal tract. A common abbreviation is BRBPR, which is short for bright
red blood per rectum. This is usually concerning for a potentially dangerously fast rate
of bleeding.
Moving on, GU stands for genitourinary. The most common complaint that isn't readily
understood by most people is dysuria, which means pain on urination. Another
common term is hematuria, which is seeing blood in the urine.
SLIDE 24
MS refers to musculoskeletal, and ext to extremities. These are often used
interchangeably. Some common terms used are myalgias or muscle aches seen with
flu-like illnesses and arthralgias, which are joint aches.
SLIDE 25
Edema means swelling. Most body parts can swell, but edema often refers to
peripheral edema, which is swelling of the peripheral body, most often the legs.
Dependent edema is swelling usually of the legs that occurs only when they are below
the heart, and this will get better with lying or elevating the legs. Another common place
to see edema referred to is in the lungs called pulmonary edema, which we will review
in the x-ray section coming up.
SLIDE 26
Derm is short for dermatologic, pertaining to the skin. Puritic or non-puritic is referring
to whether the skin itches, which is puritic, or does not itch, which is non-puritic. Neuro
stands for neurologic, and patients will often complain of paresthesias, which are an
abnormal sensation, such as tingling, in the absence of stimuli. This slide concludes
Part I of terms and abbreviations.
SLIDE 27
Terms and Abbreviations, Part II, Physical Examination. This is Part II of the Medical
Terminologies and Abbreviations presentation. The next section will cover terms and
abbreviations encountered with a physical examination of the patient. Many terms used
for the PE, or physical exam, are unfamiliar to those without medical training.
SLIDE 28
Common shorthand is on this slide. PE is an abbreviation for physical examination. If
something is positive or present, it can be listed as a plus sign (+). If it is absent or
negative, it is often a minus sign (-), or a zero with a slash through it 0. Normal is
commonly abbreviated nl or wnl for within normal limits.
SLIDE 29
Gen stands for general and refers to the general appearance of the patient, including
mood, nutritional status, and if the patient appears to be in any distress. For example,
an alert WDWN WF in NAD is an alert, well-developed, well-nourished, white female in
no apparent distress. Other commonly used abbreviations for ethnicity include AA or
usually African American and LA for Latin American. AOx3 means alert and oriented
times three, referring to orientation to person, place, and time. The patient knows who
they are and where and when they are.
SLIDE 30
Terms and abbreviations used to describe the head, eyes, ears, nose, and throat area
of the body commonly include NCAT, which means normocephalic, atraumatic, which
means normal head with no trauma visible. PERRL is short for pupils are equal, round,
and reactive to light, and the equal refers to equal in size. Erythema, which means
redness. Erythema can be used to describe just about any visible part of the body
which is red. Exudate is often used in describing the tonsils and the phrase tonsillar
exudates, and exudates strictly defines is a material, such as fluid, cells, or cellular
debris, which has escaped from blood vessels and has been deposited on or in a tissue.
This is usually the result of inflammation. A person with tonsillar exudates would have
white spots visible on their tonsils.
SLIDE 31
Purulent means consisting of or containing pus and might be used to describe nasal
discharge or the fluid draining from a ruptured, infected eardrum, though it may be used
to describe the character of any fluid draining from or contained in a body part. Injected
does not refer to needles in this case. It really refers to visible blood vessel congestion
often seen in a bloodshot eye or an infected eardrum. The neck has a few common
terms, including supple, which means moving easily and implies there is no neck
stiffness and, therefore, probably no meningitis and infection. LAD is an abbreviation
for lymphadenopathy, which means swollen lymph glands or lymph nodes.
Lymphadenopathy can be present elsewhere, such as the armpit or groin but is most
commonly examined routinely in the neck. Bruits, spelled B-R-U-I-T-S, or the absence
of bruits is commonly examined in the neck and refers to the abnormal whoosh sound
that one can hear when listening with a stethoscope to the arteries of someone with
arterial narrowing, usually due to cholesterol deposits.
SLIDE 32
The cor or cardiac examination findings most common encountered will be documented
concisely in the normal individual as rrr no mgr, which are abbreviations short for
regular rate and rhythm, no murmurs, gallops, or rubs. This refers to the fact that the
heart is beating normally, meaning regularly, and there are no extra or unusual heart
sounds. Sometimes a murmur will be described, but for the purposes of this talk, we
will not go into the details of describing a cardiac murmur.
Tachycardia and bradycardia or tachycardic and bradycardic refer to the rate or how
fast the heart beats. Tachy, which is short for tachycardic, is too fast, and brady, short
for bradycardic, is too slow. Irregular would refer to someone whose heartbeat does not
follow the usual regular clock-tick rhythm of the heart beating but instead has a different
amount of time between some of the beats.
SLIDE 33
Pulm, which is pulmonary or lung findings, usually are described in the normal individual
as CTAB no rrw. This is an abbreviation, which stands for clear to auscultation
bilaterally, no rales, rhonchi, or wheezes. Auscultation is listening with a stethoscope,
and this can refer to any part of the body. Bilaterally means both sides or both lungs in
this case. Rales are also known as crackles as that is what they sound like. They
sound like Rice Crispy cereal noises or Velcro being pulled. Rhonchi and wheezes are
two words for the same sound, and they both refer to high-pitched whistling sounds,
most commonly heard in someone who has asthma. Retractions refer to the visible
drawing back of the skin when breathing in. It occurs between the ribs above the
collarbone or in the abdomen. Retractions only occur when someone is having difficulty
breathing and is usually accompanied by tachypnea, which means breathing more
rapidly or taking more breaths per minute than is normal for the patient's age.
SLIDE 34
Abd is the abbreviation for abdomen. BS means something quite different to medical
personnel. It is an abbreviation for bowel sounds, which should be present and normal
active, meaning normal amount of activity. One may also have ascent, hypoactive, or
hyperactive bowel sounds if something is wrong. TTP can refer to any area of the body.
It stands for tender to palpation. To palpate is to examine by touch or feeling. Often, if
the patient has no tenderness, it will be documented as NTTP for nontender to
palpation. Tenderness will often be greater in one of the four quadrants described
earlier. Guarding refers to the tendency to tense the stomach muscles when someone
is palpating a tender area. Rebound tenderness refers to a pain that is worse as the
examining hands are quickly removed rather than as they press in.
SLIDE 35
A few terms are commonly used when examining the extremities. 2+ DTR refers to
deep tendon reflexes, otherwise known simply as reflexes. An example is the knee jerk
response when the knee is struck with a reflex hammer. 2+ refers to how much of a
response is elicited by the reflex hammer. The scale is from 0 to 4, with 2+ being
normal, and less or more being abnormal. No CCE is an abbreviation for no cyanosis,
clubbing, or edema. Cyanosis means blue tissues, which is an indication of low oxygen.
Clubbing is a bulbous shape to the fingertips of someone who has lived for many years
with a low oxygen concentration in their blood, such as someone with severe
emphysema. Edema has been discussed above. In the context of the extremities, it
usually pertains to swelling of the lower part of the legs.
SLIDE 36
There is a lot of terminology specific to dermatology and describing the skin. A full
overview is beyond this discussion, but some basics may be helpful. A macule is a flat
spot of discoloration. A papule is a raised bump up to 5mm in diameter. A
circumscribed, elevated, solid lesion bigger than 5mm is a nodule. This will look and
feel like a pellet or something lodged under the skin. Groups of papules that have
grown together to form a large raised area are called a plaque.
SLIDE 37
Sacs in the skin have different names depending on their size and appearance. A
vesicle is a fluid-filled sac less than 5mm in size. A bulla is a fluid-filled sac larger than
5mm, and a pustule is a sac filled with pus. An erosion is a superficial loss of skin,
whereas an ulcer is a loss of skin deep enough to cause scarring. Scale refers to the
dry, flaky areas of skin that you might see in someone with dander for allergies. The
term is used because sometimes these dry flakes resemble the scales of a reptile.
We've discussed erythema before. Erythema refers to visible redness.
SLIDE 38
Neuro is short for neurologic, which pertains to the nervous system. A full neurologic
examination is beyond the scope of this presentation, but a normal individual will often
be described by notation, such as CNII-XII intact, meaning the cranial nerves which
control the functions of the head and face are normal. These functions can include eye
movement, vision, hearing, and sensation. Grossly intact implies that while no specific
neurologic testing was done, the individual has no obvious problems.
SLIDE 39
Next, we will briefly discuss laboratory terms and abbreviations. Laboratory studies
should be relatively self-explanatory. The results will be either normal or abnormal and
if abnormal, should be clearly marked so on the lab report form. We will cover only a
few of the more commonly used abbreviations for some very common tests.
SLIDE 40
The CBC stands for complete blood count, which is a count of the red or oxygencarrying cells, the white cells, which fight infection, and the platelets, which help blood
clot. A Chem 7, 8, 14, or 20 refers to a large panel of chemistry tests looking at blood
concentrations of chemicals, including salts, sugars, and certain enzymes. LFTs are
specific to liver function tests and can be part of a larger chemistry panel. ABG stands
for arterial blood gas, which is a test to determine the concentrations of various gases in
the blood and, therefore, how well the patient's cardiopulmonary system is working. A
urinalysis is abbreviated UA, and this is a chemical and often microscopic analysis of
the patient's urine.
SLIDE 41
Radiologic studies, such as x-rays, are another area full of specialized terminology.
SLIDE 42
If you are relying on a non radiologist's interpretation of an x-ray or other imaging test in
the overall chart note, you may only get the visual impression of the provider with no
conclusion as to what the x-ray means, though it will often be implied in the overall
assessment or diagnosis. On a dictated report from a radiologist, however, they will
describe in radiologic terms what they see and then offer one diagnosis, or more often,
several possible diagnoses that can appear similar to the pictures. If the study they are
interpreting is not conclusive as to the diagnosis, they will often suggest another
imaging test to determine the final diagnosis.
SLIDE 43
For our purposes, learning some chest x-ray anatomy and terminology will probably be
most helpful as the chest x-ray is one of the most commonly ordered studies.
SLIDE 44
Two x-rays are usually taken, the PA, or posteroanterior view, and the lateral view. The
PA is shot with the x-rays penetrating the patient's back, and the x-ray film in front of the
patient's chest. The lateral is shot from the side. Included will be all of the lung
anatomy, the surrounding boney tissue, including the ribs, the clavicle or collarbone, the
spine, and the sternum, as well as other organs in the chest. When looking at the PA xray, you look at it as if the patient is standing in front of you, which means the patient's
right side is on the left side of the x-ray and vice versa.
SLIDE 45
The lungs themselves have five lobes or sections, three in the right lung and two on the
left. They are called the right upper, right middle, and right lower lobes and on the left,
the left upper and left lower lobes. On this lateral view, you can see all three of the right
lobes roughly outlined. Knowing where the lobes are can tell you where an infection or
mass is located.
SLIDE 46
This diagram of a lateral chest x-ray shows the left upper and lower lobes.
SLIDE 47
This is the right upper lobe viewed on a PA chest x-ray.
SLIDE 48
The right middle lobe is visible on this PA chest x-ray.
SLIDE 49
This is a picture of a pneumonia visible in the right middle lobe.
SLIDE 50
The right lower lobe is highlighted on this PA chest x-ray.
SLIDE 51
On this PA view, the left upper lobe is highlighted.
SLIDE 52
And the left lower lobe again on a PA view.
SLIDE 53
In the chest cavity, all organs besides the lungs will be in the center of the chest, which
is called the mediastinum.
SLIDE 54
This is an x-ray of someone with a widened mediastinum due to inhalational anthrax.
An x-ray with this appearance could be due to infection, cancer, or dangerously
enlarged blood vessels.
SLIDE 55
The largest structure in the mediastinum is the heart.
SLIDE 56
The silhouette sign refers to a loss of the silhouette outlining a structure in the chest.
This sign occurs when fluid or a mass fills part of the lung next to a structure. This sign
tells you that an abnormality is present, as well as its relative location. In this x-ray, the
patient's right heart border is missing because of a pneumonia in the right lung.
SLIDE 57
Atelectasis is one of the most common findings on a chest x-ray and refers to an
incomplete expansion or collapse of all or part of the lung. This can be due to
something blocking an airway or by something compressing the lung from the outside,
but most often, it is due to some mucous plugging the airways. This x-rays shows
several right-sided partial collapse. Notice the silhouette sign at the patient's right heart
border.
SLIDE 58
This x-ray shows complete collapse of the right lung, which is much easier to see than a
partial collapse.
SLIDE 59
Consolidation and air space disease refer to a non-collapsed lung filled with something.
Most commonly, this is pus associated with pneumonia but could also be blood, other
fluids, or cancer cells. This right middle lobe pneumonia is a good example of
consolidation on a chest x-ray.
SLIDE 60
Pleural effusions are collections of fluid in the pleural space compressing the lungs from
the outside. The pleural space is between the lungs and the surrounding tissues and
normally isn't a space at all. It should be invisible, unless it is filled with air or fluid. On
this example x-ray, you can see the pleural effusions where the lower outer corners of
the lungs are around it instead of coming to a sharp, downward point.
SLIDE 61
Pulmonary edema is fluid accumulation in the lungs and swelling of the lung tissues.
Without knowing anything about the patient's illness, differentiating pulmonary edema
from a widespread infection can be difficult, as you can see from the example x-ray.
SLIDE 62
This concludes Part II of Medical Terminology and Abbreviations.