11 Medical Specialty-related Terms, Abbreviations and Classification Systems
Click on each word below to navigate to the part of this chapter that addresses that medical specialty.
Respiratory Medicine/Respirology
Cardiology
Terminology
Atherosclerosis vs. Arthrosclerosis
Cor refers to the heart and is sometimes used as a subheading. Cor is synonymous with heart, cardiac, coronary.
The abbreviation bpm or BPM means ‘beats per minute’ and is used to report a patient’s heart rate.
EKG terms
‘Downsloping’ is one word (NOT down sloping or down-sloping)
There is no such thing as an ST wave or an STT wave. These incorrect terms represent a combination of the ST segment and the T wave in an ECG. When you hear either of these, change to ‘ST segment and T wave.’
When naming parts of an ECG, do NOT use a hyphen, unless you are using these terms to describe a noun.
Examples
nouns: T wave, ST segment, non-Q wave
adjectives: ST-depression, T-wave abnormality, non-Q-wave myocardial infarction
Click here to better understand EKG terminology.
Heart Sounds
S3 and S4 are abnormal heart sounds.
S1 and S2 are the normal “lub-dub” heart sounds.
Heart murmurs:
Examples
The patient has a grade 2/6 murmur. (NOT 2 over 6, and NOT 2 out of 6!)
Range: The patient has a grade 4/6 to 5/6 murmur.
Click here to better understand abnormal heart sounds, such as murmurs, rubs, and gallops.
Heart Failure
Expressed in roman numerals I-IV, depending on the level of functional impairment.
Example
New York Heart Association class II cardiac failure. (NOT: New York Heart Association class 2 (or two) cardiac failure)
Clinical Immunology/Allergy
Terminology
Adaptive immunity means that a specific defence is developed for each type of pathogen.
Some WBCs attack and kill the invader directly, while other WBCs form antibodies against the pathogen.
Antibodies are also called immunoglobulins (Ig).
Examples:
IgD
mIgM (monomeric IgM)
sIgA (surface IgA)
T lymphocytes=T cells
B lymphocytes=B cells
Only hyphenate these terms when you are using this term as an adjective that describes the noun which follows them.
Examples:
HIV is a disease that affects a person’s T cells. (T cell is the noun)
The patient’s T-cell count has decreased significantly since his last visit. (T-cell is the adjective that describes the noun ‘count’)
Examples:
HLA-B27
HLA-DR5
HLA-DRw10
CD (clusters of differentiation)
Examples:
CD10
CD4
CD20
Interferons
Use lowercase letters when naming interferons, unless they occur at the beginning of a sentence
Examples:
The patient’s bloodwork reveals high levels of interferon alfa. (NOT alpha!)
Interferon beta has been shown to be a useful marker in this disease.
Graves disease, NOT ‘Grave’s’ or ‘Grave’ disease.
ABVD regimen or protocol.
DMARDs (disease-modifying antirheumatic drugs) are pronounced ‘DEE-mardz.’
Dermatology
Terminology
Maculopapular, NOT macular papular
Mohs microscopic surgery, NOT Moh or Moh’s
Burns:
Partial thickness, NOT partial sickness
Full thickness, NOT full sickness
Naris=one nostril, NOT Nare, Naree
Nares=both nostrils
The suffix -form vs. the suffix -forme (pronounced FOR-may)
Examples
This patient has 2 herpetiform lesions on her upper lip.
The prognosis for glioblastoma multiforme is often very poor.
Allergies skin tests are also called prick test, scratch test, challenge test, patch test or RAST test (only RAST is capitalized, the other terms are lowercase).
Bed sores are correctly written as ‘decubitus ulcers’, NOT decubitus, decubiti.
The Clark system is sometimes used for staging malignant melanoma.
ABCDE acronym is used for describing any skin lesion.
Gastroenterology
Terminology
TIPS procedure=transjugular intrahepatic portosystemic shunt procedure.
Some practitioners refer to GI blood tests as ‘belly labs’.
Specific gravity is a lab value. It is a 4-digit number with a decimal after the first number.
Example
If the voice file says, “specific gravity ten twenty”, transcribe: specific gravity 1.020
The Gram stain is an eponym. Capitalize the word ‘Gram’ except in the case where the dictator adds the word ‘negative’ or ‘positive’, using gram as an adjective.
Examples
The Gram stain reveals a bacterial infection.
The specimen was gram-positive.
Medical Oncology
Terminology
‘radio-’, when used as a prefix relating to the use of radiation, is not hyphenated.
Examples: radiosurgery, radioisotope, radiograph
Metric units of absorbed radiation are gray (Gy)and centigray (cGy). Please use their abbreviations.
‘Woody’ is an adjective used to describe the way skin looks and feels after radiation therapy (looks and feels thick and rough).
patent (pronounced with a long a) vs. patient
Example: The nurse flushed the IV to check if it was still patent.
bcr/ablgene (all lowercase) is an abnormal genetic marker sometimes found in patients with leukemia.
Cancer Staging and Grading Systems
Please watch this short video.
The words ‘grade’ and ‘stage’ are both transcribed using lowercase (unless they are the first word in a sentence).
- grades 1, 2, 3, or 4: use arabic numerals
- stages I, II, III, or IV: use roman numerals
Depending on the type of cancer, there may be more classification categories, such as stage IIB or stage IIIA2.
Colorectal cancers may be classified using the Dukes system (NOT Duke or Duke’s).
The TNM system (video) is used to determine the overall stage for malignant tumours.
- T=tumour size and level of invasion of surrounding tissues (1-4)
- N=lymph node involvement (0-3) (N0 means that there is no spread to nearby lymph nodes)
- M=metastasis (0-1) (M0 means that the cancer has not spread to other body parts)
- X is used instead of a number when one of the 3 factors is not determined
Example: The current diagnosis is T2N1MX breast cancer.
Click here for more information about cancer staging and grading.
Neurology
Terminology
EEG report terms
- Alpha waves, beta waves, delta waves, theta waves
- Fast or slow activity
- Photic stimulation
- Epileptiform discharges
- Hz (Hertz=a unit of measuring frequency)
- K complexes
- Lateralizing focus
- Sharp waves
- (symmetric) sleep spindles
- Spike-and-wave pattern
- Attenuation
- Amplitude
Cranial nerves
You can use either roman numerals (I, II, III, IV, V, VI, VII, VIII, IX, X, XI, XII) or arabic numerals(1, 2, 3,…12).
Arabic numbers should be used if you are referring to the nerve as an ordinal.
Examples
Cranial nerve II is the optic nerve.
Cranial nerve 2 is the optic nerve.
BUT
The optic nerve is the 2nd cranial nerve.
Spinal Nerves
Since neurological pathologies may involve the spinal cord or spinal nerves, corresponding reports will refer to levels of the spine or intervertebral disks.
L1-L2 or L1-2 are both correct for describing the space or disk between 2 vertebrae.
Use the letter before each number when you list vertebrae.
Example: The patient is experiencing symptoms at C4, C5, and C6. (NOT “….C4-6” and NOT C4, 5 and 6”)
Nerve conduction study reports contain the units mV (millivolt), ms (millisecond), mcV (microvolt).
Coma
Glasgow coma scale and Glasgow coma score are used to describe patient’s level of consciousness. Only capitalize the word ‘Glasgow’.
Brain Aneurysms
Cerebral aneurysms may involve the anterior communicating artery (ACOM) and/or the posterior communicating artery (PCOM). If the voice file or original report used the abbreviations for these vessels, you can also use them.
Obstetrics/Gynecology
Terminology
If you hear (on the voice file) BUS (sounds like ‘bus’) or EG/BUS (sounds like ‘egg-bus’), these abbreviations refer to ‘Bartholin, urethral, and Skene glands’ and ‘external genitalia/Bartholin, urethral, and Skene glands’ respectively.
Cervical dilation during labour is measured in cm. Example: The cervix is 3 cm dilated.
Cervical effacement during labour is measured in %. Example: The cervix is 100% effaced.
Apgar scores are expressed as arabic numerals, and the minutes at which the Apgar scores are recorded are expressed in words:
Example: Apgar scores were 8 at one minute and 9 at five minutes.
Tanner system of classifying sexual maturity at puberty:
Example: The patient was a Tanner stage 3.
CIN (cervical intraepithelial neoplasia): grade 1 to grade 3
Example: CIN-1, or CIN grade 1.
Obstetric History: GPA, TPAL, GTPAL Systems
GPA System
P = Para = # of live births
A = Abortus = # of abortions
Examples
Obstetric history: G2, P2, A0
Obstetric history: gravida 2, para 2, abortus 0. (If the voice file has the full terms, you must type the full terms. If the dictator uses the abbreviations, you can type the abbreviations.)
TPAL System
P = Premature infants
A = Abortions
L = Living children
Examples
Obstetric history: 2-0-0-2
Obstetric history: 2 term infants, 0 premature infants, 0 abortions, 2 living children. (If the voice file has the full words, you must type them)
Combination of GPA and TPAL (sometimes called GTPAL)
Examples
The patient is gravida 3, 3-0-0-3.
The patient is gravida 3, para 3-0-0-3. (this is a bit confusing since ‘para’ and ‘term births’ really mean the same thing. This patient had 3 pregnancies, 3 full-term deliveries, no premature infants, no abortions, 3 live children.
The patient is G3, P3-0-0-3. (if the voice file used these abbreviations)
The patient is gravida 3-0-0-3. (if the voice file said this)
Ophthalmology
Terminology
O’Brien fashion: this is a type of local anesthetic (freezing) for eye surgery
Sound-alike words:
Macule
Macula
Macular is the adjective form of both of these words
adnexa oculi (always plural)
The optic disc is the only disc in the body that is spelled DISC. All other types of disks are spelled DISK.
Sclera is singular (one eye), sclerae is plural (both eyes).
Conjunctiva is singular (one eye), conjunctivae is plural (both eyes).
Remember that the abbreviations OD, OS, OU should NOT be used, since they may have multiple meanings. However, they are commonly found when on reports of vision tests.
Visual Acuity
Visual acuity is transcribed as a fraction, for example, 20/20.
Corrective lenses (glasses or contacts) are written as +1.25 or -2.5 (NOT ‘plus’ 1.25 or ‘minus’ 2.5)
Orthopedic Surgery
Terminology
Disk vs. disc: Please only use the spelling disc for the optic disc in the eye. All other disks in the body, including the intervertebral disks in the spine, are spelled disk.
Weightbearing is one word (NOT weight bearing)
Example: Please print out the weightbearing exercises for the patient.
BUT, weight bear are 2 separate words, NOT weightbear.
Example: This patient is not quite ready to weight bear
Fingerbreadth=a unit of measuring distance using the examiner’s finger
Example: The mass was 2 fingerbreadths inferior to the xiphoid.
Fluctuation, fluctuance, or fluctuant (adjective), but NOT fluctuants.
Transcribing Vertebrae
- For one single vertebra: C7, T12, L4
- For any part of one vertebra: L1 spinous process, T7 lamina
- For the intervertebral space (location of the disk): L1-2 or L1-L2
- For a range of non-adjacent vertebrae (each one in the range is not articulating with all of the others in the range): L1 through L4, NOT L1-L4
Examples (the image shows a spinal fusion)
X-rays reveal a fractured C6 lamina.
We will schedule a T12-L1 diskectomy as soon as possible.
This patient has a history of spinal fusion surgery at T11 through L2. (These 4 vertebrae were not all fused to each other. Each is fused to the adjacent vertebra)
Orthopedic Tests
There are many tests done to check the function of various joints in the body. Click here for a list of tests.
Only capitalize them if they are eponyms or acronyms, and do NOT capitalize the words sign or test.
Examples
Notice that the words ‘test’ and ‘sign’ are not capitalized, even when the name of the test is capitalized.
FABER test=flexion, abduction and external rotation (acronym)
This patient exhibits a positive Tinel sign and a positive Phalen test, but the carpal compression test is equivocal. The most likely diagnosis is carpal tunnel syndrome.
Otolaryngology
Terminology
In general, do NOT use the abbreviations AD (right ear), AS (left ear), AU (both ears) even if they are dictated. Expand them out in full. The only instance in which it may be acceptable to transcribe these abbreviations as dictated is in a report of a diagnostic test that includes measured values.
The correct term for nostril is naris (plural: nares).
Respiratory Medicine/Respirology
Terminology
Spell out breaths per minute and respirations per minute. Do NOT abbreviate these terms to bpm or rpm. The abbreviation bpm (or BPM) = ‘beats per minute’ and is used when reporting a patient’s heart rate.
Transcribing Gases
- Oxygen or O2 or O₂
- Carbon dioxide or CO2 or CO₂
- Litres of oxygen:
- Examples:
- The patient is currently on oxygen at a rate of 5L/min. (no spaces between 5 and L/min!)
- The patient’s oxygen saturation is 97% on 2L O2.
Sleep Apnea
The Epworth Sleepiness Scale: measurement of daytime sleepiness and ranges from 1-24.
Example: The patient scored 12 on the Epworth Sleepiness Scale.
Urology
Terminology
Antibiotic brief forms (expand them out to their full forms)
| Brief Form | Full Form |
| vanc | vancomycin |
| amp | ampicillin |
| gent | gentamycin |
‘Acute-on-chronic renal failure’ means that a patient with CRF is displaying signs/symptoms of ARF. Please do NOT type “…acute and chronic renal failure…”
Renal transplants: The transplanted organ is called ‘the donor kidney’, NOT the donor’s kidney and the anatomical location of the transplant is called ‘the donor site’, NOT ‘the donor’s site.’
Double-J-ureteral stent is the correct way to transcribe this implant.
NOT “J and J ureteral stent”
NOT “J&J ureteral stent”
NOT “JJ ureteral stent”
References
Canadian Cancer Society. (2021). Stage and grade. Retrieved May 17, 2021, from Canadian Cancer Society: https://www.cancer.ca/en/cancer-information/cancer-101/what-is-cancer/stage-and-grade/staging/?region=on
Canadian Medical Association. (2021). Canadian specialty profiles. Retrieved May 18, 2021, from Canadian Medical Association: https://www.cma.ca/canadian-specialty-profiles
Case-Lo, C., & Whitworth, G. (2019, December 18). What Causes Heart Murmurs. Retrieved May 17, 2021, from Healthline: https://www.healthline.com/health/heart-murmurs
Gilmore, D. M. (2014). Medical Transcription Projects. Stamford, Connecticut, United States of America: Cengage Learning.
Heiting, G. (2020, April). How to read your eyeglasses prescription. Retrieved May 16, 2021, from All About Vision: https://www.allaboutvision.com/en-ca/eyeglasses/glasses-prescription/
ISMP Institute for Safe Medication Practices. (2021, February 5). List of Error-Prone Abbreviations. Retrieved May 10, 2021, from ISMP Institute for Safe Medication Practices: https://www.ismp.org/recommendations/error-prone-abbreviations-list
Johns Hopkins Medicine. (n.d.). What is a tracheostomy? Retrieved May 11, 2021, from Johns Hopkins Medicine: https://www.hopkinsmedicine.org/tracheostomy/about/what.html#:~:text=Breathing%20is%20done%20through%20the,terms%20are%20sometimes%20used%20interchangeably.
Medical Transcription Word Help. (2021). List of Orthopedic Tests ( Word List ) For Medical Transcriptionists. Retrieved May 15, 2021, from Medical Transcription Word Help: https://www.medicaltranscriptionwordhelp.com/orthopedic-tests-word-list-for-medical-transcriptionists/
Merriam-Webster. (2021). Medical Dictionary. Retrieved May 14, 2021, from Merriam-Webster: https://www.merriam-webster.com/medical
Potter, D. L., & Jackson, D. M. (2021, May 11). Understanding an ECG. Retrieved May 17, 2021, from Geeky Medics: https://geekymedics.com/understanding-an-ecg/
Sims, L. M. (2008). The Book of Style for Medical Transcription (3rd ed.). Modesto, California, United States of America: Association for Healthcare Documentation Integrity.
An abnormal condition of hardening of the arteries due to fatty plaques building up in their walls.
An abnormal condition of stiffening of joints in the body.
A micro-organism that causes disease.
White blood cell or leukocyte.
Proteins created by B lymphocytes. These antibodies bind to specific markers on the outside of cells, thus causing a clumping and ultimate destruction of these cells.
A marker found on body cells. Cells of specific tissues have a specific marker. These markers are important when trying to match donor and recipients for tissue transplants.
Labels given to surface proteins found on cells.
These infection-fighting proteins are produced by immune system cells when a pathogen is detected in the body.
Autoimmune disease, causing overactive thyroid. Named after Robert Graves.
An example of a chemotherapy treatment that uses a combination of drugs to treat lymphoma.
A group of medications that are used to treat autoimmune diseases
An organ feels like it is filled with pellets, like shotgun pellets.
Something that is not well made. A cheap-quality item.
A rash, often due to a virus or a drug reaction, that features both macules (small areas of skin that have changed colour) and papules (small, hard bumps on the skin).
Surgical procedure named after F. Mohs.
The adjective form of bulla (blister that is larger than 1 cm in diameter).
A means of administering a substance (like an IV medication) all at once, rather than dripping it in slowly over time.
Similar in meaning to the suffix -oid, which means 'resembling'
A suffix sometimes used in names of diseases. For example, gliobastoma multiforme.
Looks similar to herpes lesions
A primary brain tumour that originates from glial cells.
A part of the small intestine.
the largest part of the pelvic bone
Open or unblocked. Example: Check to see if the IV is patent.
Central nervous system (includes brain and spinal cord)
Culture and Sensitivity=Taking a sample from a patient and growing it in a lab to determine the type of bacteria and which antibiotics will be effective
Electroencephalogram=electrical recording of brain activity
Electrocardiogram=electrical recording of heart activity
A number that indicates the position on a list. For example, 1st, 2nd, 3rd....
When the wall of an artery becomes weak and starts to balloon outwards. As blood continues to travel through the compromised vessel under high pressure, the weakened area could burst, causing a hemorrhagic stroke.
A type of skin lesion.
The part of the retina that provides the best focus.
The structures surrounding the eye (lashes, lids, muscles, brows, lacrimal system).
The part of the retina where all the axons of the rods and cones come together to form the optic nerve.
A type of manual movement of the eye performed by the physician.
The white of the eye.
A thin mucous membrane that covers the front of the eye and lines the eyelids.
right eye (oculus dexter)
Left eye (oculus sinister)
Both eyes (Oculus uterque
Visual acuity is a measure of how clearly you can see. For example, someone with 20/20 vision can see things that are 20 feet away as clearly as anyone with normal, healthy vision.
The action of putting weight on a lower extremity, often used as an adjective.
Verb. An action or a command to carry your body's weight on a lower extremity or both lower extremities.
Something is changing randomly. Also, the rate or level of change.
When a place or thing is named after the person who invented or discovered it.
A short form that is created by using the first letter of each word in the name of the thing.
When a test does not provide a clear answer.
pertaining to the ear
pertaining to the mouth
A test used by audiologists that provided information about balance and movement issues
A test for muscles and nerves
One of the auditory ossicles (tiny bones in the ear that conduct vibrations)
A part of ankle joint
Large airways branching from the trachea.
An abnormal respiratory sound heard on auscultation.
Blood supply to an organ.
A large quantity of something.
Pertaining to the serous membrane surrounding the lungs.
more than one
Pertaining to pleurisy (inflammations of pleura).
Pertaining to pruritus (itching).
Insertion of a breathing tube through a surgical incision into the trachea. May be long-term or permanent.
Create an artificial opening in the trachea.
The tube that carries urine from each kidney to the bladder. There are 2 ureters.
The tube that carries urine from the bladder out of the body.
Chronic renal failure. A gradual, permanent loss of kidney function. Patients will need dialysis or transplant.
Acute renal failure. A sudden loss of kidney function. This is sometimes caused by medications and it is possible that it will resolve.
A tube that is implanted into the ureter to prevent it from re-occluding. It has a pigtail-shaped curve at both ends, which help hold the stent in place.
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