chapter 12 med transcription

40 terms by ddonovan 

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CR

Cardiorespiratory

GU

Genitourinary

GYN

Gynecology

NP

Neuropsychiatric

GI

Gastrointestinal

EOMS

Extra ocular movements

HTN

Hypertension or high blood pressure

HEENT

head, eyes, ears, nose, throat

Gravida

number of pregnancies

Para

number of births

full block

justified to the left side of the page

modified block

tabbed over and aligned

PERLA

pupils equally react to light and accommodation

Dysmenorrhea

bad/painful/abnormal menstrual flow

Syncope

fainting

cholecystitis

inflammation of the gallbladder

tachycardia

rapid heartbeat

bradycardia

slow heartbeat

Hematemesis

vomiting blood

Tinnitus

ringing in the ear

Alopecia

baldness

Epistaxis

nosebleed

Menarche

first period for female

Metrorrhagia

excessive uterine bleeding

Glaucoma

Atrophy of the optic nerve and increased intraocular pressure

Conjunctivitis

pink eye, inflammation of the mucous membranes of the eye

Cephalocaudal

head to foot

Varicosities

varicos veins, distended, knotted or swollen veins

skin

dryness, scaling, eruptions, rash, dicoloration, palor

Diagnosis and Impression

they have the same meaning on report also called assessment or conclusion

4 parts of PE

Inspection, palpation, percussion, and auscultation

short stay record

used for outpatient or surgical center in place of an H&P

Interval History

patient returns to the hospital within a month

demographic data

name, address, phone #, SS, place of work

4 parts of a HX

CC, ROS, HPI, PFSH

CC

Chief complaint

ROS

review of systems

HPI

history of present illness

PFSH

past family social history

how do you list allergies on a report

bold/ underline could be life or death to the patient

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