Word(s)

Definition

Abbreviation

History and Physical

Clients medical history and physical examination

H&P

Right lower quadrant

The lower right quarter of the abdomen which contains the

terminal ileum, cecum and appendix.

RLQ

History of present illness

Record of the symptoms pertaining to the chief complaint

HPI , H/oPI

Emesis

Vomit or process of vomiting

ED

Medical Term

Emergency
Department

Also known as an emergency room

Patient Medical History

Complete recording of patients medical health before

presenting with new chief complaint

Past Surgical History

Record of patients surgical procedures or operations

Tonsillectomy

Surgical removal of the tonsils

Adenoidectomy

Surgical removal of the lymphatic tissue known as the

adenoids or nasopharyngeal tonsils.

Umbilical

Pertaining to the umbilicus

Hernia

Protrusion of an organ through the surrounding muscle tissue

NKDA

No Known Drug
Allergies

Allergic status of a patient who has no known drug allergies

GERD

Gastroesophageal
reflux disease

A condition in which stomach contents backup into the

esophagus

Vital signs

Physiological assessment including heart rate, respiratory

rate, blood pressure and temperature.

PMH

Normocephalic

Head has normal shape and size upon inspection

Atraumatic

Without trauma

Auscultation

Listening

Percussion

Tapping

Cyanosis

Blue discoloration of tissues caused by lack of oxygenated

blood.

Edema

Swelling due to the presence of fluid

Distal

Furthest from the point of attachment

extremities

Limbs or appendages

Hemoglobin

the iron-containing pigment in red blood cells that carries

oxygen in the blood

Hematocrit

Blood test that measures the concentration of red blood cells

used to test for anemia

Abdomen

part of the torso between the chest and pelvis

N/C

Hb

ab, abd

CT

Computed
tomography

Process of radiologic imaging of slices of tissue to determine CAT

density, anomalies, etc.

NPO

Nil per os

Nothing by mouth

Appendectomy

Surgical removal of the appendix

History

A form of collapsing breakage usually involving the vertebrae Hx

Complains of

Subjective reporting of patients symptoms

expiration

exhalation

Bilaterally

Both sides

C/O

Lymphadenopathy

Disease of the lymph tissue

Liver or spleen
enlargement

Hepatomegal
y or
splenomegaly

Chronic

Constant, long duration

Rhinitis

Inflammation of the nasal passages

Compression fractures

a bone break that crushes short bone, usually vertebrae

Osteoporosis

bone condition that occurs when normal minerals that

compose the bone are leached or poorly absorbed causing
bones to become porous and fragile.

Osteoarthritis

Degenerative joint condition that is progressive with age due OA

to loss of cartilage

Fractures

broken bone, can be either complete or incomplete

Sphincter

a ring-like muscle that closes an opening in the body to

prevent regurgitation or leakage

Deep tendon reflexes

Motor responses to sensory stimulation used to assess the

response of the nervous system.

DTR

Physical Therapy

Therapeutic treatment of physical dysfunctions in order to

rehabilitate a patient to prior functionality or to facilitate
normal range of motion.

PT

Ambulating

Walking

Subjective

A persons opinions, recollection or personal interpretation of

an event or symptom

Flexion

Decreasing of the angle of a joint

Fx

Abduction

Moving away from the midline

Objective

Impartial observable signs

Range of motion

the extent of movement of joint measured in degrees

Impingement

tissue trapped between bones or hard processes

Adduction

to move a limb toward the bodys center or midline

Symptoms

subjective indications of a disease or disorder

Postmenopausal

referring to the time after menopause

Dyspnea

Abnormal breathing

Orthopnea

pain with breathing while lying down that is improved with

sitting up

Peripheral

Pertaining to the periphery or extremities, away from the

center

Atypical

Abnormal, unusual

Inspiration

Inhalation

Coronary artery disease

Narrowing or full blockage of coronary arteries causing a lack CAD

of oxygen, and ultimately myocardial infarction

Myocardial infarction

Necrosis of the myocardium due to lack of blood flow and

oxygen, also known as heart attack

MI

Hypertension

High blood pressure

HTN

Diabetes mellitus

Inability of the pancreas to secrete enough insulin which

causes decreased or inability of glucose absorption

HTN
Cholecystitis

hypertension

High blood pressure

Inflammation of the gallbladder

ROM

Sx

Cholecystectomy

Surgical removal of the gallbladder

Carcinoma

Malignant epithelial tumor

Bruits

Abnormal cardiac sounds usually indicating a presence of

obstruction

Murmurs

abnormal heart sound that indicates a valvular defect

Congestive heart failure

inability of the heart to pump enough blood with enough

force to meet the bodys demands; characterized by
peripheral edema and electrolyte imbalance

CHF

Echocardiogram

record of images of the heart obtained by ultrasound

ECG, EKG

CA