MEDICAL TERMINOLOG Y 1 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 sa id, 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 2 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 Electro cardi ogram (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 3 Anatomy/Positioning Abbreviations Anterio r (ant) Also referred to as Ventral Posterior (post) Also referred to as Dorsal Caudal – m oving away from head Cephalic – moving towards head Lateral – left or right Medial – middle/midline Supine – lying fla t on your back P rone – lying flat, face down Proximal – m oving towards Distal – m oving away 4 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 5 Titles/Positions /Departments PCP – primary care physician Attending – the physician present in hospital Resident – professional school graduate who is sup ervised 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 grad uated 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 nur se OB/GYN – obstetrics and gynecology L&D – labor and delivery OT – Occupational Therapist PT – Physical Therap ist PTA – Physical Therapist Assistant RT – Respiratory Therapist ED – Emergency Department MICU – medical intensive care unit NICU – Neonat al intensive care unit PICU – Pediatric intensive care unit CVICU – cardiovascular intensive care unit 6 General Abbreviations and T erms 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 7 Tier 2: Abx – antibiotics Dx – Diagnosis Rx – prescription IVF – IV fluids NS – normal saline Bolus – rapid “push” or i njection 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 acc ident/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 admi nistration 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 outermo st 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, indica ting 2 nd pregnancy with 1 living offspring 8 Pre - existing Conditions (co - morbidities) Tier 1 : COPD – Chronic obstructive pulmonary disease Diabetes Mellitus (DM) – sometimes called DM2, indicating type - 2 D iabetes Hyperlipidemia (HLD) – high cholesterol NKA – no known allergies Tier 2: CAD – coronary artery disease PVD – peripheral vascular disease Vital Signs Electro cardio gram (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 A trial F ibrillati on (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 Abn ormally 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 hear t. Diastolic – measure of blood pressure, indicated by “bottom” number of reading. Measures pressure of blood as it returns to heart. 9 Normal Adult : 120/80 Child : 105/70 Infant : 90/60 Hypotensive – Low blood pressure Hypertensive – high blood pressure Resp iratory SPO2 – Oxygen levels in blood , often called “ saturation levels ” , or even “ O 2 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 breath s / 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 10 Imaging Tier 1 : Chest X - ray (CXR) Ultrasound (US) Transabdominal Transvag inal/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 ner ves/ner vous system Tier 2: Laryngoscop y – Endoscop y of larynx. Used to view vocal folds and glottis Bronchoscop y – 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 opt ic camera Arthroscop y – 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 11 Lab Values (with normal values) AB G — 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 saturat ion (O2 Sat) 94 - 100% CBC — complete blood count (includes tests below) o RBCs - Red Blood cells, M en - 4.7 - 6.1mil/microL, W omen - 4.2 - 5.4mil/microL o Hgb – hemoglobin M en: 135 - 175 grams/L W omen: 120 - 155 grams/L o Hct – hematocrit M en: 38.8 - 50.0 percent W omen: 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 t o 5.4 g/dL (34 to 54 g/L) o Mg – magnesium Normal: 1.5 - 2.5 mEq/L o CO 2 – 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 12 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 H igher 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 - /hyper kalemia – low /high potassium o Hypo - /hyper natremia – low /high sodium o Hypo - /hyper magnesemia – low/ high magnesium levels 13 Instruments and Equipment Crash Cart Foley catheter 14 AED (Automatic External Defibrillator ) Defibrillator Central L ine kit 15 Blood - pressure device (sphygmomanometer) Stethoscope Lactated ringers Pulse Oximeter 16 Scalpel Pelvic Specula Ear Specula 17 IO ( intraosseous ) Drill Otoscope Ophthalmoscope Laryngoscope 18 Nasal cannu la (BNC) Oropharyngeal Nasopharyngeal 19 ETT – endotracheal tube Tracheostomy tube (trach) Laryngeal Mask Airway