Terms and Strategies

for Medical Records

Reading and Writing
 Lesson 6

Respiratory Unit
 Appendix
16. dyspnea on exertion (DOE) /
Signs and Symptoms (S/S) exertional dyspnea
1. apnea 17. fatigue
2. atelectasis 18. finger clubbing
3. blood-tinged sputum 19. hemoptysis
4. bronchospasm 20. hoarseness
5. collapsed lung 21. hyperventilation
6. consolidation 22. hypopnea
7. crackle 23. hypoxemia
8. crackle (coarse) 24. hypoxia
9. crackle (fine) 25. low-grade fever (mild fever)
10. cyanosis 26. pale
11. decreased breath sound, right 27. peribronchial infiltrations
12. deviation of trachea 28. respiratory distress
13. diaphoresis 29. respiratory pattern: rapid and shallow
14. dizziness 30. rhinorrhea
15. dyspnea 31. rhonchus
 Appendix
Diagnosis
32. sore throat
47. acute lung injury (ALI)
33. stridor
48. acute respiratory distress syndrome (ARDS)
34. subcutaneous emphysema
49. adult respiratory distress syndrome (ARDS)
35. tachypnea
50. asthma
36. use of the accessory muscles
51. atypical pneumonia
37. wheezing
52. bird flu (avian flu)
Diagnostic Test 53. bronchiectasis
38. acid-fast bacillus (AFB) 54. bronchitis
39. arterial blood gas (ABG) 55. chronic obstructive lung disease (COLD)
40. bronchoscopy 56. chronic obstructive pulmonary disease
41. capnography (COPD)
42. chest X-ray (CXR) 57. chronic renal failure (CRF)
43. cytology 58. common cold
44. pulmonary function test (PFT) 59. community-acquired pneumonia (CAP)
45. sputum culture (SP/C) 60. cor pulmonale
46. sputum smear 61. emphysema
 Appendix
62. empyema 79. pulmonary abscess
63. hemothorax 80. pulmonary edema (PE)
64. hypercapnic respiratory failure 81. pulmonary embolism (PE)
65. hypertension 82. pyothorax
66. hypoxemic respiratory failure 83. recurrent pneumonia
67. influenza (flu) 84. respiratory failure
68. microcytic anemia 85. severe acute respiratory syndrome (SARS)
69. neutropenia 86. swine flu
70. obstructive sleep apnea (OSA) 87. UGI bleeding
71. pharyngolaryngitis 88. upper respiratory infection (URI)
72. pleural effusion 89. ventilator-associated pneumonia (VAP)
73. pleurisy Treatment & Care
74. pneumonia 90. antitussive
75. pneumonoconiosis 91. breath sound (BS)
76. pneumonomelanosis 92. bronchodilator
77. pneumonomycosis 93. continuous positive airway pressure (CPAP)
78. pneumothorax 94. decongestant
 Appendix
95. empiric antibiotics 110. tracheostomy
96. expectorant 111. tracheotomy
97. extubation 112. ventilator
98. fever of unknown origin (FUO)
99. inhalation
100. intermittent positive pressure
breathing (IPPB)
101. intermittent positive pressure
ventilation (IPPV)
102. intubation
103. liter/minute = l/m = liters per minute
104. mechanical ventilation (MV)
105. moxifloxacin
106. nasal cannula (N/C, NC)
107. pneumonectomy
108. PRBC (packed red blood cell) 8U
109. thoracentesis
 Supplementary Reading
Respiratory Failure
Chief Complaint
Progressive dyspnea for 2 days

Present Illness
This 72-year-old male has a history of chronic obstructive pulmonary disease
(COPD) with cor pulmonale. He has had a productive cough and progressive
dyspnea for 2 days. The dyspnea worsened this morning, so he was brought to
our ER.

Moderate expiratory wheezing was noted. CXR showed right middle lobe (RML)
and right lower lobe (RLL) pneumonia. Right pleural effusion was also noted.
With the presence of impending respiratory failure, he was intubated
(endotracheal tube; ET) and placed on mechanical ventilation (MV).
Subcutaneous emphysema was present over the right chest wall. CXR revealed
a right-sided pneumothorax; therefore, a chest tube was inserted. An altered level
of consciousness was noted. The patient was admitted to our ICU for further
management.
 Lesson 6

Respiratory Unit
-The End-