Layman's Terms - ScribeAmerica Course 1

Layman’s term

what the patient will likely call the disease

PMHx

Past Medical History

high blood pressure

Hypertension (HTN)

high cholesterol

Hyperlipidemia (HLD)

diabetes

Diabetes Mellitus (DM)

“I only take pills for my diabetes.”

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

“I take shots (insulin) for my diabetes.”

Insulin Dependent Diabetes Mellitus (IDDM)

heart disease

Coronary Artery Disease (CAD)

heart attack

Myocardial Infarction (MI) and CAD

heart failure

Congestive Heart Failure (CHF)

irregular heartbeat

Arrhythmia

emphysema or chronic bronchitis

Chronic Obstructive Pulmonary Disease (COPD)

blood clot in lung

Pulmonary Embolism (PE)

pneumonia or lung infection

Pneumonia (PNA)

reflux

Gastroesophageal Reflux Disease (GERD)

ulcers

Gastric Ulcer or Peptic Ulcer Disease (PUD)

irritable bowel

Irritable Bowel Syndrome (IBS)b

bladder infection

Urinary Tract Infection (UTI)

kidney infection

Pyelonephritis

“I’m on dialysis.”

Chronic Kidney Disease (CKD) on dialysis

enlarged prostate

Benign Prostatic Hyperplasia (BPH)

stroke

Cerebrovascular Accident (CVA)

“blood clot in brain”

Ischemic CVA

brain bleed

Hemorrhagic CVA

“mini stroke”

Transient Ischemic Attack (TIA)b

blood clot in leg

Deep Vein Thrombosis (DVT)

“bulge in my aorta”

Aortic Aneurysm

bad blood flow in my legs

Peripheral Vascular Disease (PVD)

cancer

Cancer or Carcinoma (CA)

spread to my…

With metastasis to the…

chemo

Chemotherapy

radiation

Radiation Therapy

“They cut it out.”

Status-Post (S/P) Surgical Resection

“It’s gone.”

In remission

PSHx

Past Surgical History

-ectomy

removal

tonsils removed

Tonsillectomy

adenoids removed

Adenoidectomy

“neck arteries cleaned”

Carotid Endarterectomy

leg amputated

Above Knee Amputation (AKA) or Below Knee Amputation (BKA)

joint repair

Arthroplasty

“balloon in my heart”

Angioplasty —> PMHx CAD

“stents in my heart”

Coronary Stents —> PMHx CAD

heart bypass

Coronary Artery Bypass Graft (CABG) —> PMHx CAD

breast removal

Mastectomy

part of my lung removed

Partial Lobectomy

appendix removed

Appendectomy

gallbladder removed

Cholecystectomy

part of my colon removed

Partial Colectomy

spleen removed

Splenectomy

kidney removed

Nephrectomy

uterus removed

Hysterectomy

ovary removed

Oophorectomy

FHx

Family History; lists diseases and health conditions in the patient’s family that may put the patient at an increased risk of also having

SHx

Social History; addresses substance use, occupation, diet, exercise, living situation, marital status, …