USING MEDICAL CARE TERMINOLOGY AND ABBREVIATIONS

1. USING MEDICAL CARE TERMINOLOGY AND ABBREVIATIONS

2. Upon completion of this unit, the student will • use basic medical terminology and approved abbreviations

3. Presented by Gloria Lemay on WizIQ

4. MEDICAL TERMINOLOGY HEPAT CYST RHIN EMIA ECTOMY NEURO SUPRA

5. Mr. Jones was admitted to the ER c/o epigastric pain, dyspepsia, and pc bloating. The MD ordered a CBC, UA, EKG, CXR, and a CT of the abdomen. While in radiology, Mr. Jones had hematemesis and his BP dropped to 80/50. He became diaphoretic, had circumoral cyanosis and dyspnea, and the RN noticed abdominal distention. Mr. Jones suddenly had LOC, apnea, and absent vs, so CPR was initiated. In spite of the heroic efforts, Mr. Jones expired. Autopsy showed a ruptured aortic aneurysm. HUH?

6. Health care workers have a language all of their own. They use medical terminology and abbreviations in communicating information to others. At first, medical terms may seem hard to learn, especially since the list is long and most look hard to pronounce. But medical terms are combinations of word elements - root words, prefixes, and suffixes - three lists of words that, when put together in different combinations, give meaning to the word. Pronouncing medical terms is not difficult if you remember a few simple rules.

7. ch - sounds like k (like in chronic) ps - sounds like s (like in psychology) pn - sounds like n (like in pneumonia) c - sounds soft when it comes before e, i, and y (cycle) g - sounds like j when it comes before e, i, and y (giant) i - sounds like eye when added to the end of a word to form a plural (nevi) Can you think of any other words to use as examples?

8. Medical dictionaries have been written to include many words used in health care professions. It would be impossible for anyone to memorize all of the words. But, by breaking words into parts, you can often figure out the meaning of words. Medical terms are often a combination of different parts: a prefix is placed at the beginning of a word a suffix is placed at the end of a word a root is the main word to which prefixes and suffixes are added; a root is the subject of the word

9. Prefixes and suffixes have set meanings. For example, the suffix “itis” means inflammation of. Therefore, tonsillitis means inflammation of the tonsils. Note that the meaning of the suffix (inflammation of) is said first when the word is defined. In other words, we don’t say tonsil inflammation. Can you figure out what appendicitis is? How about gastritis?

10. By learning basic prefixes, suffixes, and word roots, you will frequently be able to interpret the meaning of a word even though you have never heard it before. Some medical terms use combining vowels to help make the term easier to pronounce. The most commonly used combining vowels are i and o and sometimes y and u. Look at the word speedometer. Without that combining vowel “o” in the middle, we would be saying speedmeter which is much more difficult to pronounce. Combining vowels are most often used when putting a root word that ends with a consonant together with a suffix that begins with a consonant.

11. Study the lists of prefixes, suffixes, and root words in your handout. See how many words you can make up by combining elements. Some students like to make flash cards to study with - they are certainly lighter than carrying around a textbook! When you learn at least the word elements listed in your handout, you have the tools to combine hundreds of medical terms. Maybe you’ll end up with cerebromegaly!

12. ABBREVIATIONS ac BID amb BUN CBC AMA

13. A doctor’s order for Mr. Jones: BR c BRP, FFl qh, VS qid NPO 8PM, to Lab for CBC, BUN, and FBS HUH?

14. As a health care worker, you will be expected to recognize the most common abbreviations. Abbreviations are just shortened forms of words. You already know a.m. which means morning, and p.m. which means afternoon or evening. (The a is the abbreviation for ante or before; the p is the abbreviation for post or after; the m means middle of the day.) Abbreviations are used in many health care fields and are sometimes used in narrative charting or combined by physicians to give orders or directions to other health care workers. Abbreviations help to save time and conserve space in the medical record.

15. Your handout has a list of the most common abbreviations that health care workers use. Some students also find it helpful to make flash cards to study with. Remember, though, every facility has its own list of abbreviations approved for that facility. Although they are not different from the list in your handout, the facility list may be shorter! Some abbreviations may be written either as capitals or lower case letters - either is correct. For instance, BID (which means twice a day) can also be written as bid.

16. Some abbreviations use a lower case xpreceded by a capital such as Bx which means biopsy The B is the first letter of the word biopsy and the xtakes the place of the rest of the word. Tx means treatment (or traction, or transplant!) Hx means history Px means prognosis Dx means diagnosis Rx means prescription Sx means symptom Fx means fracture Ex means examination

17. The abbreviations to know by heart are the ones associated with time. Medications, treatments, and foods are often given at specified intervals, and it is extremely important for the health care worker to know the abbreviations so that the patient receives the proper care. Most often, Q or q means every. So, if the doctor writes Q4H, the abbreviation means every 4 hours. If the doctor writes QD, the abbreviation means every day. If the doctor writes QOD, the abbreviation means every other day. If the doctor writes QHS, the abbreviation means every “hour of sleep” or bedtime.

18. Medications and treatments are most often given on a daily basis (QD), or two, three or four times a day. BID means two times a day (remember the B as standing for bi or two) TID means three times a day (remember the T as standing for tri or three) QID means four times a day (remember the Q as standing for quatro or four PRN or prn means whenever necessary or when required

19. The other important category of abbreviations has to do with patient activity. The doctor often gives specific orders as to what the patient can and cannot do. BR means bedrest CBR means complete bedrest BR c BRP means bedrest with bathroom privileges(note that BR not only means bedrest but bathroom!) amb means ambulate (walk) as tol means as tolerated amb c assist means the patient may only walk with assistance amb ad lib means the patient can walk “as desired” OOB means out of bed

20. Some other abbreviations are not shortened forms of the words they mean but single letters to represent the words. For instance, @ means at c means with (also can be written as w/) a means before (remember ante means before) p means after (remember post means after) s means without (also can be written as w/o) Note the little lines over some of the letters - very important to include those!

21. Most health care workers take patient vital signs (VS). Vital signs are the patient’s temperature, pulse, respirations, and blood pressure. BP means blood pressure T means temperature P means pulse R means respirations TPR means temperature, pulse and respirations

22. Abbreviations are also used to describe a place or service within the health care facility. Some facilities have different names for their units, so you will have to check with the facility you work for to learn the names of the units. PEDS means pediatrics OB means obstetrics (some facilities call this the women’s unit) CS means central supply (but some facilities call it materials) MED/SURG means a unit that has both medical and surgical patients

23. PostOp means post-operative, also may be abbreviated as RR which means recovery room DS means day surgery ICU means intensive care unit, CCU means coronary or cardiac care unit, NICU means neonatal intensive care unit (for newborns) ER means emergency room, OPD is outpatient department Usually, these abbreviations are pretty easy to figure out.

24. Those who are administering medications need to know a special list of abbreviations - those associated with where the medications is taken in. PO or po means per os or by mouth PR means by rectum IV means intravenous IM means intramuscular SC means subcutaneous SL means sublingual or under the tongue NG means nasogastric tube

25. Some other abbreviations that health care workers see on a routine basis are: ac - before meals (a for ante, c for comida!) pc - after meals (p for post) BM or bm - bowel movement c/o - complains of dc or d/c - discontinue or discharge hs - hour of sleep or bedtime noct or noc - night NPO - nothing by mouth

26. ROM - range of motion SOB - short of breath STAT - at once or immediately wc or w/c - wheelchair UA - urine ASAP - as soon as possible ADL - activities of daily living I&O - intake and output (measuring what goes in and what comes out!)

27. SELF CHECK See if you can interpret this narrative. Do it without looking at the lists! Mrs. Brown was adm to the ERper amb c/o R abd pain. The MD ordered a CT att RLQ, a CBC, UA, and VS Q30min. She had no Hx of renal disease, and had an appendectomy and hysterectomy 10 years ago. Her T was 104 F and her BP, P, and R wnl. Mrs. Brown also c/oN and Vx 2D and no BM for the past week. The CT showed a mass in the transverse colon and she was prepped for the OR. The RN started an IV in Mrs. Brown’s R arm and she transported her to radiology for a pre-opCXR. The surgeon found a large tumor in the colon and the Bx showed it to be Ca. The surgery required Mrs. Brown to have a colostomy. Post-op, Mrs. Brown did well and was D/C on the 5th post-op day with planned Tx by an oncologist.

28. I hope you found this a fun way to learn about medical terms. Please ask any questions now.