Hayley Aanestad

CLINICAL ORIENTATION INTERN ASSIGNMENT

During introductory clinical rotations, the dietetic intern acquires basic nutrition assessment skills. This
Orientation Packet (LAP) was designed by a dietetic internship to prepare the intern for these introductory
rotations and to develop basic skills in nutrition assessment and patient care. When completing the
definitions for disease entities, tests, and procedures, provide detailed information regarding the affected
body part or system, methods of diagnosis, etiology, treatment plans, and nutrition implications. Complete
the definitions as fully as possible. See the term Ascites for an example. Abbreviations are listed as a
learning experience. As electronic medical records become more readily accessible abbreviations will be
terms of the past.
Terms/Abbreviations
ac
achalasia

adenoadenocarcinoma

adm

Definitions

Latin for ante cibum i.e. before food or meals.

Achalasia is a failure of smooth muscle fibers to relax, which can
cause a sphincter to remain closed and fail to open when needed. It
affects the esophagus, which can affect eating and digestion. The
approach to treatment is to reduce the pressure at the lower
esophageal sphincter. Therapy may involve: Botox injections,
medications, and surgery. Those with severe achalasia symptoms
may benefit from a liquid diet for a period of time. Nutritional
supplements are usually necessary in this situation.
Prefix pertaining to a gland.
Adenocarcinoma is a type of cancer that may affect various organs. It
is derived from the word adeno meaning 'pertaining to a gland' and
carcinoma meaning cancer. These cancers may appear as glands
and possess secretion properties. They may not have definite
glandular appearance in some cases. While each gland may not be
secreting the same substance, any secretory property, glandular form
and malignant appearance is named adenocarcinoma. The leading
cancer of the colon is adenocarcinoma, and adenocarcinomas are
extremely common in the lungs. Other organs that may be affected by
adenocarcinoma include: cervix, pancreas, prostate, stomach, thyroid,
and breast. Adenocarcinomas are diagnosed like other cancers. They
are usually detected by taking a biopsy of the tumor and examining it
under the microscope. Treatment includes surgical removal of the
tumor to prevent its growth. After surgery, the patient may undergo
chemotherapy and radiation to prevent the adenocarcinoma coming
back.
Admission or administered. Could refer to the date the patient was
admitted to the hospital to dates and times medications were
administered.

AKA

amt
angiography

Above the knee amputation. There are many reasons an amputation

may be necessary. The most common is poor circulation because of
damage or narrowing of the arteries, called peripheral arterial disease.
Without adequate blood flow, the body's cells cannot get oxygen and
nutrients they need from the bloodstream. As a result, the affected
tissue begins to die and infection may set in. Other causes for
amputation may include: severe injury, cancerous tumor in the bone
or muscle of the limb, serious infection that does not get better with
antibiotics or other treatment, thickening of nerve tissue, called a
neuroma, and frostbite. When performing an amputation, the surgeon
removes all damaged tissue while leaving as much healthy tissue as
possible. During the procedure itself, the surgeon will: remove the
diseased tissue and any crushed bone, smooth uneven areas of bone,
seal off blood vessels and nerves, and cut and shape muscles so that
the stump, or end of the limb, will be able to have an artificial limb
(prosthesis) attached to it. To calculate your ideal caloric need postamputation, you will need to determine your ideal body weight postamputation and use an equation to find your estimated energy
expenditure.
Amount. Pertaining to food or medications taken by the patient.
Angiography is the x-ray study of the blood vessels. Angiography is
used to detect abnormalities or blockages in the blood vessels (called
occlusions) throughout the circulatory system and in some organs.
The procedure is commonly used to identify atherosclerosis; to
diagnose heart disease; to evaluate kidney function and detect kidney
cysts or tumors; to detect an aneurysm, tumor, blood clot, or
arteriovenous malformations in the brain; and to diagnose problems
with the retina of the eye. It is also used to give surgeons an accurate
"map" of the heart prior to open-heart surgery, or of the brain prior to
neurosurgery.

apnea

Apnea is a cessation or pause in breathing. Very short episodes of

apnea can be normal, and a person can induce voluntary, short-term
apnea by holding one's breath. However, apnea can also be a
symptom of a variety of mild to serious disorders, diseases or
conditions. Apnea can occur in any age group or population. Apnea
can result from neurological disorders, infection, toxicity, trauma,
malignancy, airway obstruction and other abnormal processes. In
addition to the respiratory system, apnea can occur as a symptom of
diseases, disorders and conditions of other body systems. For
example, in the cardiovascular system, apnea can be a symptom of
end-stage congestive heart failure or a severe heart attack. Apnea can
also be chronic and happen in relatively short episodes over a long
period of time, such as when it is due to sleep apnea. Apnea is
generally immediately diagnosed upon an examination, which reveals
an absence of respiration. Diagnosing the underlying cause of apnea
begins with taking a thorough personal and family medical history,
including symptoms, and completing a physical examination. This
includes listening with a stethoscope to the sounds that the lungs
make. Certain lung sounds point to some underlying causes of apnea.
Complications of apnea can include low oxygen levels and high
carbon dioxide levels in the body. This is called respiratory acidosis.
If not treated immediately, this leads to respiratory failure, cardiac
arrest, irreversible damage to the major organs of the body, and death.
According to the National Sleep Foundation, "As the person gains
weight, especially in the trunk and neck area, the risk of sleepdisordered breathing increases due to compromised respiratory
function." There's no doubt that obesity, which is largely influenced
by nutrition and diet, significantly increases the risk of sleep apnea.

ascites

Accumulation of serous fluid in the peritoneal (abdominal) cavity

containing large amounts of protein. Serial measurements of abdominal
girth may determine the presence of ascites. Results in abdominal swelling,
blood dilution and decreased urinary output. Perhaps associated with
inflammatory disorders of the peritoneum, hypoalbuminemia, portal and
hepatic hypertension (cirrhosis of the liver and congestive heart failure).
Input/output records, daily weights, and electrolyte values are necessary to
monitor fluid status. Fluid restriction may be necessary to ameliorate ascites
formation. Sodium restriction (20 mEq to 90 mEq) may be necessary to
alleviate fluid retention with ascites. The patients may require meals served
in small portions and more frequently because ascites limits the capacity for
gastric expansion.

aspiration

ASHD

A&O
barium enema

Aspiration is the entry of material (such as pharyngeal secretions,

food or drink, or stomach contents) from the oropharynx or
gastrointestinal tract into the larynx (voice box) and lower respiratory
tract. Consequences of pulmonary aspiration range from no injury at
all, to chemical pneumonitis or pneumonia, to death within minutes
from asphyxiation. Measures to prevent aspiration depend on the
situation and the patient. In patients at imminent risk of aspiration,
tracheal intubation by a trained health professional provides the best
protection. A simpler intervention that can be implemented is to lay
the patient on their side in the rescue position (as taught in first aid
and CPR classes), so that any vomitus produced by the patient will
drain out their mouth instead of back down their pharynx. Enteral
nutrition may be recommended for serious cases of aspiration.
Arteriosclerotic Heart Disease (aka Coronary Heart Disease). A
person with ASHD has narrowing of the arteries that supply blood
and oxygen to the heart. ASHD is caused by atherosclerosis. As the
narrowing worsens, the arteries become unable to supply enough
oxygen to meet demand. This can cause chest pain. Severe narrowing
increases the risk for heart attack. Treatment for ASHD includes no
smoking, weight reduction, and a low fat and cholesterol heart diet.
Some may benefit from medications to reduce chest pain and lower
blood pressure. Some patients may be candidates for angioplasty or
coronary artery bypass surgery. it is important to exercise, to avoid
saturated fats, and to keep their LDL cholesterol level low, as it is a
major contributing factor to arteriosclerotic heart disease. Cutting
down on smoking and alcohol intake is critical too.
Alert and Oriented. Relates to the patients psychological status.
A barium enema, or lower gastrointestinal (GI) examination, is an Xray examination of the large intestine (colon and rectum). The test is
used to help diagnose diseases and other problems that affect the large
intestine. A barium enema is done to: identify inflammation of the
intestinal wall that occurs in inflammatory bowel diseases, such as
ulcerative colitis or Crohn's disease. A barium enema also may be
used to monitor the progress of these diseases, find problems with the
structure of the large intestine, such as narrowed areas or pockets or
sacs (diverticula) in the intestinal wall, help correct ileocolic
intussusception, in which the end of a child's small intestine protrudes
into the large intestine, evaluate abdominal symptoms such as pain,
blood in stool, or altered bowel habits, or evaluate other problems
such as anemia or unexplained weight loss. To make the intestine
visible on an X-ray picture, the colon is filled with a contrast material
containing barium. The barium blocks X-rays, causing the bariumfilled colon to show up clearly on the X-ray picture. Patients who
have a barium enema are on a clear liquid diet 3 days prior to the
procedure, and can resume to a regular diet once the procedure is
over.

bid
biopsy

BKA

BR

BP

Bis In Die (Twice Daily). Refers to prescription medication dosing,

where it is to be taken twice daily.
A biopsy is a sample of tissue taken from the body in order to
examine it more closely. Biopsies are most often done to look for
cancer. There are many different kinds of biopsies. Some of these
include: Needle biopsy, CT-guided biopsy, ultrasound-guided biopsy,
bone biopsy, bone marrow biopsy, liver biopsy, kidney biopsy,
aspiration biopsy, prostate biopsy, skin biopsy, and surgical biopsy.
Below the knee amputation. Similar to AKA, there are many reasons
for amputation, with the most common being lack of circulation to the
area. The procedure is common to AKA, with the patella remaining
in place. Nutritional adjustments are the same as AKA as well.
Bed rest is a medical treatment in which a person lies in bed for most
of some period of time to gain health benefits. Bed rest refers to
voluntarily lying in bed as a treatment, and not being confined to bed
because of a health impairment which restricts a person from leaving
the bed. There are no known conditions where bed rest is shown to
be an effective treatment. However, bed rest is commonly prescribed
in the following cases: for sufferers of acute or chronic pain,
complications of pregnancy, heart diseases, and conditions of the feet
that affect walking. Prolonged bed rest has long been known to have
deleterious physiological effects, such as muscle atrophy and other
forms of deconditioning such as arterial constriction.
Blood pressure (BP), sometimes referred to as arterial blood pressure,
is the pressure exerted by circulating blood upon the walls of blood
vessels, and is one of the principal vital signs. Doctors generally
consider a blood pressure of 120/80 mm Hg or less to be normal and
healthy. Either a systolic pressure above 120 or diastolic pressure
above 80 may be cause for concern if readings remain consistently
high. High blood pressure, or hypertension, over time can lead to
heart attack, stroke, kidney damage and vision problems. Low blood
pressures are generally only of concern if they're below 90/60 mm Hg
or accompanied by symptoms such as dizziness, fainting, clammy
skin, shallow breathing or fatigue. Causes of low blood pressure
include dehydration, serious infection, anemia and some heart
conditions. Lifestyle modifications can help an individual maintain a
normal blood pressure. A diet low in salt that balances fruits,
vegetables and whole grains usually is recommended. Regular
exercise or physical activity and maintaining a healthy weight also
can help. The American Heart Association suggests that managing
stress, not smoking cigarettes and limiting alcohol consumption are
all important steps to better blood pressure.

CA

Ca

CAD

cc

Cardiac arrest. A sudden cessation of the pumping function of the

heart with disappearance of arterial blood pressure, connoting either
ventricular fibrillation or ventricular standstill. The immediate cause
of most sudden cardiac arrests is an abnormal heart rhythm. The
hearts electrical activity becomes chaotic, and it cant pump blood to
the rest of the body. Conditions that can trigger sudden cardiac arrest
include: Coronary Artery Disease, Cardiomyopathy, Long QT
syndrome, and problems with heart structure.
Calcium is a mineral that is an essential part of bones and teeth. The
heart, nerves, and blood-clotting systems also need calcium to work.
Calcium is used for treatment and prevention of low calcium levels
and resulting bone conditions including osteoporosis (weak bones due
to low bone density), rickets (a condition in children involving
softening of the bones), and osteomalacia (a softening of bones
involving pain). Calcium is also used for premenstrual syndrome
(PMS), leg cramps in pregnancy, high blood pressure in pregnancy
(pre-eclampsia), and reducing the risk of colon and rectal cancers.
Foods high in calcium include dark leafy greens, dairy products,
almonds, and fish.
Coronary artery disease (CAD) is the most common type of heart
disease and cause of heart attacks. The disease is caused by plaque
building up along the inner walls of the arteries of the heart, which
narrows the lumen of arteries and reduces blood flow to the heart.
A cubic centimeter is a commonly used unit of volume that extends
the derived SI-unit cubic meter, and corresponds to the volume of a
cube that measures 1 cm 1 cm 1 cm. 1 cc is the equivalent to 1
ml. This unit is commonly used to medications or fluids used in the
medical field.

cholecystectomy

cm

A cholecystectomy is the surgical removal of the gallbladder. The two

basic types of this procedure are open cholecystectomy and the
laparoscopic approach. A cholecystectomy is performed to treat
cholelithiasis and cholecystitis. In cholelithiasis, gallstones of varying
shapes and sizes form from the solid components of bile. The
presence of stones may produce symptoms of excruciating right upper
abdominal pain radiating to the right shoulder. The laparoscopic
cholecystectomy involves the insertion of a long narrow cylindrical
tube with a camera on the end, through an approximately 1 cm
incision in the abdomen, which allows visualization of the internal
organs and projection of this image onto a video monitor. Three
smaller incisions allow for insertion of other instruments to perform
the surgical procedure. A laser may be used for the incision and
cautery (burning unwanted tissue to stop bleeding), in which case the
procedure may be called laser laparoscopic cholecystectomy. In a
conventional or open cholecystectomy, the gallbladder is removed
through a surgical incision high in the right abdomen, just beneath the
ribs. A drain may be inserted to prevent accumulation of fluid at the
surgical site. Post-operative care for the patient who has had an open
cholecystectomy, as with those who have had any major surgery,
involves monitoring of blood pressure, pulse, respiration and
temperature. Breathing tends to be shallow because of the effect of
anesthesia, and the patient's reluctance to breathe deeply due to the
pain caused by the proximity of the incision to the muscles used for
respiration. The patient is shown how to support the operative site
when breathing deeply and coughing, and given pain medication as
necessary. Fluid intake and output is measured, and the operative site
is observed for color and amount of wound drainage. Fluids are given
intravenously for 24-48 hours, until the patient's diet is gradually
advanced as bowel activity resumes. The patient is generally
encouraged to walk 8 hours after surgery and discharged from the
hospital within three to five days, with return to work approximately
four to six weeks after the procedure.
Centimeter. Unit of measurement.

colonscopy

c/o

CBC/diff

Cl

Colonoscopy is a procedure that enables an examiner to evaluate the

inside of the colon. The colonoscope is a four foot long, flexible tube
about the thickness of a finger with a camera and a source of light at
its tip. The tip of the colonoscope is inserted into the anus and then is
advanced slowly, under visual control, into the rectum and through
the colon usually as far as the cecum, which is the first part of the
colon. Colonoscopy may be done for a variety of reasons. Most often
it is done to investigate the cause of blood in the stool, abdominal
pain, diarrhea, a change in bowel habit, or an abnormality found on
colonic X-rays or a computerized axial tomography (CT) scan.
Individuals with a previous history of polyps or colon cancer and
certain individuals with a family history of some types of non-colonic
cancers or colonic problems that may be associated with colon cancer
(such as ulcerative colitis and colonic polyps) may be advised to have
periodic colonoscopies because their risks are greater for polyps or
colon cancer. How often should one undergo colonoscopy depends on
the degree of the risk and the abnormalities found at previous
colonoscopies.
Care of. An abbreviation that is used to direct correspondence to a
particular place. It is typically used for an addressee who is not at the
usual place where he or she would receive correspondence.
Complete Blood Count (CBC) and Differential Count. The CBC is a
series of lab tests that measure the amount, shapes, and sizes of red
and white blood cells in a sample. The CBC is routinely ordered
during annual physicals and other routine checkups, as it is an
inexpensive and easy test to run that provides a lot of information
about the patient's health. The CBC is also used to diagnose various
illnesses. The differential count measures the different types of white
blood cells and compares their amounts to the total count. It is usually
done by a machine (automated differential) but it can be done by a
technologist who hand-counts the cells using a microscope (manual
differential).
Chloride. Chloride is one of the most important electrolytes in the
blood. It helps keep the amount of fluid inside and outside of your
cells in balance. It also helps maintain proper blood volume, blood
pressure, and pH of your body fluids. Most of the chloride in your
body comes from the salt (sodium chloride) you eat. Chloride is
absorbed by your intestines camera.gif when you digest food. Extra
chloride leaves your body in your urine. Sometimes a test for
chloride can be done on a sample of all your urine collected over a
24-hour period (called a 24-hour urine sample) to find out how much
chloride is leaving your body in your urine. Chloride can also be
measured in skin sweat to test for cystic fibrosis.

CHF

CRF

CNS

Congestive Heart Failure. CHF means that the heart's pumping

power is weaker than normal. With heart failure, blood moves
through the heart and body at a slower rate, and pressure in the heart
increases. As a result, the heart cannot pump enough oxygen and
nutrients to meet the body's needs. The chambers of the heart may
respond by stretching to hold more blood to pump through the body
or by becoming stiff and thickened. This helps to keep the blood
moving, but the heart muscle walls may eventually weaken and
become unable to pump as efficiently. As a result, the kidneys may
respond by causing the body to retain fluid (water) and salt. If fluid
builds up in the arms, legs, ankles, feet, lungs, or other organs, the
body becomes congested, and congestive heart failure is the term
used to describe the condition. Heart failure is caused by many
conditions that damage the heart muscle, including: CAD, heart
attack, cardiomyopathy, and conditions that overwork the heart.
Doctors may also order other tests to determine the cause and severity
of your heart failure. These include: blood tests, BNP blood test, chest
xray, ECG, cardiac catheterization, and stress test. Tight control over
your medications and lifestyle, coupled with careful monitoring are
the most effective ways of treating CHF.
Chronic renal failure is the gradual loss of the kidneys' ability to filter
waste and fluids from the blood. Chronic kidney disease can range
from mild dysfunction to severe kidney failure. When the kidneys are
damaged by disease or inherited disorders, they no longer function
properly, and lose their ability to remove fluids and waste from the
bloodstream. Fluid and waste products building up in the body can
cause many complications. Most systems in the body, including the
respiratory, circulatory, and digestive systems, are adversely affected
by chronic kidney disease. Underlying disease is usually responsible
for CKD. Diseases leading to kidney damage may be confined to the
kidney, as in kidney infections, or may affect multiple organs, as in
hypertension or diabetes. Approximately 40% of CKD patients have
the disease as a result of diabetes, 30% have it as a result of
hypertension, and 10% have it as a result of a disease called
glomerulonephritis. Glomerulonephritis is a kidney disease that
causes decreased output of urine, the spilling of blood and protein
into the urine, and body swelling. Diabetes mellitus is the most
common cause of CKD. A high-carbohydrate, low-protein, low-salt
diet can reduce the workload on the kidneys. Also, it is important to
balance your fluid intake to your urine output to avoid dehydration.
Patients with CKD may need to adhere to a strict diet to control
symptoms and avoid complications.
The central nervous system (CNS) is the part of the nervous system
consisting of the brain and spinal cord. The peripheral nervous system
(or PNS), is composed of nerves leading to and from the CNS, often
through junctions known as ganglia.

CT scan or CAT scan

Computed tomography is a diagnostic medical test that, like

traditional x-rays, produces multiple images or pictures of the inside
of the body. CT images of internal organs, bones, soft tissue and
blood vessels typically provide greater detail than traditional x-rays,
particularly of soft tissues and blood vessels. Using specialized
equipment and expertise to create and interpret CT scans of the body,
radiologists can more easily diagnose problems such as cancer,
cardiovascular disease, infectious disease, appendicitis, trauma and
musculoskeletal disorders. The CT scanner is typically a large, boxlike machine with a hole, or short tunnel, in the center. You will lie on
a narrow examination table that slides into and out of this tunnel.
Rotating around you, the x-ray tube and electronic x-ray detectors are
located opposite each other in a ring, called a gantry. The computer
workstation that processes the imaging information is located in a
separate control room, where the technologist operates the scanner
and monitors your examination in direct visual contact and usually
with the ability to hear and talk to you with the use of a speaker and
microphone. In many ways CT scanning works very much like other
x-ray examinations. Different body parts absorb the x-rays in varying
degrees.

CVA

cyst-

Cerebral Vascular Accident (Stroke) is the loss of brain function due

to a disturbance in the blood supply to the brain. This disturbance is
due to either ischemia (lack of blood flow) or hemorrhage. As a
result, the affected area of the brain cannot function normally, which
might result in an inability to move one or more limbs on one side of
the body, failure to understand or formulate speech, or a vision
impairment of one side of the visual field. A stroke is a medical
emergency and can cause permanent neurological damage or death.
An ischemic stroke is occasionally treated in a hospital with
thrombolysis (also known as a "clot buster"), and some hemorrhagic
strokes benefit from neurosurgery. Treatment to recover any lost
function is termed stroke rehabilitation, ideally in a stroke unit and
involving health professions such as speech and language therapy,
physical therapy and occupational therapy. Prevention of recurrence
may involve the administration of antiplatelet drugs such as aspirin,
control of high blood pressure, and the use of statins. Some people
may benefit from carotid endarterectomy and the use of
anticoagulants. Strokes can be classified into two major categories:
ischemic and hemorrhagic. Ischemic strokes are caused by
interruption of the blood supply, while hemorrhagic strokes result
from the rupture of a blood vessel or an abnormal vascular structure.
About 87% of strokes are ischemic, the rest are hemorrhagic. Some
hemorrhages develop inside areas of ischemia ("hemorrhagic
transformation"). It is unknown how many hemorrhagic strokes
actually start as ischemic stroke. A healthy diet can reduce your risk
for acquiring medical conditions such as hypertension (high blood
pressure), diabetes, high lipid levels, coronary artery disease and
obesity. All of these conditions can increase your chance of getting a
stroke.
A chest radiograph, also called a chest X-ray is a projection
radiograph of the chest used to diagnose conditions affecting the
chest, its contents, and nearby structures. Chest radiographs are
among the most common films taken, being diagnostic of many
conditions. Like all methods of radiography, chest radiography
employs ionizing radiation in the form of X-rays to generate images
of the chest. The mean radiation dose to an adult from a chest
radiograph is around 0.02 mSv (2 mrem) for a front view (PA or
posterior-anterior) and 0.08 mSv (8 mrem) for a side view (LL or
latero-lateral).
Prefix meaning sac or vesicle.

d/c

Discontinued.

D/C

Discharge. Order given by a physician when a patient can go home.

CXR

DKA

DM, Type 1

Diabetic ketoacidosis (DKA) is a life-threatening condition that

develops when cells in the body are unable to get the sugar (glucose)
they need for energy because there is not enough insulin. When the
sugar cannot get into the cells, it stays in the blood. The kidneys filter
some of the sugar from the blood and remove it from the body
through urine. Because the cells cannot receive sugar for energy, the
body begins to break down fat and muscle for energy. When this
happens, ketones, or fatty acids, are produced and enter the
bloodstream, causing the chemical imbalance. Ketoacidosis can be
caused by not getting enough insulin, having a severe infection or
other illness, becoming severely dehydrated, or some combination of
these things. It can occur in people who have little or no insulin in
their bodies (mostly people with type 1 diabetes but it can happen
with type 2 diabetes, especially children) when their blood sugar
levels are high. Laboratory tests, including blood and urine tests, are
used to confirm a diagnosis of diabetic ketoacidosis. When
ketoacidosis is severe, it must be treated in the hospital, often in an
intensive care unit. Treatment involves giving insulin and fluids
through your vein and closely watching certain chemicals in your
blood (electrolytes).
A form of diabetes mellitus that results from the autoimmune
destruction of the insulin-producing beta cells in the pancreas. The
subsequent lack of insulin leads to increased blood and urine glucose.
The cause of diabetes mellitus type 1 is unknown. Type 1 diabetes can
be distinguished from type 2 by autoantibody testing. Lack of care
can be lethal and administration of insulin is essential for survival.
Insulin therapy must be continued indefinitely and does not usually
impair normal daily activities. People are usually trained to manage
their diabetes independently; however, for some this can be
challenging. Untreated, diabetes can cause many complications.[4]
Acute complications include diabetic ketoacidosis and nonketotic
hyperosmolar coma. Serious long-term complications include heart
disease, stroke, kidney failure, foot ulcers and damage to the eyes.[4]
Furthermore, complications may arise from low blood sugar caused
by excessive treatment.

DM, Type 2

DVT

Unlike people with type 1 diabetes, the bodies of people with type 2
diabetes make insulin. But either their pancreas does not make
enough insulin or the body cannot use the insulin well enough. This is
called insulin resistance. When there isn't enough insulin or the
insulin is not used as it should be, glucose (sugar) can't get into the
body's cells. When glucose builds up in the blood instead of going
into cells, the body's cells are not able to function properly. Type 2
diabetes is initially managed by increasing exercise and dietary
changes. If blood sugar levels are not adequately lowered by these
measures, medications such as metformin or insulin may be needed.
In those on insulin, there is typically the requirement to routinely
check blood sugar levels.
Deep Vein Thrombosis (DVT) is a blood clot (thrombus) in a deep
vein, usually in the legs. Clots can form in superficial veins and in
deep veins. Blood clots with inflammation in superficial veins (called
superficial thrombophlebitis or phlebitis) rarely cause serious
problems. But clots in deep veins (deep vein thrombosis) require
immediate medical care. These clots are dangerous because they can
break loose, travel through the bloodstream to the lungs, and block
blood flow in the lungs (pulmonary embolism). Pulmonary embolism
is often life-threatening. DVT can also lead to long-lasting problems.
DVT may damage the vein and cause the leg to ache, swell, and
change color. Blood clots can form in veins when you are inactive.
DVT is usually treated with anticoagulant medicines. Walking can
also relieve symptoms and prevent complications.

dyspepsia

Dyspepsia can be defined as painful, difficult, or disturbed digestion,

which may be accompanied by symptoms such as nausea and
vomiting, heartburn, bloating, and stomach discomfort. The digestive
problems may have an identifiable cause, such as bacterial or viral
infection, peptic ulcer, gallbladder, or liver disease. A physical
examination by a health care professional may reveal mid-abdominal
pain. A rectal examination may be done to rule out bleeding. If blood
is found on rectal exam, laboratory studies, including a blood count
may be ordered. Endoscopy and barium studies may be used to rule
out underlying gastrointestinal disease. Upper gastrointestinal x-ray
studies using barium may allow for visualization of abnormalities.
Endoscopy permits collection of tissue and culture specimens which
may be used to further confirm a diagnosis. The treatment of
dyspepsia is based on assessment of symptoms and suspected
causative factors. Clinical evaluation is aimed at distinguishing those
patients who require immediate diagnostic work-ups from those who
can safely benefit from more conservative initial treatment. Some of
the latter may require only reassurance, dietary modifications, or
antacid use. Medications to block production of stomach acids,
prokinate agents, or antibiotic treatment may be considered. Further
diagnostic investigation is indicated if there is severe abdominal pain,
pain radiating to the back, unexplained weight loss, difficulty
swallowing, a palpable mass, or anemia. Additional work-up is also
indicated if a patient does not respond to prescribed medications.

dysphagia

dx

Difficulty swallowing is usually a sign of a problem with your throat

or esophagus. Although dysphagia can happen to anyone, it is most
common in older adults, babies, and people who have problems of the
brain or nervous system. There are many different problems that can
prevent the throat or esophagus from working properly. Some of these
are minor, and others are more serious. If you have a hard time
swallowing once or twice, you probably do not have a medical
problem. But if you have trouble swallowing on a regular basis, you
may have a more serious problem that needs treatment. Normally, the
muscles in your throat and esophagus squeeze, or contract, to move
food and liquids from your mouth to your stomach without problems.
Sometimes, though, food and liquids have trouble getting to your
stomach. There are two main types of dysphagia: esophageal and
oropharyngeal. In esophageal dysphagia, digested material stops
moving in the esophagus, the tube leading from the throat to the
stomach. This may be due to acid reflux, the back up of stomach acid
into the esophagus, causing inflammation and constriction of the
esophagus. Esophageal dysphagia causes a burning sensation in the
chest. A dysphagia diet typically starts with liquids, since patients
may find it easier to swallow thickened liquids. When following this
type of diet, the patient should take care to eat slowly, take small
bites, maintain an upright posture, and refrain from talking while
eating. One of the major concerns is making sure that the patient is
consuming enough calories. Foods can be fortified with powdered
milk, fruit juice, honey, sugar, jelly, margarine, or pureed baby food
to increase their caloric content. The first level of a dysphagia diet is
pureed foods. The food should have a smooth, uniform consistency to
make swallowing easier. Next, the patient can progress to minced
foods. The individual pieces of food in this stage should be very
small, about the size of sesame seeds. The third level is ground
foods, with individual food pieces similar in size to rice, while the
fourth is chopped foods, in pieces about the size of croutons. If the
patient can comfortably eat foods in this stage, he or she can progress
to normal foods, but should stick to foods of a moist, soft, and regular
consistency. Depending upon the severity of a patient's dysphagia, he
or she may not need to begin at the first level. Whatever level a
patient can eat and swallow comfortably at is an appropriate starting
level.
Diagnosis. The discovery of a disease made by a physician.

-ectomy

Suffix meaning the surgical removal of something.

entero-

Prefix meaning intestines.

ESRD

etiology

ETOH

Fx

g tube

End stage renal disease is when the kidneys stop working well
enough for you to live without dialysis or a transplant. This kind of
kidney failure is permanent. It cannot be fixed. Most cases of ESRD
are caused by diabetes or high blood pressure. Some problems you
are born with, some reactions to medicine, and some injuries can also
cause ESRD. If you have ESRD, you will need dialysis or a kidney
transplant to live. The best way to prevent ESRD is to prevent CKD.
Diabetes and high blood pressure are the two leading causes of CKD.
You can help to protect your kidneys by keeping these in control. Get
your blood sugar and blood pressure checked often.
The study of all factors that may be involved in the development of a
disease, including the susceptibility of the patient, the nature of the
disease agent, and the way in which the patient's body is invaded by
the agent.
Ethyl Alcohol (Ethanol) a member of a class of organic compounds
that are given the general name alcohols; its molecular formula is
C2H5OH.
Fracture is the separation of an object or material into two or more
pieces under the action of stress. Fractures can be treated either
surgically or nonsurgically. It usually takes at least six weeks for the
bones to heal. Individuals most at risk for bone fractures include
those with osteoporosis, bone tumors or disorders affecting bone.
There is an increase in metabolic demands for individuals suffering
from bone fractures. Calcium and vitamin D play vital roles in the
development of healthy bones. Antioxidants such as vitamin C,
vitamin E and lycopene may be beneficial for bone fracture healing as
well.
A medical device used to provide nutrition to patients who cannot
obtain nutrition by mouth, are unable to swallow safely, or need
nutritional supplementation. During the procedure, the doctor will
insert an endoscope through your mouth and into the stomach.
Through a camera on the endoscope, the doctor will view the stomach
lining to determine the G tube insertion site. A small incision will be
made in the abdominal wall to insert the feeding tube.

gastritis

H/O
HTN

HPI
hx

Gastritis is an inflammation, irritation, or erosion of the lining of the

stomach. It can occur suddenly (acute) or gradually (chronic). It can
be caused by irritation due to excessive alcohol use, chronic vomiting,
stress, or the use of certain medications such as aspirin or other antiinflammatory drugs. Endoscopies, blood tests, and stool tests are
used to diagnosis gastritis. Avoid acidic beverages, including coffee
(both caffeinated and decaffeinated), carbonated beverages, and fruit
juice with citric acid. Avoid caffeine, which is found in coffee, some
soft drinks, chocolate, and tea. Eating a diet that is high in fiber and
flavonoids and low in fat and sodium might help. Flavonoids,
believed to stop the growth of H pylori, are found in apples, celery,
cranberries, onions, garlic, and tea. If left untreated, gastritis can lead
to peptic ulcers in the stomach or first part of the intestine and
bleeding. Some forms of chronic gastritis increase the risk of stomach
cancer.
History of.
Hypertension, also referred to as high blood pressure, is a condition in
which the arteries have persistently elevated blood pressure. Every
time the human heart beats, it pumps blood to the whole body through
the arteries. Hypertension can lead to damaged organs, as well as
several illnesses, such as renal failure (kidney failure), aneurysm,
heart failure, stroke, or heart attack. The normal level for blood
pressure is below 120/80. Blood pressure between 120/80 and 139/89
is called prehypertension (to denote increased risk of hypertension),
and a blood pressure of 140/90 or above is considered hypertension.
To prevent high blood pressure, everyone should be encouraged to
make lifestyle modifications, such as eating a healthier diet, quitting
smoking, and getting more exercise. Treatment with medication is
recommended to lower blood pressure to less than 140/90 in people
younger than 60, and less than 150/90 in people older than 60. It is
recommended for patients with HTN to follow a low sodium
(<2300mg) diet.
History of present illness.
Medical History. A list of the patients current and past illnesses,
surgical procedures, and medications.

hyperglycemia

hypertonic

idiopathic
I&O
infarction

ischemia

Hyperglycemia, or high blood sugar (glucose), is a serious health

problem for those with diabetes. Hyperglycemia develops when there
is too much sugar in the blood. In people with diabetes, there are two
specific types of hyperglycemia that occur: Fasting hyperglycemia is
defined as a blood sugar greater than 130 mg/dL (milligrams per
deciliter) after fasting for at least 8 hours. Postprandial or after-meal
hyperglycemia is defined as a blood sugar usually greater than 180
mg/dL. In people without diabetes postprandial or post-meal sugars
rarely go over 140 mg/dL. However, occasionally after a large meal, a
1-2 hour post-meal sugar level can reach 180 mg/dL. Consistently
elevated high post-meal blood sugar levels can be an indicator that a
person has or is at high risk for developing type 2 diabetes.
Hyperglycemia in diabetes may be caused by: Skipping or forgetting
insulin or oral glucose-lowering medicine, eating too many grams of
carbohydrates for the amount of insulin administered or just eating
too many grams of carbohydrates in general, infection, illness,
increased stress, decreased activity or exercising less than usual,
strenuous physical activity, especially when blood glucose levels are
high to begin with and insulin levels are low. Medications, exercise,
and low carb diet can help in the treatment of hyperglycemia.
Of or pertaining to a solution (e.g. extracelllular fluid) with higher
solute concentration compared with another. For example, if the
extracellular fluid has greater amounts of solutes than the cytoplasm,
the extracellular fluid is said to be hypertonic.
Relating to or denoting any disease or condition that arises
spontaneously or for which the cause is unknown.
Intake and Output.
Infarction is tissue death (necrosis) caused by a local lack of oxygen,
due to an obstruction of the tissue's blood supply. The supplying
artery can be blocked by an obstruction, may be mechanically
compressed, ruptured by trauma, or vasoconstricted.
Ischemia is an insufficient supply of blood to an organ, usually due to
a blocked artery. Ischemia is almost always caused by blockage of an
artery, usually due to atherosclerotic plaque. Myocardial ischemia is
also caused by blood clots (which tend to form on plaque), artery
spasms or contractions, or any of these factors combined. Silent
ischemia is usually caused by emotional or mental stress or by
exertion, but there are no symptoms. Ischemia is treated with drug
therapy and surgery. Drugs such as nitrates, beta-blockers, and
calcium channel blockers relieve chest pain, but they cannot clear
blocked arteries. Aspirin helps prevent blood clots. Surgical
procedures include percutaneous transluminal coronary angioplasty
and coronary artery bypass graft surgery.

isotonic

jaundice

j tube

NKFA
KUB

marasmus

Isotonic means with balanced concentration of salts and minerals:

specially formulated to supply the body's chemical needs in situations
in which minerals and fluids are used up by the body,
Jaundice is a yellowish pigmentation of the skin, the conjunctival
membranes over the sclerae, and other mucous membranes caused by
hyperbilirubinemia. This hyperbilirubinemia subsequently causes
increased levels of bilirubin in the extracellular fluid. Concentration
of bilirubin in blood plasma is normally below 1.2 mg/dL. A
concentration higher than approx. 3 mg/dL (>50mol/L) leads to
jaundice.
A feeding jejunostomy tube, also called a J-tube, is a tube inserted
through the abdomen and into the jejunum (the second part of the
small bowel) to assist with feeding and to provide nutrition. A
feeding tube is placed for the patient who is unable to take in enough
food or drink through the mouth to maintain body weight. Most
people who receive a J-tube are those who have trouble digesting
food or emptying their stomach, aspirate food into their lungs, or have
pancreatic disease.
No known food allergies
Abbreviation for kidney, ureter, and bladder; a term used in a
radiographic examination to determine the location, size, shape, and
malformation of the kidneys, ureters, and bladder. Stones and
calcified areas may be detected.
Marasmus is a severe form of malnutrition that consists of the chronic
wasting away of fat, muscle, and other tissues in the body.
Malnutrition occurs when your body does not get enough protein and
calories. This lack of nutrition can range from a shortage of certain
vitamins to complete starvation. Marasmus is one of the most serious
forms of protein-energy malnutrition (PEM) in the world. Marasmus
symptoms will vary depending on the severity and whether associated
infections or other conditions are present. General symptoms of
marasmus include chronic diarrhea, dizziness, fatigue, and rapid
weight loss. If the disease is caused solely by poor nutrition, then a
change in diet should be enough to correct the problem and prevent
recurrence. Marasmus that is related to an underlying disease may
require additional treatment. A nutritious, well-balanced diet with
lots of fresh fruits and vegetables, grains, and protein will reduce the
risk of malnutrition and any related marasmus.

metastasis

molality
MRI

MS

nephr-

The process by which cancer spreads from the place at which it first
arose as a primary tumor to distant locations in the body. Metastasis
depends on the cancer cells acquiring two separate abilities -increased motility and invasiveness. Cells that metastasize are
basically of the same kind as those in the original tumor. If a cancer
arises in the lung and metastasizes to the liver, the cancer cells in the
liver are lung cancer cells. However, the cells have acquired increased
motility and the ability to invade another organ.
The molal concentration of a solute, usually expressed as the number
of moles of solute per 1,000 grams of solvent.
Magnetic resonance imaging (MRI) is a test that uses a magnetic field
and pulses of radio wave energy to make pictures of organs and
structures inside the body. In many cases, MRI gives different
information about structures in the body than can be seen with an Xray, ultrasound, or computed tomography (CT) scan. MRI also may
show problems that cannot be seen with other imaging methods. For
an MRI test, the area of the body being studied is placed inside a
special machine that contains a strong magnet. Pictures from an MRI
scan are digital images that can be saved and stored on a computer for
more study. The images also can be reviewed remotely, such as in a
clinic or an operating room. In some cases, contrast material may be
used during the MRI scan to show certain structures more clearly.
MRI is done for many reasons. It is used to find problems such as
tumors, bleeding, injury, blood vessel diseases, or infection. MRI also
may be done to provide more information about a problem seen on an
X-ray, ultrasound scan, or CT scan. Contrast material may be used
during MRI to show abnormal tissue more clearly.
Multiple sclerosis (MS) is a disease in which your immune system
attacks the protective sheath (myelin) that covers your nerves. Myelin
damage disrupts communication between your brain and the rest of
your body. Ultimately, the nerves themselves may deteriorate, a
process that's currently irreversible. Signs and symptoms vary
widely, depending on the amount of damage and which nerves are
affected. Some people with severe MS may lose the ability to walk
independently or at all, while others experience long periods of
remission during which they develop no new symptoms.
Prefix referring to the kidney.

NG tube

NJ tube

nocturia

NA

A nasogastric tube is a tube that is passed through the nose and down
through the nasopharynx and esophagus into the stomach.
Abbreviated NG tube. It is a flexible tube made of rubber or plastic,
and it has bidirectional potential. It can be used to remove the
contents of the stomach, including air, to decompress the stomach, or
to remove small solid objects and fluid, such as poison, from the
stomach. An NG tube can also be used to put substances into the
stomach, and so it may be used to place nutrients directly into the
stomach when a patient cannot take food or drink by mouth.
NJ tube is short for nasojejunal tube. It carries food
through the nose to the jejunum part of the small
intestine. The NJ tube is soft and flexible so it can pass
through the nose and stomach comfortably. In the
jejunum, food and medication can be quickly absorbed
into your body. The jejunum is small, so it can only take
a small amount of food at a time. With an NJ tube, food
is given at a slow, continuous rate. An NJ tube can usually be used
for as long as it is needed.
Nocturia is a condition in which you wake up during the night
because you have to urinate. Causes of nocturia include: Congestive
heart failure, edema of lower extremities (swelling of the legs),
sleeping disorders such as obstructive sleep apnea (breathing is
interrupted or stops many times during sleep), certain drugs,
including diuretics (water pills), cardiac glycosides, demeclocycline,
lithium, methoxyflurane, phenytoin, propoxyphene, and excessive
vitamin D, drinking too much fluid before bedtime, especially coffee,
caffeinated beverages, or alcohol. Treatment options for nocturia
may include: Restrict fluids in the evening (especially coffee,
caffeinated beverages, and alcohol)., time intake of diuretics (take
mid- to late afternoon, six hours before bedtime), take afternoon naps,
elevate the legs (helps prevent fluid accumulation), wear compression
stockings (helps prevent fluid accumulation).
Not applicable.

NAD and NADP

NPO
N&V
OA

Nicotinamide adenine dinucleotide (NAD) is a coenzyme found in all

living cells. The compound is a dinucleotide, because it consists of
two nucleotides joined through their phosphate groups. One
nucleotide contains an adenine base and the other nicotinamide.
Nicotinamide adenine dinucleotide exists in two forms, an oxidized
and reduced form abbreviated as NAD+ and NADH. In metabolism,
nicotinamide adenine dinucleotide is involved in redox reactions,
carrying electrons from one reaction to another. The coenzyme is,
therefore, found in two forms in cells: NAD+ is an oxidizing agent
it accepts electrons from other molecules and becomes reduced. This
reaction forms NADH, which can then be used as a reducing agent to
donate electrons. These electron transfer reactions are the main
function of NAD.
Nil per os (nothing by mouth). Patient is not allowed to eat or drink
anything. Usually patients are put on NPO for procedures or testing.
Nausea and Vomiting.

onc-

Osteoarthritis (OA), which is also known as osteoarthrosis or

degenerative joint disease (DJD), is a progressive disorder of the
joints caused by gradual loss of cartilage and resulting in the
development of bony spurs and cysts at the margins of the joints. The
name osteoarthritis comes from three Greek words meaning bone,
joint, and inflammation. Osteoarthritis results from deterioration or
loss of the cartilage that acts as a protective cushion between bones,
particularly in weight-bearing joints such as the knees and hips. As
the cartilage is worn away, the bone forms spurs, areas of abnormal
hardening, and fluid-filled pockets in the marrow known as
subchondral cysts. As the disorder progresses, pain results from
deformation of the bones and fluid accumulation in the joints. The
pain is relieved by rest and made worse by moving the joint or
placing weight on it. In early OA, the pain is minor and may take the
form of mild stiffness in the morning. In the later stages of OA,
inflammation develops; the patient may experience pain even when
the joint is not being used; and he or she may suffer permanent loss of
the normal range of motion in that joint. Medications, physical
therapy, and surgery are some treatment options. Cutting calories,
eating fruits and vegetables, adding omega-3 fatty acids, and boosting
vitamin C are some nutritional treatments for OA patients.
Prefix meaning "swelling, mass, or tumor"

OOB

Out of bed.

PEG

plegia

Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure

for placing a tube for feeding without having to perform an open
operation on the abdomen (laparotomy). It is used in patients who
will be unable to take in food by mouth for a prolonged period of
time. A gastrostomy, or surgical opening into the stomach, is made
through the skin using an a flexible, lighted instrument (endoscope)
passed orally into the stomach to assist with the placement of the tube
and secure it in place. The purpose of a percutaneous endoscopic
gastronomy is to feed those patients who cannot swallow food.
Irrespective of the age of the patient or their medical condition, the
purpose of percutaneous endoscopic gastronomy is to provide fluids
and nutrition directly into the stomach.
A PEJ tube is a feeding tube that is put inside an outer tube which
goes to the stomach. The inside tube goes into the small intestine
(jejunum). A special instrument, called an endoscope, is used to insert
the tube. The endoscope has a light on it that helps the doctor put the
feeding tube through the mouth into the small intestine (jejunum).
A large membrane in the abdominal cavity that connects and supports
internal organs. It is composed of many folds that pass between or
around the various organs. Two folds are of primary importance: the
omentum, which hangs in front of the stomach and intestine; and the
mesentery, which attaches the small intestine and much of the large
intestine to the posterior abdominal cavity.
Positron emission tomography (PET) camera.gif is a test that uses a
special type of camera and a tracer (radioactive chemical) to look at
organs in the body. The tracer usually is a special form of a substance
(such as glucose) that collects in cells that are using a lot of energy,
such as cancer cells. During the test, the tracer liquid is put into a vein
(intravenous, or IV) in your arm. The tracer moves through your
body, where much of it collects in the specific organ or tissue. The
tracer gives off tiny positively charged particles (positrons). The
camera records the positrons and turns the recording into pictures on
a computer.
The pharynx is a cone-shaped passageway leading from the oral and
nasal cavities in the head to the esophagus and larynx. The pharynx
chamber serves both respiratory and digestive functions. Thick fibers
of muscle and connective tissue attach the pharynx to the base of the
skull and surrounding structures. Both circular and longitudinal
muscles occur in the walls of this organ; the circular muscles form
constrictions that help push food to the esophagus and prevent air
from being swallowed, while the longitudinal fibers lift the walls of
the pharynx during swallowing.
Suffix meaning paralysis or a stroke.

PMH

Past medical history. Any previous medical records for a patient.

PEJ

peritoneum

PET

pharynx

pneumonia

qid

Pneumonia is an infection that inflames the air sacs in one or both

lungs. The air sacs may fill with fluid or pus, causing cough with
phlegm or pus, fever, chills and difficulty breathing. A variety of
organisms, including bacteria, viruses and fungi, can cause
pneumonia. Antibiotics and antiviral medications can treat many
common forms of pneumonia. Pneumonia has many possible causes.
The most common are bacteria and viruses in the air we breathe. Your
body usually prevents these germs from infecting your lungs. But
sometimes these germs can overpower your immune system, even if
your health is generally good.
People with proteinuria have urine containing an abnormal amount of
protein. The condition is often a sign of kidney disease. Proteinuria
can also be a result of overproduction of proteins by the body. ACE
inhibitors and ABDs are commonly prescribed medications.
plasma thromboplastin antecedent - coagulation factor whose
deficiency results in a hemorrhagic tendency
Quarter in die meaning four times daily.

qod

Every other day.

Re-feeding Syndrome

Refeeding syndrome can occur when a person is recovering from a

period of starvation. If a starving person is fed too aggressively, it can
cause refeeding syndrome, which is a dangerous and sometimes fatal
condition. It is associated with low levels of phosphate, potassium,
and magnesium in the bloodstream. Refeeding syndrome is most
commonly seen in patients who have anorexia nervosa, chronic
alcoholism, cancer, chronic malnutrition, uncontrolled diabetes, or are
post-op and/or have not eaten well for several days. Individuals who
are obese and have severely restricted calories and/or sudden weight
loss are also at risk. Refeeding syndrome can occur in patients who
eat orally or in those who depend on tube feeding for their nutrition.
Refeeding syndrome occurs because the body adapts to starvation.
Under normal conditions, the body uses carbohydrate from the diet
for energy. If no food is available for 24 hours, the body uses energy
that is stored in the liver and muscles. After about 3 days, the body
adapts again and uses other stored sources of energy. After a few days
of starvation, the body becomes used to starvation. When a person
finally begins eating, the body suddenly shifts back to food as its
source of energy. During this shift, changes occur in the body
processes, which result in fluid and electrolyte imbalances and
vitamin deficiencies.
prefix meaning "backward, or located behind"

proteinuria

PTA

retro

rhinoplasty

s/p

Rhinoplasty is surgery to reshape the nose. It can make the nose

larger or smaller; change the angle of the nose in relation to the upper
lip; alter the tip of the nose; or correct bumps, indentations, or other
defects in the nose. During rhinoplasty, the surgeon makes incisions
to access the bones and cartilage that support the nose. The incisions
are usually made inside the nose so that they are invisible after the
surgery. Depending on the desired result, some bone and cartilage
may be removed, or tissue may be added (either from another part of
the body or using a synthetic filler). After the surgeon has rearranged
and reshaped the bone and cartilage, the skin and tissue is redraped
over the structure of the nose. A splint is placed outside the nose to
support the new shape of the nose as it heals.
Abbreviation for rule out. Usually referring to possible illnesses or
problems.
A medical prescription. The symbol "Rx" is usually said to stand for
the Latin word "recipe" meaning "to take."
A sarcoma is a rare kind of cancer. Sarcomas are different from the
much more common carcinomas because they happen in a different
kind of tissue. Sarcomas grow in connective tissue -- cells that
connect or support other kinds of tissue in your body. These tumors
are most common in the bones, muscles, tendons, cartilage, nerves,
fat, and blood vessels of your arms and legs, but they can happen
anywhere. Surgery, radiation, and chemotherapy are common
treatments for sarcoma.
Pertaining to sepsis. Sepsis is a condition in which the body is
fighting a severe infection that has spread via the bloodstream. If a
patient becomes "septic," they will likely have low blood pressure
leading to poor circulation and lack of perfusion of vital tissues and
organs.
Shortness of Breath. This could be due to overexertion or an
underlying disease.
Status post.

sx

Abbreviation for surgery.

R/O
Rx
sarcoma

septic

SOB

tachycardia

tid

Tachycardia is a faster than normal heart rate at rest. A healthy adult

heart normally beats 60 to 100 times a minute when a person is at
rest. Heart rate is controlled by electrical signals sent across heart
tissues. Tachycardia occurs when an abnormality in the heart
produces rapid electrical signals. Tachycardia is caused by something
that disrupts the normal electrical impulses that control the rate of
your heart's pumping action. Many things can cause or contribute to
problems with the heart's electrical system. Some factors include:
damage to heart tissues from heart disease, disease or congenital
abnormality of the heart, abnormal electrical pathways in the heart
present at birth (congenital), high blood pressure, medication side
effects, and smoking.
Thrombosis is the formation of a blood clot (thrombus) inside a blood
vessel, obstructing the flow of blood through the circulatory system.
When a blood vessel is injured, the body uses platelets and fibrin to
form a blood clot, because the first step in repairing it (hemostasis) is
to prevent loss of blood. If that mechanism causes too much clotting,
and the clot breaks free, an embolus is formed.
Ter in die. Three times daily.

-tomy

Suffix meaning surgical incision.

TIA

A transient ischemic attack (TIA) occurs when blood flow to a part of

the brain stops for a brief time. A person will have stroke-like
symptoms for up to 24 hours. In most cases, the symptoms last for 1
to 2 hours. A TIA is different than a stroke. After a TIA, the blockage
breaks up quickly and dissolves. A TIA does not cause brain tissue to
die. TIAs do not cause lasting damage to the brain. But, TIAs are a
warning sign that you may have a true stroke in the coming days or
months. More than 10% of people who have a TIA will have a stroke
within 3 months.

thrombosis

TPN

ultrasonography

Total parenteral nutrition (TPN) is a form of feeding in which all

nutritional needs are met with a solution which is infused into the
veins. This feeding technique is only used in very specific settings,
and care providers usually try to make sure that TPN is only used in
the short term. However, patients can and have received TPN for
decades in cases where this is necessary. The most common reason to
use TPN is because the gastrointestinal tract is nonfunctional. In the
case of a premature infant, this may be because it's not fully formed
yet. For adults, it can be the result of complications of disease or
severe trauma. People such as cancer patients, burn victims, and
AIDS patients sometimes require TPN. The biggest risk with this
feeding method is a bacterial infection caused by leaving a catheter in
place to provide the nutrition. The catheter needs to be meticulously
cared for, and it is critical that it be used only for TPN, with any other
fluids and medications being delivered through a different catheter.
Some people who require this form of nutrition in the long term can
develop gallstone and liver problems, as well, and it is important to
monitor for these.
Ultrasonography makes use of generated sound waves to produces
visible images of soft body tissues. Sonic waves, as a form of energy,
are known as longitudinal pressure waves. These waves result when
molecules are pushed together, becoming less dense (rarified). As a
wave passes through molecules, they are not transported by the wave
but merely vibrate back and forth (around a neutral position). A
molecule will be moved through the compression and rarification
cycle a specific number of times per second and this is called the
frequency of the wave. The unit of measurement for sound wave
frequency is termed Hertz (Hz). The human ear is capable of
detecting frequencies ranging between 20Hz and 20,000Hz. (The
greater the frequency, the higher the audible sound of the wave).
Frequencies beyond 20,000Hz are inaudible to the human ear and are
called ultrasonic. Ultrasonography utilizes sound waves between one
million and 15 million Hz. Ultrasonography has wide application in
the field of medical diagnostics. It is best suited for obtaining images
of solid, or uniform soft tissue and fluid-filled tissue. Performance is
limited when imaging calcified structures (like bone) or air-filled
objects (like the bowel). Most ultrasonic examinations are performed
externally by moving a transducer over the skin surface. Normally, a
gel would be applied to the skin. This allows the transducer to glide
smoothly as well as to eliminate the formation of air pockets between
the skin and transducer (this would interfere with the imaging
obtained). Where necessary, a probe is inserted into a bodily orifice.

uremia

W/U

Uremia is a clinical state in which the blood urea nitrogen level, an

indicator of nitrogen waste products, is elevated. In uremia, the
kidneys failure to filter nitrogen waste properly leads to excessively
high levels of nitrogen wastes in the bloodstream. Uremia is lifethreatening because too much nitrogen in the blood is toxic to the
body. Symptoms of uremia include confusion, loss of consciousness,
low urine production, dry mouth, fatigue, weakness, pale skin or
pallor, bleeding problems, rapid heart rate (tachycardia), edema
(swelling), and excessive thirst. Uremia may also be painful. Uremia
is reversible if treated quickly; however, permanent damage to the
kidneys may occur. Uremia may arise from any condition that
damages the kidney including: Autoimmune disorders, kidney
damage from diabetes or HTN, certain medications, kidney disease,
surgery, obstruction, or trauma to the kidney.
A urinary tract infection or UTI is a bacterial infection that occurs
when bacteria invade the urinary tract system; the bacteria multiply
throughout the urinary track system. While the majority of urinary
tract infections or UTIs are not serious, they often cause severe
symptoms such as pain and/or burning upon urination. The most
common cause of UTIs are bacteria from the bowel that live on the
skin near the rectum or in the vagina, which can spread and enter the
urinary tract through the urethra. Once these bacteria enter the
urethra, they travel upward, causing infection in the bladder and
sometimes other parts of the urinary tract. Antibiotics (medications
that kill bacteria) are the usual treatment for bladder infections and
other urinary tract infections. Drinking six to eight glasses of water
each day, as well as plenty of other fluids like herbal teas and
unsweetened fruit juices may help to reduce UTIs. Adding
blueberries and cranberries or unsweetened cranberry juice might
prevent harmful bacteria from adhering to your bladder tissues. Also,
enrich your diet with high-fiber foods like root vegetables and beans,
as well as antioxidant foods like squash, cherries, tomatoes and bell
peppers.
Within normal limits. This usually pertains to lab values or physical
examination.
Work-up or complete evaluation.

y/o

Years old pertaining to age to patient.

UTI

WNL

LAB VALUES
Diagnostic Test

Normal Value

Conditions When
Elevated

Conditions When Depressed

albumin

3.4-5.4 g/dL

alkaline
phosphate(ALP)

44 to 147
IU/L

blood glucose
(BG)

70-100 mg/dL

Severe infections
Congenital disorders
Severe dehydration
Hepatitis
Malnourishment
Chronic inflammatory
diseases
Tuberculosis
An overdose of cortisone
drugs, excessive
synthesis of cortisol by
the adrenals, tumor that
manufactures cortisollike substances
Congestive cardiac
failure
Kidney diseases
HIV
Cancer
Biliary obstruction
Bone conditions
Osteoblastic bone tumors,
osteomalacia, a fracture
that is healing
Liver disease or hepatitis
Eating a fatty meal if you
have blood type O or B
Hyperparathyroidism
Leukemia
Lymphoma
Paget's disease
Rickets
Sarcoidosis
Diabetes

Poor nutritional state

Renal dysfunction
Liver disease
GI issues
Cancer
Infections

Hypophosphatasia
Malnutrition
Protein deficiency
Wilson's disease

Confusion, Dizziness,
hunger, headaches,
weakness, pale skin, shaky

blood urea nitrogen

(BUN)

6 - 20 mg/dL

hemoglobin (hgb)

Male: 13.8 to
17.2 grams
per deciliter
(g/dL)
Female: 12.1
to 15.1 g/dL

Congestive heart failure

Excessive protein levels
in the gastrointestinal
tract
Gastrointestinal bleeding
Hypovolemia
(dehydration)
Heart attack
Kidney disease, including
glomerulonephritis,
pyelonephritis, and acute
tubular necrosis
Kidney failure
Shock
Urinary tract obstruction
Certain birth defects of
the heart, present at birth
(congenital heart disease)
Failure of the right side
of the heart (cor
pulmonale)
Severe COPD
Scarring or thickening of
the lungs (pulmonary
fibrosis) and other severe
lung disorders

Liver failure
Low protein diet
Malnutrition
Over-hydration

Anemia due to red blood

cells being destroyed earlier
than normal (hemolytic
anemia)
Anemia (various types)
Bleeding from digestive
tract or bladder, heavy
menstrual periods
Chronic kidney disease
Bone marrow being unable
to produce new blood cells.
This may be due to
leukemia, other cancers,
drug toxicity, radiation
therapy, infection, or bone
marrow disorders
Poor nutrition
Low level of iron, folate,
vitamin B12, or vitamin B6
Other chronic illness, such
as rheumatoid arthritis

hematocrit (hct)

Male: 40.7 to
50.3%
Female: 36.1
to 44.3%

Potassium (K)

3.7 to 5.2
mEq/L

Congenital heart disease

Failure of the right side
of the heart (cor
pulmonale)
Dehydration
Abnormal increase in red
blood cells
(erythrocytosis)
Low blood oxygen levels
(hypoxia)
Scarring or thickening of
the lungs (pulmonary
fibrosis)
Bone marrow disease that
causes abnormal increase
in RBCs (polycythemia
vera)
Addison's disease (rare)
Blood transfusion
Certain medications
Crushed tissue injury
Hyperkalemic periodic
paralysis
Hypoaldosteronism (very
rare)
Kidney failure
Metabolic or respiratory
acidosis
Red blood cell
destruction
Too much potassium in
your diet

Anemia
Bleeding
Destruction of red blood
cells
Leukemia
Malnutrition
Nutritional deficiencies of
iron, folate, vitamin B12,
and vitamin B6
Overhydration

Chronic diarrhea
Cushing syndrome (rare)
Diuretics such as
hydrochlorothiazide,
furosemide, and indapamide
Hyperaldosteronism
Hypokalemic periodic
paralysis
Not enough potassium in the
diet
Renal artery stenosis
Renal tubular acidosis (rare)
Vomiting

Sodium (Na)

135 to 145
milliequivalen
ts per liter
(mEq/L)

Adrenal gland problems

such as Cushing
syndrome or
hyperaldosteronism
Diabetes insipidus (type
of diabetes in which
kidneys are not able to
conserve water)
Increased fluid loss due
to excessive sweating,
diarrhea, use of diuretics,
or burns
Too much salt or sodium
bicarbonate in the diet
Use of certain medicines,
including birth control
pills, corticosteroids,
laxatives, lithium, and
NSAIDs such as
ibuprofen or naproxen

Nitrogen Balance
(N2)

12 to 20
grams per 24
hours
4000 10,500
leucocytes/cu
mm
<200 mg/dL

Increased protein
breakdown in the body
Too much protein intake
Leukocytosis

Total Lymphocyte
Count (TLC)
Total Chol

Risk for heart attack or

stroke.

Adrenal glands not making

enough of their hormones
(Addison disease)
Dehydration, vomiting,
diarrhea
Buildup in urine of waste
product from fat breakdown
(ketonuria)
Increase in total body water
seen in those with heart
failure, certain kidney
diseases, or cirrhosis of the
liver
Syndrome of inappropriate
antidiuretic hormone
secretion (antidiuretic
hormone is released from an
abnormal place in the body)
Too much of the hormone
vasopressin
Use of medicines such as
diuretics (water pills),
morphine, and SSRI
antidepressants
Kidney problems
Malnutrition (inadequate
protein in diet)
Immune system is not
functioning optimally.
Increased risk of: Cancer
Depression
Anxiety
Preterm birth and low birth
weight if your cholesterol is
low while you're pregnant

MEDICATIONS
Example: See Diabeta (glyburide)
Medication
(Brand and Chemical)

Indication

Nutritional
Ramifications

Drug Class Relation to

the Indication

Ativan

used to treat anxiety Do not drink alcohol

disorders.
while taking this
medication.

Bactrim
(trimethoprim/sulfam
ethoxazole)

used to treat ear

Do not take if you are
infections, urinary
malnourished or
tract infections,
deficient in folate.
bronchitis, traveler's
diarrhea,
shigellosis, and
Pneumocystis
jiroveci pneumonia.

Compazine
(prochlorperazine)

Controlling severe
nausea and
vomiting and
treating
schizophrenia.
used to treat
moderate-to-severe
pain.

May react with

nutrition supplements.
Do not take with
alcohol.
Likely to cause
breathing problems in
people who are
malnourished.

is an opioid pain
medication. An opioid
is sometimes called a
narcotic.

A sulfonylurea agent,
controls blood sugar

Take with breakfast

Prescribed diet should be
followed
Limit alcohol intake
Not with lactation
May cause dyspesia,
nausea, and GI distress
Decreases glucose
Increases SGOT, SGPT,
LDH, ALP, BUN, and
creatinine

Lower plasma glucose by

stimulating insulin
secretion and enhancing
target tissue uptake and
inhibiting hepatic glucose
synthesis.

Demerol
(meperidine)

Diabeta (glyburide)

A group of drugs called

benzodiazepines. It
affects chemicals in the
brain that may become
unbalanced and cause
anxiety.
Bactrim contains a
combination of
sulfamethoxazole and
trimethoprim.
Sulfamethoxazole and
trimethoprim are are
both antibiotics that
treat different types of
infection caused by
bacteria.
is classified as an antiemetic and
antipsychotic agent.

Inderal (propranolol)

Lasix (furosemide)

Synthroid
(levothyroxine)

used to treat
tremors, angina
(chest pain),
hypertension (high
blood pressure),
heart rhythm
disorders, and other
heart or circulatory
conditions. It is also
used to treat or
prevent heart attack,
and to reduce the
severity and
frequency of
migraine headaches.
treats fluid retention
(edema) in people
with congestive
heart failure, liver
disease, or a kidney
disorder such as
nephrotic
syndrome. This
medication is also
used to treat high
blood pressure
treats
hypothyroidism
(low thyroid
hormone).
Synthroid is also
used to treat or
prevent goiter
(enlarged thyroid
gland), which can
be caused by
hormone
imbalances,
radiation treatment,
surgery, or cancer.

Do not take if you have

low blood sugar or
diabetes.

is a beta-blocker. Betablockers affect the heart

and circulation

Ask doctor before

taking medication if
you have an electrolyte
imbalance, diabetes, or
high cholesterol.

is a loop diuretic (water

pill) that prevents your
body from absorbing
too much salt, allowing
the salt to instead be
passed in your urine.

Avoid walnuts, cotton

seed meal, and high
fiber foods.

a replacement for a
hormone normally
produced by your
thyroid gland to
regulate the body's
energy and metabolism.

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