Medical Terminology - Anthony Correale

Please enable JavaScript to view the full PDF

MEDICAL TERMINOLOGY This is not a comprehensive list of Medical Terminology. We at CHIPS conferred and agreed upon the items in this list such that we feel it is a suitable representation of the language required for a simulation operations role. With this said, it can be expected that terminology will vary among simulation centers and, therefore, it may not be completely identical with the terms and abbreviations designated in this list 1 Table of Contents Anatomy/Positioning Abbreviations ............................................................................................... 3 Titles/Positions/Departments .......................................................................................................... 5 General Abbreviations and Terms .................................................................................................. 6 Certifications ............................................................................................................................... 6 Patient Exam ............................................................................................................................... 6 Tier 1: ...................................................................................................................................... 6 Tier 2: ...................................................................................................................................... 7 Pre-existing Conditions (co-morbidities) .................................................................................... 8 Tier 1: ...................................................................................................................................... 8 Tier 2: ...................................................................................................................................... 8 Vital Signs ....................................................................................................................................... 8 Electrocardiogram (EKG/ECG) –measures heart rhythm and rate ...................................... 8 Rhythms ...................................................................................................................................... 8 BP – blood pressure .................................................................................................................... 8 Respiratory .................................................................................................................................. 9 Blood Glucose Level (BGL) ....................................................................................................... 9 Imaging ......................................................................................................................................... 10 Tier 1: ........................................................................................................................................ 10 Tier 2: ........................................................................................................................................ 10 Lab Values (with normal values) .................................................................................................. 11  ABG—arterial blood gas ................................................................................................... 11  CBC.................................................................................................................................... 11  CMP ................................................................................................................................... 11  Labs .................................................................................................................................... 12 Instruments and Equipment .......................................................................................................... 13 Procedures and related terms ........................................................................................................ 22 Tier 1: ........................................................................................................................................ 22 Tier 2: ........................................................................................................................................ 22 2 Anatomy/Positioning Abbreviations  Anterior (ant)  Also referred to as Ventral  Posterior (post)  Also referred to as Dorsal  Caudal – moving away from head  Cephalic – moving towards head  Lateral – left or right  Medial – middle/midline  Supine – lying flat on your back  Prone – lying flat, face down  Proximal – moving towards  Distal – moving away 3  Abd – abdomen/abdominal  RUQ/LUQ – Right upper quadrant of abdomen, Left upper quadrant of abdomen, respectively  RLQ/LLQ – Right lower quadrant of abdomen, Left lower quadrant of abdomen, respectively.  RUE/LUE - Right upper extremity, Left upper extremity, respectively  RLE/LLE – Right lower extremity, Left lower extremity, respectively 4 Titles/Positions/Departments  PCP – primary care physician  Attending – the physician present in hospital  Resident – professional school graduate who is supervised in clinic (e.g. graduates of medical school, pharmacy school, nursing school, etc.)  PGY – Post-graduate year. This is used to identify the students who have graduated professional school. PGY-1 is first year, PGY-2 is second year, etc.  Fellows – physician, pharmacist, or nurse who has completed residency and elects to do further training.  PA – Physician assistant  NP/DNP – nurse practitioner  RN – registered nurse  OB/GYN – obstetrics and gynecology  L&D – labor and delivery  OT – Occupational Therapist  PT – Physical Therapist  PTA – Physical Therapist Assistant  RT – Respiratory Therapist  ED – Emergency Department  MICU – medical intensive care unit  NICU – Neonatal intensive care unit  PICU – Pediatric intensive care unit  CVICU – cardiovascular intensive care unit 5 General Abbreviations and Terms Certifications  ACLS – advanced cardiac life support  ATLS – advanced trauma life support  BLS – basic life support  PALS – pediatric advanced life support  NRP – Neonatal resuscitation program Pre-fix/Suffix  Resource Patient Exam Tier 1: • Pt- patient • Hx – history • Px - physical • H&P – history and physical exam • HPI – History of present illness • CC – Chief complaint • ROS – Review of Systems • PTA – prior to admission/prior to arrival • Anemia • Bilateral (Bil/Bilat) – occurring on both sides of body • CHF – Congestive heart failure • “Hyper-” – High, above • “Hypo-” – Low, below • Lac—Laceration, splitting/tear in the skin • NVD – nausea, vomiting, diarrhea (sometimes only N/V) • NKDA (NKA) – No known drug allergies • UTI – Urinary Tract infection • URI – Upper Respiratory Infection • PNA – pneumonia • SOB – shortness of breath 6 Tier 2:  Abx – antibiotics  Dx – Diagnosis  Rx – prescription  IVF – IV fluids  NS – normal saline  Bolus – rapid “push” or injection  Primary IV bags – 500 to 1000mL  Secondary IV bags – 50 to 250mL  AMS – altered mental status  CVA – cerebral vascular accident (stroke)  MI – myocardial infarction, “heart attack”  TIA – Trans-ischemic attack (mini-stroke)  MVA/MVC – Motor vehicle accident/collision  GSW – Gunshot wound  Code Stroke – protocol for stroke is initiated at the direction of the treating physician  Code STEMI – Protocol for ST Elevated Myocardial Infarction is initiated by physician  NAD – no apparent distress  PO – oral administration of medicine or food  NPO — nothing by mouth  Intraosseous injection (IO) – Direct injection into bone marrow  Intramuscular injection (IM) – Direct injection to muscle tissues  Subcutatneous (S.C., SQ, Subq) – direct injection under the outermost layer of the skin  GxPx – Gravidity and parity, respective numbers designated by “x”.  Used to communicate how many pregnancies the patient has experienced, as well as how many of the pregnancies produced viable, living offspring.  Example: G2P1, indicating 2nd pregnancy with 1 living offspring 7 Pre-existing Conditions (co-morbidities) Tier 1:  COPD – Chronic obstructive pulmonary disease  Diabetes Mellitus (DM) – sometimes called DM2, indicating type-2 Diabetes  Hyperlipidemia (HLD) – high cholesterol  NKA – no known allergies Tier 2:  CAD – coronary artery disease  PVD – peripheral vascular disease Vital Signs Electrocardiogram (EKG/ECG) –measures heart rhythm and rate  Heart rate normal values:  Adult: 60-100bpm  Child: 70-115  Infant: 80-160  Asystole: no electrical activity (i.e. no heart rate registering)  Tachycardia (ST) – increased heart rate (normally designated above 100bpm)  Bradycardia (brady) – slow heart rate Rhythms  Normal Sinus Rhythm (NSR) – standard and normal rhythm  Atrial Fibrillation (A. Fib) – abnormal heart rhythm resultant of unsynchronized and incomplete atrial contractions  V-tach or VT – ventricular tachycardia  ST Elevation – irregularity of heartbeat, often indicative of a heart attack  SVT – supraventricular tachycardia. Abnormally high HR (normally >150 bpm) resulting from chaotic arrhythmias in ventricles BP – blood pressure  Systolic – measure of blood pressure, indicated by the “top” number in the reading.  Measures the pressure of the blood as it moves away from the heart.  Diastolic – measure of blood pressure, indicated by “bottom” number of reading.  Measures pressure of blood as it returns to heart. 8  Normal  Adult: 120/80  Child: 105/70  Infant: 90/60  Hypotensive – Low blood pressure  Hypertensive – high blood pressure Respiratory  SPO2 – Oxygen levels in blood, often called “saturation levels”, or even “O2 sats”  RR – Respiratory rate  Tachypnea – fast/rapid breathing rate  Bradypnea – slow breathing rate  Adult: 12-20 breaths/min  Child: 20-25 breaths/min  Infant: 20-40 breaths/min  Newborn: 20-60 breaths/min Blood Glucose Level (BGL)  Hyperglycemia – High/elevated blood sugar level  Above 100mg/dL  Hypoglycemia – low blood sugar level  Below 70mg/dL 9 Imaging Tier 1:  Chest X-ray (CXR)  Ultrasound (US)  Transabdominal  Transvaginal/Pelvic  TEE – transesophageal echocardiogram  TTE – transthoracic echocardiogram  Used for pleural, cardiac scans  CT Scan – more precise than X-ray, shows soft-tissues  MRI – Useful for examination of nerves/nervous system Tier 2:  Laryngoscopy – Endoscopy of larynx. Used to view vocal folds and glottis  Bronchoscopy – endoscopy that allows for visualization of breathing pathways  Colonoscopy – visualization technique allowing for viewing of large bowel and distal part of small bowel with a CCD or fiber optic camera  Arthroscopy – minimally invasive surgical technique in which a camera is used for visualization, minimizing surgical wounds  Fluoroscopy – study of moving body structures via continuous X-ray imaging  Hysteroscopy – endoscopic inspection of uterine cavity through cerix 10 Lab Values (with normal values)  ABG—arterial blood gas o pH  Normal 7.35-7.45 o Partial pressure of oxygen (PaO2)  75 to 100 mmHg o Partial pressure of carbon dioxide (PaCO2)  35-45 mmHg o Bicarbonate (HCO3)  22-26 mEq/L o Oxygen saturation (O2 Sat)  94-100%  CBC—complete blood count (includes tests below) o RBCs- Red Blood cells,  Men - 4.7-6.1mil/microL,  Women - 4.2-5.4mil/microL o Hgb – hemoglobin  Men: 135-175 grams/L  Women: 120-155 grams/L o Hct – hematocrit  Men: 38.8-50.0 percent  Women: 34.9-44.5 percent o WBC—White blood cell count  3,500-10,500 cells/mcL  CMP – comprehensive metabolic panel (includes tests below) o ALT (alanine aminotransferase)  Normal: 4 to 36 U/L o AST (aspartate aminotransferase)  Normal: 8 to 33 U/L o Albumin  Normal: 3.4 to 5.4 g/dL (34 to 54 g/L) o Mg – magnesium  Normal: 1.5-2.5 mEq/L o CO2 –Carbon dioxide.  23 to 29 mEq/L (23 to 29 mmol/L) o Na – Sodium  135 to 145 mEq/L (135 to 145 mmol/L) o BUN – blood urea nitrogen test:  7-20 mmol/L 11 o Creatinine:  0.6 to 1.3 mg/dL (53 to 114.9 µmol/L) o Glucose (BGL)  70 to 100 mg/dL (3.9 to 5.6 mmol/L)  Lower  hypoglycemia  Higher  hyperglycemia o Potassium (K+)  3.7 to 5.2 mEq/L (3.70 to 5.20 mmol/L) o Calcium  8.5 to 10.2 mg/dL (2.13 to 2.55 mmol/L) o Chloride  96 to 106 mEq/L (96 to 106 mmol/L)  Labs (hyper-/hypo- rules apply) o Hypo-/hyperkalemia – low/high potassium o Hypo-/hypernatremia – low/high sodium o Hypo-/hypermagnesemia – low/high magnesium levels 12 Instruments and Equipment  Crash Cart  Foley catheter 13  AED (Automatic External Defibrillator)  Defibrillator  Central Line kit 14  Blood-pressure device (sphygmomanometer)  Stethoscope  Lactated ringers  Pulse Oximeter 15  Scalpel  Pelvic Specula  Ear Specula 16  IO (intraosseous) Drill  Otoscope  Ophthalmoscope  Laryngoscope 17  Nasal cannula (BNC)  Oropharyngeal  Nasopharyngeal 18  ETT – endotracheal tube  Tracheostomy tube (trach)  Laryngeal Mask Airway 19  King Airway  Bag Valve Mask (BVM)  Combi-tube 20  Simple mask  Non-rebreather 21 Procedures and related terms Tier 1:  CVL – cardiovascular line  Defibrillation – use of electric shock to attempt conversion of heart rhythm (no pulse present)  Cardioversion (Synchronized) – procedure in which different medicines are administered in attempt to return the patient’s heartbeat to a normal sinus rhythm (pulse is present)  Cardiac Pacing – Use of device (pacemaker or defibrillator) to send electrical impulses that regulate heart rate  Chest tube insertion (thoracostomy) – insertion of plastic tube into the pleural space between lungs and ribs. Used to drain air, blood, or other fluids  Intubation –implementation of tubing into the airway to assist patient who may be experiencing respiratory distress or failure  Sutures/staples—types of bonding methods used to repair skin laceration or abrasion Tier 2:  Lumbar puncture (LP)—use of a needle to extract/remove fluid from the lumbar spine  I&D – incision and drainage  Thoracentesis – procedure to remove fluid from space between lungs and chest wall through the insertion of a needle  Paracentesis – placement of needle into the abdomen, more specifically the peritoneal space, to remove air, blood, or other fluids from abdomen 22