med term ch 2

Chief complaint

the main reason for the patient's visit

History of present illness

the story of the patient's problem

Review of systems

description of individual body systems in order to discover any symptoms not directly related to the main problem

Past medical history

other significant past illnesses, light high blood pressure, asthma, or diabetes

Past surgical history

any of the patient's past surgeries

family history

any significant illnesses that run in the patient's family

Social history

a record of habits like smoking, drinking, drug abuse, and sexual practice that can impact health

Coronal

divides the body into anterior and posterior halves

Sagittal

divides the body into left and right halves

Transverse

divides the body into superior and inferior halves

proximal

closer to the trunk

distal

further from the trunk

medial

closer to the midline of the body

lateral

farther from the midline of the body

ventral/antral/anterior

front of the body

dorsal/posterior

back of the body

superior

above

inferior

below

cranial

toward the top of the body

caudal

toward the bottom of the body

supine

lying on back

prone

lying of belly

ipsilateral

same side

contralateral

opposite side

unilateral

one side

bilateral

two sides

plantar

sole of the foot

palmar

palm of the hand

dorsal

back of the hand, top of the foot

Pre-op

preoperative care

OR

operating room

PACU

post-anesthesia care unit

Post-op

postoperative care

ICU

intensive care unit

CCU

coronary care unit

SICU

surgical intensive care unit

PICU

pediatric intensive care unit

NICU

neonatal intensive care unit

ER

emergency room

ED

emergency department

ECU

emergency care unit

L&D

labor and delivery

♂

male

♀

female

(R)

right

(L)

left

(B)

lateral

↑

increased

↓

decreased

A&O

alert and oriented

CTA

clear to auscultation

NAD

no acute distress

NOS

not otherwise specified

PERRLA

pupils equal, round, and reactive to light and accommodation

RRR

regular rate and rhythm

CVL

central venous line

IM

intramuscular

IV

intravenous

NPO

nil per os (nothing by mouth)

PO

per os (by mouth)

PR

per rectum (anal)

SC

subcutaneous

AC

before meals (ante cibum)

PC

after meals (post cibum)

QHS

at bedtime (quaque hora somni)

PRN

as needed (per re nata)

QD

once a day/daily (quaque die)

BID

twice a day (bis in die)

TID

three times a day

QID

four times a day (quarter in die)

y/o

years old

Pt

patient

H/o

history of

HPI

history of present illenss

PE

physical exam

ROS

review of systems

NKDA

no known drug allergies

PCP

primary care provider

f/u

follow-up

CC

chief complaint

HX

history

FHx

family history

H&P

history and physical

PMHx

past medical history

Rx

prescription

Tx

treatment

DDx

differential diagnosis

Dx

diagnosis

HR

heart rate

RR

respiratory rate

BP

blood pressure

T

temperature

VS

vital signs

Ht

height

Wt

weight

BMI

body mass index

I/O

intake/output

Acute

it just started recently or is a sharp, severe symptom

Chronic

it has been going on for a while now

Abrupt

all of a sudden