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Understanding Medical Terms

by Health After 50  

Over recent years, more and more patients have gained online access to their electronic medical records. But those reports may be difficult to understand even for highly literate persons. Some doctors are still writing or dictating reports containing medical terminology, abbreviations, and jargon that thwart understanding. Here’s a road map to help you steer through the challenging language.

Decoding ‘doctor-speak’

The history and physical (H&P) portion of your medical records is a write-up of the information your doctor gets by asking you about your medical history and performing a physical exam. You might encounter some of the following abbreviations he or she noted on your record:

  • DOE: dyspnea on exertion (shortness of breath during activity)
  • GI: gastrointestinal (digestive system)
  • GU: genitourinary (the reproductive and urinary systems)
  • HEENT: head, eye, ear, nose, and throat
  • HPI: history of present illness (the background of your current health concerns)
  • HR: heart rate
  • NKA: no known allergies
  • NKDA: no known drug allergies
  • NVD: nausea, vomiting, and diarrhea
  • R/O: rule out
  • ROM: range of motion
  • SOB: shortness of breath
  • WNL: within normal limits

Don’t take it the wrong way

Watch out for terms that sound judgmental but aren’t meant to be: A patient’s “complaint” refers to the health concern that brought him or her to the clinician. A patient who “denies” a fever isn’t aware of having one. When a patient “fails” a treatment, it doesn’t mean the patient is at fault; it means the treatment was ineffective. “Gross,” when used as a medical term, describes something that can be seen by the naked eye (as opposed to needing a microscope to see something).

Your X’s explained

You likely know that Rx refers to a medical prescription, but what about all the similar shortcuts you may find in your records?

  • Bx: biopsy
  • Dx: diagnosis
  • Fx: fracture
  • Hx: history
  • Px: prognosis
  • Sx: symptoms, signs
  • Tx: therapy, treatment

Lab test lingo

Your patient portal will typically include a section for lab tests—the results of blood tests, urine tests, and the like. Some lab tests measure levels of a chemical or a substance, with results given in standard units—like g/dL (grams per deciliter) or mmol/L (millimoles per liter). The lab report may indicate whether those values are within a normal, or “reference,” range. Other lab tests measure, or detect the presence or absence of, certain substances. A positive result indicates the substance or condition being tested for was found; a negative result means it wasn’t.

Common blood test abbreviations include:

  • BUN (blood urea nitrogen), which assesses kidney function
  • CBC (complete blood count), which evaluates white blood cells (WBCs), red blood cells (RBCs), and platelets (PLTs)
  • CBC c¯ diff, CBC/diff (complete blood count with differential), which includes a measurement or breakdown of various types of WBCs
  • CPK (creatine phosphokinase), or CK, which is used to detect muscle damage (including the heart muscle)
  • ESR (erythrocyte sedimentation rate),a nonspecific indicator of inflammation
  • FBS (fasting blood sugar), which is used to detect diabetes mellitus (includes types 1 and 2 diabetes)
  • GTT (glucose tolerance test), which can detect diabetes or assess diabetes risk

Deciphering a diagnosis

You might find the terms below in your medical record’s plan of care section, which summarizes your diagnosis and treatment:

  • CAD: coronary artery disease
  • CHD: coronary heart disease
  • CHF: congestive heart failure
  • CKD: chronic kidney disease
  • COPD: chronic obstructive pulmonary disease (emphysema/chronic bronchitis)
  • DM: diabetes mellitus (includes type 1 and 2 diabetes)
  • OA: osteoarthritis
  • T2DM: type 2 diabetes mellitus
  • URI: upper respiratory infection
  • UTI: urinary tract infection

Instruction insight

Your record will include a list of drugs your doctor has prescribed. These abbreviations (written either with or without punctuation) tell you when or how to take them:

  • a.c.: before meals
  • b.i.d., BID: twice a day
  • h.s., HS: at bedtime
  • p.c.: after meals
  • p.r.n.: as needed
  • q 4–6 h: every 4 to 6 hours
  • q 8 h: every 8 hours
  • q.d., QD: every day
  • q.i.d., QID: four times a day
  • t.i.d., TID: three times a day
  • w/f: with food

This article first appeared in the September 2018 issue of UC Berkeley Health After 50.

Also see Accessing Your Medical Record.