Clinical Terminology

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CLINICAL TERMINOLOGY
VITAL SIGNS
Vitals (spoken) and VS (written).
 
Temperature, pulse, respiration and blood pressure. Some may include peripheral oxygen saturation (SpO2) and pain intensity. 
 
Example: the patient's vitals are temp 99, pulse 87, respiratory rate 16, and bp 167 over 110. 
Written: 99-87-16-167/110.
 
TPR (temperature, pulse and respiration).
 
 
TEMPERATURE 
 
It's measured in the mouth, ear, axilla and rectum. 
Normal body temperature- 37 Celsius or 98,6 Fahrenheit.
Fever (noun) and febrile (adjective).
Hypothermia- below 95 F or 35 C.
Hyperthermia- 100-101 F or 37,5-38,3 C. Less common (drugs with side effects, prolonged exposure to external heat and inability to dissipate it. Fainting, pulse and breathing rate are elevated.
Fever- common, often caused by infection rescuing in internal reactions including increased core body temperature. 
 
 
PULSE
 
Pulse points- carotid, apical (stethoscope at the apex of the heart), radial, femoral or pedal pulse.
Palpate or feel one carotid pulse at time. Place your fingers lightly on the neck to the side of the windpipe or trachea. Don’t apply pressure to both carotid arteries at the same time. This may decrease blood flow to the brain.
Thready - pulse is very soft, barely perceptible to palpation.
Bounding-pulses rises forcefully in the artery and can be clearly felt on palpation.
 
 
RESPIRATORY RATE
 
Number of times the patient breathes in and out over one minute.
Respirations (verbal) and rr (respiratory rate). RPM (respiration per minute).
Dyspnea - patient feels that they are unable to breath well or breath in enough air or oxygen. SOB - short of breath - frequently used instead of dyspnea.
Apnea - temporary stopping or cessation of breathing.
 
 
PULSE OXIMETRY 
 
Measure of oxygen saturation in the arterial blood. Reported as saturation or peripheral oxygen or SpO2.
It uses a small portable non-invasive device placed on the patient's fingertip or earlobe. Pulse ox.
Arterial oxygen saturation (SpO2/saturation/sat) - measure of the oxygen saturation in arterial blood by pulse oxygen and seen on the screen of the pulse oxygen machine or on a monitor.
Healthy person - SpO2 94-99%.
 
 
BLOOD PRESSURE
 
Blood pressure cuff - sphygmomanometer. BP cuff (digital/aneroid).
Systolic - measure of the pressure blood flow against the arterial walls as the left ventricle contracts.
Diastolic - heart is at rest between contractions.
Example: 120/84 (systolic and diastolic bp).
Hypertension - hypertensive - hypertensive crisis or emergency is sustained bp above 180/120.
Hypotension - below 90/60.
Orthostatic hypotension (patient has hypertension) - lowering of bp when the patient moves from recumbent (lying down) position to standing (erect) position. This is also termed postural hypotension. The patient complains of dizziness when getting out of the bed. 
VS cart or vitals cart (equipment) - BP, pulse, temperature and SpO2. 
 
HEALTH CARE PROVIDER TITLES
RN - Registered Nurse. Plans, organizes and provides direct patient care.
Supervising nurse - head nurse, charge nurse , clinical/unit coordinator.
CCRN - Clinical Coordinator Registered Nurse - or Clinical Case Manager. Coordinates patient care activities including patient education / discharge and supervises RNs and team members delivering direct patient care.
CRNP - Certified Registered Nurse Practitioner - Nurse with a master's or doctoral level education and advanced assessment medical diagnostic skills.
CNS - Clinical Nurse Specialist - nurse with a master's degree that often combines clinical supervision/consultation, teaching and administrative rules.
CNL - Clinical Nurse Leader - RN at master's level provides administrative and educational leadership.
NA or CNA - Nursing Assistant or Certified Nursing Assistant - A technician with high school education and in-hospital training. May earn certification with additional courses.
HUC - Unit secretary or Health Unit Coordinator - A person with high school or vocational school training who performs essential non-medical clerical tasks such as scheduling ad ordering supplies.
SLP - Speech and Language Pathologist - Treats swallowing and communication dysfunction.
MD - Medical Doctor.
PA - Physician Assistant - A professional with 2-6 years of education after HS with advanced skills for assessment and medical diagnostics. Generally employed by a physician. Seen most often on a surgical unit.
HOSPITAL ASSOCIATED LOCATION
Emergency Room (ER) or Emergency Department (ED) - Site in the hospital where patients receive emergency care.
 
Operating Room (OR) - Where surgery is performed.
 
Intensive Care Unit (ICU) - Where patients who are critically ill receive highly technical, life saving care.
 
Coronary Care Unit (CCU) - Unit specializing in care of patients with acute coronary problems.
 
Long Term Care (LTC) - Facility that provides extended nursing care.
 
Post Anesthesia Care Unit (PACU) - A unit where patients recover from anesthesia.
 
Long Term Acute Care Hospital (LTACH) - Special care hospital or unit for patients who are chronically acutely ill.
HEALTH CARE PRACTITIONER NOTATION
EMR 
Eletronical Medical Records. A system of electronic clinical documentation within an institution or health care system U.S. regulations support the implementation of EMR systems in all health care facilities by 2014. EMR systems are password protected and help to maintain confidentiality of medical information.
 
eMAR
The electronic medication administration system enables electronic communication of physician's orders to the pharmacy for filling prescriptions. Medications are then stored in electronically controlled medications administration machines. The nurses can recheck the physician's order, check the medication administration record, and electronically record the dose of medication he/she is administering. A patient's EMR and eMAR can be accessed with password throughout the hospital.
 
Medication cart (Med cart)
A work station on wheels that can be moved from room to room. The med cart contains a computer, the patient's medications and supplies.
NURSING ASSESSMENT NOTATION
Musculoskeletal activity
 
Range of motion (ROM) - As we bath the patient, the RN showed me how to move each other of his major joints through range of motion. ROM to upper and lower extremities.
Active Range of Motion (AROM) - Range the patient can perform. AROM right knee limited by pain to 50% of normal.
Activities of Daily Living (ADLs) - A pair of nursing assessment is noting what ADL'S patient is able to perform independently. Independent in all ADLs except applying socks and shoes.
 
 
Neurological (neuro) system
 
Pupils equal, round, react to light and accommodation (PERRLA) - Neurological evaluation of optic nerve function. Moving right extremities PERRLA.
Level of Consciousness (LOC) - Degree of level of awareness of self and surroundings. LOC decreasing.
Exercise
Transcribe the following sentences into abbreviated clinical notation.  Then check your answer.
The patient complained of a sharp headache and pain and swelling of his right ankle after falling down flight of 10 steps. On examination, his level of consciousness was normal, his pupils were equal, and round and reactive to light. He was oriented times 3, and range of motion in his ankle was limited by pain.
 
c/o headache, pain and swelling rt. ankle. LOC WNL, PERRLA, A & O x3, ROM limited by pain.
 
 
Heart and Lungs
 
Normal Sinus Rhythm (NSR) - Normal pacing of the heart from the sinoatrial. No C/O chest pain. NSR P84 R22.
Breathe Sounds (BS) - Sounds of breath heard with a stethoscope. BS=Crackles at left base.
Short of breath (SOB) - Feeling that one cannot breathe fully or comfortably. Less C/O SOB.
Paroxysmal nocturnal dyspnea - PND - Becoming short of breath after lying recumbent. Pt reports awakening with PND and must open a window to get air.Exercise
 
No c/o chest pain. NSR. R 22.
No complaints of chest pain. Normal sinus rhythm. Respirations 22.
 
 
Gastrointestinal system 
 
Abdomen (ABD) - Usually seen in writing only except when saying "ABD dressing". Abd palpation negative for pain.
Nausea and vomiting (N/V) - BS active 12 hours. S/P colectomy. No c/o N/V.
Bowel Movement (BM) - Evacuation of feces from the lower intestine. No BM X3 da. Requesting laxative. 
Bowel sounds (BS) - BS active 12 hrs. S/P colectomy.
Gastrointestinal (GI) - Stomach, small and large intestines. GI workup reveals tumors near the junction of the small and large intestine. 
S/P ("status post") means that the client has had the procedure or event in the past.
 
 
 Genitourinary system 
Genitourinary (GU) - Will do GU work up for cause of hematuria.
Intake and output (I and O) .
 
 Exercise
 
Pt c/o ABD pain.  ABD tender to palpation. No BM 3 days. BS WNL.
"Patient complained of abdominal pain. The abdomen is tender to palpation. No bowel movement for 3 days. Bowel sounds within normal limits."
 
 
 
 
HISTORY AND PHYSICAL EXAMINATION
History and physical - H and P
History of present illness - HPI
Chief complain - CC
History - HX
History of - H/O
Past medical history - PMH
Review of systems - ROS
Pt - patient
Sx - symptoms 
Dx - diagnosis 
AMB - ambulate
Example 
H & P,
Betty Smith C.R.N.P.
CC Pain left lower leg
HPI The pt was well until 24 hrs ago when he noticed pain and swelling in the posterior left lower leg. Reports long plane travel (over 12 hours) prior to onset of pain. Pts sx of pain increase with AMB. No hx of prior episodes of calf pain. No H/O blood clotting problems. No hx of prior phlebitis. Dx probable phlebitis of left calf.
CASE STUDIES
THE SURGICAL PATIENT
Personal Protective Equipment
Part of standard or universal precautions; specialized clothing or equipment such as gloves, mask, eye protection , and gowns for protection against infectious material.
Abbreviation: PPE
 
Abdominal Dressing
Another large thick more absorbent sterile gauze and cotton dressing or pad is most often used on the abdomen.  The size varies, usually 6 inches x 8 inches.
Abbreviation: ABD dressing or ABD
 
 Negative Pressure Wound Therapy
A mild suction device that employs negative pressure or suction to remove fluid from the wound and improve healing.
Abbreviation: Wound VAC
 
Nasogastric tube
A flexible plastic tube that enters the body at one nostril and extends to the stomach. Used for providing nourishment or medication. Also used for removing stomach contents by suction.
Abbreviation: NG tube
 
 
Sequential Compression Device
A machine used on the legs of immobilized patients to prevent pooling of venous blood in the lower extremities, or to increase venous blood flow from the legs to the heart
Abbreviation: SCD
THE COMATOSE PATIENT
 
MVA - Motor vehicle accident
 
Percutaneous Endoscopic Gastrostomy tube
The Peg tube is visible on the upper left abdomen.  Food and medications are injected or drained into the stomach through the feeding tube.  While the PEG tube is most common, other tubes provide direct access to the gasto-intestinal tract. 
See G-tube, J-tube, and G-J tube
Abbreviation: PEG tube
 
Tracheostomy
Opening through the skin of the throat into the trachea or windpipe. A tracheostomy tube is placed in the opening. Air passes through the tube into the lungs. The O2 mask used over the tracheostomy is called a “trach” mask.
Abbreviation: trach
 
Catheter
A hollow cylinder that allows for liquid to pass through.  Commonly used to drain fluid, such as urine out of the body. 
Abbreviation: cath
 
Foley Catheter
An indwelling urinary catheter held in the bladder by a small balloon inflated after insertion. The catheter is small (fitting into the urethra) and then is connected to a larger tubing that leads to a transparent plastic bag for collection of urine.
Abbreviation: foley
 MEDICAL PATIENT
Nasal Cannula
Mr. Cope receives low flow oxygen by nasal cannula or NC. Two types of nasal cannula are in use: the standard nasal cannula and the reservoir nasal cannula. The standard NC is a plastic tubing with short prongs that fit into the nostrils and delivers 22-44% O2. The reservoir nasal cannula stores exhaled oxygen and increases the percentage delivered to 100%. The type will be specified on physicians' orders; these NC are not interchangeable.
Abbreviation: NC (written only)
 
Your nursing note reads:
Date: 00/00/0000 
10:30AM: O2 by NC 2 L/min rr 34 
10:40AM: Pt more comfortable 10 min after starting O2 NC. RR 32. 
Note: Mr. Cope uses an NC with a reservoir
 
Antiembolic stocking or hose
An elastic stocking or hose used to control swelling and reduce the risk of developing deep vein thrombosis or blood clots in the legs. Rarely used formal name is thrombo-embolism deterrent stocking or hose.
Abbreviation: TED hose or TED stockings
 
Nursing Notes:
transferred to chair. C/O “little dizziness” on standing. 
3 position BP/ p = lying 110/70, 88; sitting 100/70, 96; standing 100/70, 100. 
Rested 14 min then amb. 10-12steps. 
Transient SOB on amb. 
A & O x3, Refused lunch. States that he is ready to die.
A and O - alert and oriented. 
EMERGENCY
Code Blue
The most common term used in U.S. hospitals for a medical emergency is code blue. Many hospitals will use a different term, such as “Code C”. Other emergency situations requiring a public announcement (such as fire, need for security, etc.) will have terms unique to that hospital.
Be sure to learn what terms are used for emergencies in your work or learning site as soon as you start your clinical experience.
 
Cardiopulmonary Resuscitation
Cardiopulmonary resuscitation is an emergency lifesaving procedure with the goal of restoring breathing function and circulation of blood when a fatal arrhythmia or cardiac arrest has occurred.
Abbreviation: “CPR”
 
Read the following question and choose the response option that best completes the sentence.
The nurse glanced at the monitor and said, “Call a code. He is in ventricular fibrillation.”
The term code means that this is a medical emergence.
 
Stat
Stat is a term derived from the Latin, statim, meaning immediately.
“Stat” = now, immediately, right away
 
Crash Cart
A set of trays and drawers on wheels, often red in color. The cart holds equipment and medications for emergency use.
 
Defibrillator
Equipment that provides electrical therapy that interrupts a fatal arrhythmia, allowing the heart to reestablish an effective rhythm. Defibrillation is the noun and defibrillate is the verb.
 
Automated external defibrillator
A portable electronic device that automatically diagnoses a life threatening heart rhythm (such as ventricular tachycardia or fibrillation) and can then treat the arrhythmia by defibrillation.
Abbreviation = AED
 
IMPORTANT
A fully automatic AED is found in all ambulances, federal buildings and many public places throughout the United States. Training for use requires about 2 hours. Modern hospital units now use an AED that has the automatic features plus a manual override so that the health care provider can defibrillate as needed.
The old defibrillator with paddles is rarely seen in modern U.S. hospitals; the electric current is delivered using gel containing pads in contact with the skin.
 
Endotracheal Intubation
Insertion of a plastic tube into the trachea in order to provide an open airway
“intubate” = common term used verbally meaning to insert an endotracheal tube
“Endo tube” = common abbreviation for endotracheal tube
 
Bag Valve Mask
A facemask provides a seal over the nose and mouth, the bag or balloon is collapsed by squeezing with the hand and oxygen or room air is pressed into the lungs. The BVM can also be attached to an adaptor for an endotracheal tube. Although the abbreviation, BVM is becoming more common, you are most likelyto hear the term “Ambu bag”, a proprietary name for the BVM. Squeezing the bag to force air into the lungs is called “bagging”.
There are a variety of different BVM products, however, the proprietary name, “Ambu bag” is commonly used in clinical conversation.
 
TIMING OF MEDICATION
Q-every.
H, hr, hrs.
BID-two times a day.
TID-three times a day.
QID-four times a day.
AC-before meals.
PC-after meals.
PRN-whenever necessary, as needed.
Hs-bedtime or hour of sleep.
 
Route of Administration
The route of administration refers to how patients receive medications. We will examine abbreviations related to three routes: by mouth, injection, or intravenously. The first, two terms below refer to administration by mouth; the last one refers to administration by injection.
	Abbreviation
	 
	Definition
	PO
	 
	By mouth
	NPO
	 
	Nothing by mouth
	IM
	 
	Intra-muscular: Injection into the muscle
	Sub-Q or SQ
	 Subcutaneous injection - Injection into the subcutaneous tissues
	PCA
	 Patient controlled analgesia - An electronically controlled infusion pump provides pain 
 medication at preset times and allows the patient to push a button and (within limits of 
 the prescribed dosage) self-administer medication for pain.
 
	IV Intravenous - infusion of liquid substances into a 
 vein using either a hollow needle or plastic tubing. 
 
	 
	IV Needle Hollow needle used for IV administration (puncture 
 the skin)
	 
	 
	 
	IV Pole Metal pole having hooked ends used for hanging IV 
 solution bags. 
	 
	 
	IV bag
	 Disposable container of IV solution, usually one 
 liter.
	D5W or D5 in water
	 5% Dextrose in water - Common solution used 
 for IV infusion. Contains dextrose and water.
 
	NSS
	 Normal saline solution – commonly used for 
 infusion or rinsing IV lines. 
	D5NS
	 IV solution containing dextrose in a normal saline 
 solution (0.9%) or dextrose in half normal saline 
 solution (0.45%).
	IVP
	 Intravenous push - when medication is injected 
 into the IV tubing or line. Medications 
 administered directly into an intravenous line may 
 be given slowly over a specific amount of time or 
 they may be given at one time. Drugs or fluid given 
 at one time rapidly is called an IV bolus.
 Medication is injected from a syringe directly into a 
 port on the IV tubing or directly into a vein.
	 
	 
 
 
 
	 
 
	PVC
	Peripheral Venous Catheter - small plastic catheter placed in the vein (usually of the arm or hand) used to administer fluids and withdraw blood. Also called IV catheter (abbreviation: IVC).
	Hep lock
-or-
Saline lock
	Heparin Lock or Saline Lock - A catheter much like the PVC is inserted in a vein and connected to a short plastic tube. This tube has a port with a site for injection of drugs. The tube can then be flushed with saline so that all of the medication is placed in the bloodstream. At one time these short catheters with tubing and a port were used solely for heparin administration; the abbreviated term "hep lock" continues in common use even though the set up now has a broader use.
	IVPB
	Intravenous piggy back - Using a previous IV solution administration set up, a container of medication is placed higher than the basic IV infusion (piggy-backed) and gravity causes the dose of medication to be infused instead of larger container of fluid hanging below the piggyback. (IV push)
	IV Pump
	A device that controls the flow of IV solution into the patient (used with a PVC). The IV infusion pump can be calibrated or set to deliver a specific amount of fluid over a specific amount of time. An alarm sounds if the flow is interrupted.
 
 
 
NEUROLOGICAL SYSTEM
 
Cerebral vascular accident
Impaired brain function resulting from decrease of blood flow to the brain. Also known as a stroke.
Abbreviation: CVA
 
	 Transient Ischemic Attack
 A temporary reduction in the blood supply and adequate oxygen to brain cells.
 Abbreviation: TIA
 
 The difference between a TIA and a CVA, is that with a TIA there is no permanent loss of body movement or 
 sensory function.
 
	Traumatic brain injury
Occurs when an external force injures the brain. Common causes are falls, vehicular accidents, and violence.
Abbreviation: TBI
 
Amyotrophic Lateral Sclerosis
A progressive and fatal degenerative disease of the nerves that control voluntary muscle function.
Abbreviation: ALS
 
	Multiple Sclerosis
A degenerative disease affecting a covering of neurons of the brain and 
spinal cord causing diffuse deficits including balance problems, increased tone or tightness of muscles, tremor and visual disturbances.
Abbreviation: MS
MUSCULOSKELETAL SYSTEM
Osteoarthritis
Degenerative change in the cartilage and bone of the joints often causing pain and disability more prevalent with aging.
Abbreviation: OA
oste - = bone     arthr = joint     - itis = inflammation
Also called: Degenerative Joint Disease
Abbreviation: DJD
 
Rheumatoid Arthritis
A chronic systemic autoimmune disease that causes inflammation of connective tissue, primarily affecting the joints of the wrists, hands, feet, and cervical spine. 
Joints of the wrists and hands acutely inflamed bilaterally. Red and warm to touch. 
Abbreviation: RA
 
CARDIOVASCULAR SYSTEM
	Myocardial Infarction
A destruction of heart muscle cells resulting from an interruption of blood supply to the heart muscle.
Abbreviation: MI
 
Coronary Artery Disease
 A narrowing or blockage of the arteries that provide oxygen and nutrients to the cells of the heart.
 Abbreviation: CAD
 
	Coronary Artery Bypass Graft
A surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore blood flow to the heart tissue.
Abbreviation: CABG
 
	Congestive Heart Failure
Occurs when the heart is unable to provide sufficient pump action to maintain blood flow to meet the body needs. Fatigue, dyspnea on exertion, and swelling in both legs.
Abbreviation: CHF
 
	Deep vein thrombosis
A blood clot in a major vein that usually develops in the legs and/or pelvis. 
We need to consider AROM (active range of motion) exercises and SCD’s (sequential compression device) to help prevent DVT.
Abbreviation: DVT
 
Abdominal aortic aneurysm
An abnormal dilation of the abdominal aorta, often asymptomatic. May require repair to prevent or treat rupture.
Abbreviation: AAA or “triple A”
 
 
 
	Atrial Fibrillation
A common cardiac arrhythmia produced by rapid unsynchronized movement of the atria and consequent irregular pulse. Often asymptomatic. Known to increase risk of CVA or stroke.
Abbreviation: A-fib -or- (less commonly AF)
 
	Ventricular Fibrillation
Abnormal fatal arrhythmia usually caused by lack of oxygen to heart muscle. The ventricles quiver rather than contract, cardiac output stops, and unless circulation is restored, the person dies.
Abbreviation: V-fib -or- (less commonly) VF
RESPIRATORY SYSTEM
Cystic Fibrosis
A disabling inherited disorder causing the secretions from the lungs anddigestive system to become abnormally thick. Although incurable, modern treatment has extended survival to adulthood.
Abbreviation: CF
 
	Chronic obstructive pulmonary disease
Chronic progressive narrowing of the airways and breakdown of lung tissue (emphysema) resulting in chronic bronchitis and oxygen deprivation.
Abbreviation: COPD
 
	Pulmonary embolism
The obstruction of the pulmonary artery by a blood clot most often from a DVT. Causes dyspnea, tachycardia, falling SpO2. Can compromise breathing and cause death.
Abbreviation: PE
 
Mr. Nguyen, the postoperative patient, suddenly develops dyspnea, tachycardia, and chest pain. What would your nursing care activity include?
Notify his physician. Check his pulse ox and LOC frequently, elevate the HOB, and make sure that emergency equipment to maintain respiration is readily available.
 
	Obstructive sleep apnea
Cessation of breathing or apnea during sleep caused by repetitive upper airway obstruction.
Abbreviation: OSA (written only)
 
Acute respiratory distress syndrome
A life threatening syndrome of lung inflammation generally caused by infection or trauma.
Abbreviation: ARDS
GASTROINTESTINAL SYSTEM
Gastroesophageal Reflux Disease
The backward flowing of gastric contents from the stomach into the esophagus. Symptoms are epigastric burning sensation (heartburn) and acidic regurgitation.
Abbreviation: GERD
 
Irritable bowel syndrome
A digestion problem affecting the large intestine (colon). Symptoms are abdominal pain, bloating gas (flatus), stomach cramps and alternating bouts of diarrhea and constipation.
Abbreviation: IBS
GENITOURINARY AND ENDOCRINE SYSTEM
	Chronic kidney disease
Slow progressive loss of kidney or renal function most often associated with HTN or diabetes.
Abbreviation: CKD (written only)
 
End stage renal disease
The final stage of CKD, also called end stage renal failure.
Abbreviation: ESRD or ESRF (written only)
 
	Benign prostatic hyperplasia
Enlargement of the prostate gland common in older men.
Abbreviation: BPH
 
	Urinary tract infection
An infection of one or more structures in the urinary system.
Abbreviation: UTI
 
	Diabetes mellitus
A group of metabolic diseases characterized by lack of effective processing of glucose and consequent development of elevated blood glucose levels.
Abbreviation: DM
 
Associated abbreviations
Type 1 diabetes mellitus
Hear: type 1 DM or type 1 diabetes
See: Type 1 DM
Type 2 diabetes mellitus
Hear: type 2 DM or type 2 diabetes
See: Type 2 DM
Insulin dependent diabetes mellitus
Hear: IDDM
See: IDDM
 
 
 GENERAL
	Cancer
Uncontrolled growth of abnormal cells in various organs or the body. Formal name for cancer is carcinoma.
Abbreviation: CA
 
	Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome
Disease characterized by progressive deterioration of the immune system and occurrence of opportunistic infections and cancers. Contracted from transfer of blood, semen, vaginal fluid, pre-ejaculate or breast milk.
Abbreviation: HIV/AIDS
 
	Gunshot wound
A form of physical trauma from the discharge of a type of ammunition.
Abbreviation: GSW
Pt c GSW to the left arm. AROM of the arm is restricted.
 
	Motor vehicle accident
Collision of a vehicle with another vehicle, pedestrian, animal or any other stationary obstruction such as a tree or utility pole.
Abbreviation: MVA
Abbreviation is commonly used as a noun or as an adjective, e.g. “MVA patient” to describe a patient injured in an MVA.
 
PATIENT WITH ANEMIA
	A patient complains of fatigue, paleness of the skin, SOB and tachycardia with exercise. The diagnosis is possible anemia. Laboratory testing will include the most common laboratory test, the Complete Blood Count.
 
Complete Blood Count
Determination of the number of white blood cells (WBCs), red blood cells (RBCs), Hemoglobin (Hgb), Hematocrit (Hct) and other important values.
 Platelets = plts
Abbreviation: CBC
See: CBC
When referred to in combination, Hemoglobin and Hematocrit are referred to as H&H. Pronounced as "H" and "H" and written as H&H.
PATIENT WITH DIABETES
A patient with symptoms of fatigue, sleepiness, increased thirst and frequent urination is admitted to your unit. Diabetes Mellitus (DM) is suspected. Laboratory testing will include: a metabolic panel with fasting blood glucose, glycated hemoglobin, and/or and oral glucose tolerance test.
Metabolic Panel
The Basic Metabolic Panel measures 7 components: urea nitrogen, carbon dioxide, creatinine, glucose, chloride, potassium and sodium. The Comprehensive Metabolic Panel measures 14 blood components. In clinical conversation these tests are referred to as a "chem" 7 or "chem" 14. The "chem" is a shortening of the word chemistry.
 
Abbreviation: Chem 7 or Chem 14
See Chem 7 or Chem 14
Note: "Panel" refers to a group of tests that generally target evaluation of a particular organ or disease, eg. thyroid panel or Lipid panel.
 
Fasting Blood Glucose
A blood test that measures the glucose level 12 hours after eating. Blood glucose is also called blood sugar.
Abbreviation: FBG
See: FBG
Note: This test is also called a Fasting Blood Sugar or FBS. The scientific term glucose is preferred.
 
Glycated Hemoglobin
Measures the percentage of hemoglobin associated with glucose. Computation provides an estimate of the average glucose level over the previous six weeks.
Abbreviation A1C
See: A1C
Note: Hemoglobin A1C and HbA1c are also commonly used. The shortest form (A1C) is preferred
 
Oral Glucose Tolerance Test
Measurement of blood glucose level before and over a 3 hour interval after consuming a sugary drink.
Abbreviation: OGTT or GTT
See: OGTT or GTT
 
The doctor orders nothing by mouth for 12 hours prior to a Chem 14. What does the note say?
NPO 12 hrs, Chem 14 in am
PATIENT WITH LIVER DISEASE
You are assigned to a patient with a history of alcoholism and possible liver disease. Laboratory tests will include tests for liver function and tests for liver enzymes.
Liver Function Tests
Examination of the blood for levels of components that are processed by the liver. When liver function is compromised less
albumin, bilirubin and prothrombin are present in the blood.
Abbreviation: LFTs
See: LFTs
 
Liver enzyme tests
The major liver enzymes are alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP). Only the abbreviations will be used to refer to these enzymes. When liver damage occurs these enzymes are released into the blood. Rising levels indicate liver damage.
Abbreviation: ALT, AST and ALP
See: ALT, AST and ALP
 
PATIENT WITH TRAUMATIC BRAIN INJURY
You are assigned to a patient who had a TBI 2 months ago and was doing well at home when he developed fever, sleepiness, and confusion. The doctor orders radiological examinations and then a lumbar puncture for analysis of cerebral spinal fluid.
Computerized tomography scan-or-Computerized axial tomography scan
A radiographic technique used to see internal body structures by slices of body tissue and results are assembled to give a three-dimensional picture of a body organ.
Abbreviation: CT or CAT
See: CT or CAT
 
Magnetic Resonance Imaging
The MRI uses nuclear magnetic resonance to image nuclei of atoms within the body. It is particularly useful for imaging soft tissue of the brain, muscles, and heart.
Abbreviation: MRI
See: MRI
 
Cerebrospinal fluid analysis -or- CSF analysis
Examination of the cerebrospinal fluid (a clear substance in the subarachnoid space) obtained via lumbar puncture (LP) or spinal tap. CSF analysis is used to differentiate diagnosis of infection or hemorrhage of the brain.
Abbreviation:
CSF= Cerebral spinal fluid
LP = lumbar puncture
See: CSF or LP 
 
To evaluate the presence of a possible infection or inflammation, the physician orders an erythrocyte sedimentation rate (ESR).Erythrocyte sedimentation rate
A measure of the sedimentation rate of red blood cells in one hour. Increased in the presence of infection or inflammatory disease.
Abbreviation: ESR or SED rate
See: ESR or SED rate
 
The patient’s condition suddenly deteriorates. Respiratory rate is slow and labored. The doctor orders evaluation of arterial blood gasses.
Arterial Blood Gases
The measurement of arterial blood oxygen, carbon dioxide (CO2), pH and bicarbonate used to evaluate respiratory function and acid-base balance.
Abbreviation: ABGs
See: ABGs
MONITORING A PATIENT ON ANTICOAGULATION
You are assigned to a patient who has atrial fibrillation. The drug heparin has been in use for two days and the patient will be sent home using warfarin or Coumadin. Laboratory testing includes Activated Partial Thromboplastin Time (aPTT), Prothrombin time (PT), and International Normalized Ratio (INR).
Activated partial thromboplastin time
Measure of the time required for clot formation involving all factors of the intrinsic pathway, except platelets. Commonly used to evaluate the effect of ‘heparin’ therapy.
Abbreviation: aPTT
See: aPTT or PTT
 
Prothrombin time
Measures the extrinsic pathway of coagulation and evaluates clotting ability. It is usually used to evaluate the effect of ‘warfarin’ therapy.
Abbreviation: PT or pro time
See: PT or pro time
 
International Normalized Ratio
A calculation made to standardize prothrombin time (PT). INR is based on the ratio of the patient’s PT and the normal mean PT.
Reference Values: 0.8-1.2
Abbreviation: INR
See: INR
 PATIENT WITH URINARY TRACT PROBLEMS
You are assigned to a man with BPH. Laboratory testing includes Urinalysis (UA), Prostate specific antigen (PSA), and Cystoscopy (cysto).
Urinalysis
Measures or identifies the possible constituents of urine including proteins, glucose, ketones, nitrites, WBC’s, RBC’s, bacteria and other substances.
Abbreviation: UA
See: UA
 
Prostate specific antigen
To measure the blood level of PSA, a tumor marker associated with prostate cancer.
Reference Values: <4.0 ng/mL
Abbreviation: PSA
See: PSA
 
Cystoscopy
Examination of the urethra and interior of the urinary bladder using a special scope.
Cyst- = bladder or sac     -oscopy= to look at
Abbreviation: cysto
See: cystoscopy
Note: The cystoscopy is a type of endoscopy