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ad lib
as desired
alert
Referring to a state in which an individual is awake and appropriately answers all questions
ambulate
Walk; move about
anemic
someone who has a decreased number of red blood cells
anorexia
an obsessive fear of gaining weight in which a person refuses to eat
aphasia
impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to wernicke's area (impairing understanding)
asepsis
the process of removing pathogenic microorganisms or protecting against infection by such organisms
atrophy
any weakening or degeneration (especially through lack of use)
b.i.d.
twice a day
BM
bowel movement
bradycardia
abnormally slow heartbeat
bradypnea
slow respiratory rate, usually below 10 respirations per minute
c (with overline)
with
CBC
complete blood count
c/o
complains of
cyanosis
a bluish discoloration of the skin and mucous membranes
defecate
have a bowel movement
diaphoresis
Excessive sweating
diastolic
the blood pressure during that part of the heartbeat when the hearts venticles are relaxing
discharge
eliminate (substances) from the body
disoriented
Confused as to time or place; out of touch
distention
A condition of being stretched, inflated, or larger than normal
dorsal
pertaining to the back
dysphagia
condition in which swallowing is difficult or painful
dysplasia
abnormal development or growth of cells, tissues, or organs
dyspnea
difficult or labored respiration
dysuria
painful or difficult urination
ECG/EKG
electrocardiogram
edema
swelling caused by excess fluid in the body tissues
emesis
vomiting
epistaxis
nosebleed
excretion
the process by which wastes are removed from the body
expectorate
discharge (phlegm or sputum) from the lungs and out of the mouth
feces
solid excretory product evacuated from the bowels
flatus
gas in the digestive tract or expelled through the anus
gait
manner of walking
hematemesis
vomiting blood
hematuria
the presence of blood in the urine
hemoccult
Test which determines bleeding in the GI tract
hemoptysis
coughing up blood from the respiratory tract
hs
hour of sleep, bedtime
hyperplasia
abnormal increase in number of cells
hypertension
a common disorder in which blood pressure remains abnormally high (a reading of 140/90 mm Hg or greater)
hypertrophy
abnormal enlargement of a body part or organ
hypotension
abnormally low blood pressure
incontinence
involuntary urination or defecation
inflammation
condition defined by redness, swelling, pain, and warmth
jaundice
yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood
lateral
Away from the midline of the body
lesion
any visible change in tissue resulting from injury or disease
LLQ
left lower quadrant
LMP
last menstrual period
mass
a body of matter without definite shape
medial
toward the midline of the body
medical asepsis
practices used to remove or destroy pathogens and to prevent their spread from one person or place to another person or place; clean technique
nausea
an upset stomach that makes a person feel like vomiting
NIDDM
mild form of diabetes mellitus that develops gradually in adults
NKA
no known allergies
NPO
nothing by mouth
nocturia
Excessive urination during the night
OOB
out of bed
orthopnea
ability to breathe only in an upright position
palpitation
A noticeably rapid, strong, or irregular heartbeat due to agitation, exertion, or illness
paresthesia
abnormal sensation of numbness and tingling without objective cause
PRN
as needed
prone
lying face downward
pruritis
severe itching
purulent
producing or containing pus
RBC
red blood cells
R/O
This part of a patients medical record means to rule out. Used to indicate a differential diagnosis when one or more diagnoses are suspected.
ROM
range of motion
RUQ
Right upper quadrant
s with a line above it
without
secretion
Release of a substance by exocytosis from a cell that may be a gland or part of a gland
sta
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