Medical Transcription Phrases, Words, And Helpful Hints


CORONARY ARTERY BYPASS GRAFT SURGERY TERMS FOR MEDICAL TRANSCRIPTIONISTS:

ACT

 

antegrade cold cardioplegia 

 

aorta was cross clamped 

 

aortotomies 

 

arterial limb of the bypass tubing 

 

arteriotomy 

 

atrial appendage 

 

bypass cooling 

 

cardiac index 

 

cardioplegic solution 

 

cardiopulmonary bypass 

 

cold and tepid blood cardioplegia 

 

CoSeal 

 

cross clamp 

 

crystalloid quadriplegia 

 

de-airing maneuvers 

 

endoscopic vein harvesting technique 

 

foreshortened aorta 

 

innominate artery 

 

kinking in the grafts 

 

median sternotomy 

 

Morse sternal retractor 

 

Myo/Wires II 

 

nonpedicled technique 

 

pericardial cradle was created 

 

pericardial well 

 

rewarming 

 

side-biting clamp 

 

sinotubular junction  

 

skin bridging technique (vein harvested using) 

 

sternal saw

 

sternal wires 

 

Tisseel
 

BREAST AUGMENTATION/REDUCTION/MASTECTOMY TERMS FOR MEDICAL TRANSCRIPTIONISTS:

 

"postage stamp" dissection 

 

areolar graft 

 

areolar margins 

 

axillary tail of Spence 

 

capsular release 

 

clavipectoralis fascia 

 

cookie cutter 

 

de-epithelialized 

 

dog ear (means a flap of tissue left by the doc after surgery) 

 

expander port 

 

inferior pedicles 

 

inferolateral stab incision 

 

inframammary crease 

 

inframammary fold 

 

lighted breast retractor 

 

lines of Langer 

 

loupe magnification 

 

McGhan Style tissue expander 

 

medial and lateral pillars 

 

Mentor adjustable implant 

 

Mentor Siltex contour profile expander 

 

Mentor smooth surface saline inflatable style implant 

 

moistened laparotomy pads

 

nipple mound  

 

nipple-areolar complex 

 

nipple-areolar reconstruction 

 

poles of the breast 

 

saline implants 

 

silicone gel implants 

 

Siltex Becker 25 tissue expander 

 

skate flap nipple  

 

Skin flaps were raised using traction and countertraction 

 

standard bra 

 

submuscular flap 

 

subpectoral implant 

 

surgical bra

 

tailor-tacked 

 

tie-over dressing 

 

tissue expander

 

MEDICAL WORDS & PHRASES DATABASE (FOR NEW MTs ESPECIALLY):

 

(two/three/four/five) pillow orthopnea 

 

1:100,000 epinephrine

 

a. fib  = atrial fibrillation 

 

AAA       (dictated "triple A" – stands for abdominal aortic aneurysm) 

 

abduction pillow 

 

ablation therapy 

 

ACE inhibitor 

 

ACOG      (full form is American College of Obstetrics & Gynecology) 

 

ADA diet (eg. 1800-calorie ADA diet) 

 

ADHD (attention deficit hyperactivity disorder) 

 

adenosine sestamibi 

 

adjuvant 5-FU 

 

Adkin diet 

 

AMA = against medical advice 

 

ampulla of Vater 

 

ANA screen 

 

anasarca 

 

anatomic snuffbox 

 

anion gap (found in the labs section of a report) 

 

ankylosing spondylitis 

 

Apgar score (term found in infant physical exam) 

 

Apley sign 

 

Apligraf

 

aponeurosis

 

AAROM = active assisted range of motion 

 

AROM = active range of motion 

 

aromatase inhibitor 

 

artifacts (found in radiology reports)  

 

arytenoids 

 

ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon 

 

astereognosis 

 

asynclitism 

 

autoclaved instrument 

 

avulsion/evulsion 

 

axial load 

 

axillary nerve palsy 

 

baby aspirin 

 

ballottable 

 

base excess  

 

beta blocker 

 

Bead memory 

 

Berger disease versus Buerger disease (sounds the same - be careful of what you put in) 

 

blood is typed and crossed 

 

boggy prostate 

 

Bovie cautery 

 

bowleg deformity 

 

BRAT diet (bananas, rice, applesauce and toast) 

 

bronchial washings

 

bucket-handle tear 

 

BUS [Bartholin, urethral, and Skene (glands) ] -- occurs in female genitalia exam 

 

C&S = culture and sensitivity  (CNS = central nervous system) - sound alike - verify based on 

 

C. diff     (Clostridium difficile)

 

café au lait spots (sounds cafe o lay)

 

cancellous bone

 

cath   = catheterization or catheter

 

CD4 count (estimate of the immunologic status of patient)

 

cerclage

 

Charcot-Marie-Tooth disease (also peroneal muscular atrophy)

 

chin tuck technique (for patients with dysphagia/trouble swallowing food)

 

cholesteatoma

 

cholesteatoma

 

cicatrix (means scar)

 

claudication

 

clean-catch urine

 

CLOtest

 

CO2 insufflation

 

cogwheel rigidity (seen in Parkinson disease patients)

 

Colles' fracture

 

COX-2 inhibitor

 

CRAB diet (carrots, rice, apples and bananas)

 

cushingoid

 

D&C = dilatation and curettage

 

de Quervain disease/tenosynovitis/thyroiditis/fracture

 

dehiscence  (bursting/splitting along natural/sutured lines)

 

diff        (as in differential - relating to CBC) Eg. CBC with diff

 

dig     = digoxin

 

DOT physical (DOT = Department of Transportation)

 

Dupuytren contracture/amputation/canal/fracture/fascia/sign/suture/tourniquet

 

ehrlichiosis

 

en bloc     (sounds "on bloc")

 

Ensure shakes (nutritional supplem't)

 

epileptiform discharges (dictated in EEG reports mostly)

 

ER/PR positive (relating to breast cancer)

 

EtOH (ethanol or ethyl alcohol)

 

facet joint

 

factor V Leiden mutation

 

fat pad

 

FES (functional electronic stimulation)

 

fifth disease

 

FLAIR sequence (dict'd in MRIs)

 

follicular small cleaved lymphoma

 

foramen ovale

 

frog pelvis x-ray

 

gent   = gentamicin

 

Gleason score (tumor grading)

 

global period of surgery

 

glycosylated hemoglobin or hemoglobin A1c HbA1c

 

Ginkgo biloba

 

Glasgow coma scale (GCS)

 

glove-stocking anesthesia

 

gnathic (relating to jaw)

 

G-tube

 

Guillain-Barré syndrome (sounds "gee yan bah ray")

 

gurney (eg. the patient transferred from gurney)

 

H. pylori (Helicobacter pylori)

 

halo vest (type of neck brace)

 

hammer toe

 

Harrington rod (ortho files) (instrumentation for spine)

 

HCTZ  - short for hydrochlorothiazide

 

heart healthy diet

 

Heberden nodes

 

hep = hepatitis

 

hep lock

 

heparinized

 

HER-2/neu negative

 

Hibiclens (antibacterial surgical soap)

 

HNP versus H&P (sound alike) ---- HNP = herniated nucleus pulposus; H&P = history and physical

 

Hoffmann sign

 

hospice care

 

HSGYV - heat, steam, gum, yawn, Valsalva

 

Humalog Pens

 

ilium versus ileum (sound alike) ---- ilium pertains to the hip bone; ileum pertains to the intestine

 

in toto

 

indoluria

 

INH therapy (for tuberculosis)

 

insuff = insufflation (as in CO2 insufflation - occurs in op reports)

 

interferon therapy

 

intertrigo (dermatitis - relating to skin)

 

IV push

 

jamais vu (opposite of deja vu)

 

Jevity (nutritional supplmn't)

 

Jewett staging

 

kappa light chain excretion

 

Kernig sign

 

K-wire (Kirschner wire)

 

knismogenic (tickling feeling)

 

lactated Ringer's solution

 

latissimus dorsi

 

Lhermitte sign

 

Lisfranc strain

 

lordosis

 

loupe magnification

 

Lyme disease

 

maceration

 

mask facies (found in Parkinson's disease patients - expressionless face)

 

mass effect (its not mass affect)

 

Mastisol (surgical adhesive)

 

mechanical soft diet

 

meibomian

 

menarche

 

millicurie (mCi)

 

Monsel solution

 

mono = mononucleosis

 

mortise

 

MRSA (dictated "MERSA" Expansion is methicillin-resistant Staphylococcus aureus)

 

muscle belly

 

nectar-consistency liquids (for patients with dysphagia/aspiration)

 

needle and sponge counts

 

neural foramen

 

nitro paste (written nitroglycerin paste)

 

normal-pressure hydrocephalus

 

NSAID (short for nonsteroidal anti-inflammatory drug)

 

O&P (ova and parasites) - as in stool exam results

 

os naviculare

 

pannus versus penis (sound alike) --- pannus as in abdominal pannus

 

peak and trough level (eg. vancomycin peak and trough level)

 

peau d'orange

 

PEG tube  (percutaneous endoscopic gastrostomy tube)

 

pessary

 

PICC line (sounds pic/pik line)

 

Philadelphia collar (for the neck)

 

piggyback (as in IV piggyback)

 

pilonidal

 

PPI (proton pump inhibitor)

 

PRAFO (stands for pressure relief ankle foot orthosis)

 

pressure-relief technique (to prevent pressure ulcers)

 

psoas muscle

 

psoas sign

 

pulsatile

 

raccoon eyes

 

radicle versus radical (sound alike) ---- radicle refers to arteries/veins ---- radical (eg. free radical)

 

RAST test (related to allergy testing)

 

red reflex

 

reperfusing

 

restless leg syndrome

 

retic count = reticulocyte count

 

Roux-en-Y (sounds rou  n  y)

 

sats = saturation (eg. O2 sat of 98%)

 

satting = saturating

 

sequelae

 

sickle cell crisis

 

silicon versus silicone (Note the "e" in the second term - this is what is meant in breast reconstructions)

 

silastic tape

 

sliding board technique (rehab technique for patients undergoing rehabilitation)

 

spider angioma

 

spherocytosis

 

split-thickness skin graft

 

Stanford-Binet Intelligence Scale

 

staph = staphylococcus

 

stocking distribution

 

strep = streptococcus

 

sugar-tong splint

 

sulci

 

syndesmosis

 

tandem gait

 

tardive dyskinesia

 

tenesmus

 

thallium stress test

 

tib-fib (tibia-fibula)

 

tinea versicolor

 

TNTC      (too numerous to count)

 

trismus (relating to masseter muscles)

 

toe-touch weightbearing

 

torticollis

 

trigone

 

Tuohy needle

 

U-drape

 

uncinate

 

Unna boot

 

uncinate process

 

updraft treatment with albuterol, Combivent, etc

 

urobilinogen

 

V tach = ventricular tachycardia

 

valproic acid level

 

vanco = vancomycin

 

Veress needle

 

verumontanum

 

vibrissae

 

vitiligo

 

von Willebrand factor/disease

 

Weber-Rinne testing

 

wet-to-dry dressing

 

white-coat hypertension

 

wound VAC

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