18.2 Medical Terminology II: Conditions, Procedures, Medications & Sound-Alikes
Key Takeaways
Brand-name drugs are capitalized (Percocet, Lyrica) and generic names are lowercase (oxycodone, gabapentin).
Medical abbreviations are typed only when spoken as letters (an MRI, the ER); words spoken in full are typed in full.
Sound-alikes such as ileum/ilium, perineal/peroneal, dysphagia/dysphasia and hypertension/hypotension change meaning and must be decided by context.
An independent medical examination (IME) is an examination by a physician retained by the opposing side, often an insurer or employer.
This section continues blueprint topic 50301 with the terms that fill medical depositions and injury trials.
Common injuries and conditions
| Term | Meaning |
|---|---|
| cervical strain / sprain ("whiplash") | Neck muscle or ligament injury |
| herniated disc (bulging, protruding, ruptured) | Disc material pressing out between vertebrae |
| radiculopathy | Nerve-root irritation causing radiating pain, numbness or weakness |
| stenosis | Narrowing, such as of the spinal canal |
| concussion / traumatic brain injury (TBI) | Brain injury from impact |
| fracture: comminuted (in pieces), compound or open (through the skin), hairline or stress | A broken bone |
| rotator cuff tear | Shoulder tendon injury |
| meniscus tear; ACL tear (anterior cruciate ligament) | Knee injuries |
| carpal tunnel syndrome | Median-nerve compression at the wrist |
| contusion / abrasion / laceration | Bruise / scrape / cut |
| post-traumatic stress disorder (PTSD) | A psychological condition after trauma |
| maximum medical improvement (MMI) | The point at which recovery has plateaued (workers' compensation) |
Tests and procedures
| Term | What it is |
|---|---|
| X-ray (radiograph) | Imaging of bone |
| MRI (magnetic resonance imaging) | Soft-tissue imaging |
| CT or CAT scan (computed tomography) | Cross-sectional imaging |
| EMG / NCS (electromyography / nerve conduction study) | Tests of nerve and muscle function |
| arthroscopy | Joint surgery through small incisions with a scope |
| discectomy / laminectomy / spinal fusion | Disc removal / removal of part of a vertebra / joining vertebrae |
| epidural steroid injection | An anti-inflammatory injection near the spinal nerves |
| open reduction internal fixation (ORIF) | Surgical setting of a fracture with hardware |
| physical therapy (PT) / occupational therapy (OT) | Rehabilitation |
| independent medical examination (IME) | An examination by a doctor retained by the opposing side, often an insurer or employer |
Medications
Brand vs. generic
- Brand names are proper nouns: capitalize them. Percocet, Vicodin, Lyrica, Flexeril, Tylenol.
- Generic names are common nouns: lowercase. oxycodone, hydrocodone, gabapentin, cyclobenzaprine, acetaminophen, ibuprofen.
- Verify unfamiliar drug names in a drug reference (for example, DailyMed, from the National Library of Medicine) or a medical dictionary. Many drug names sound alike (Celebrex and Cerebyx; hydroxyzine and hydralazine), so confirm with context: what condition was it prescribed for?
Doses and units
Type doses as spoken, using figures for the amounts: "ten milligrams" becomes 10 milligrams. Abbreviate only if the speaker says the letters: "ten M-G" becomes 10 mg. Keep the speaker's frequency words: "twice a day" stays twice a day; "b.i.d." (spoken as letters) is typed b.i.d.
Spoken abbreviations
Type medical abbreviations only when spoken as letters: an MRI, the ER, her BP was high, ICU, PT. If the witness says "emergency room," type emergency room. Use capitals without periods for initialisms (Chapter 5), except conventional forms such as b.i.d.
Medical sound-alikes
| Word | Meaning | Sound-alike | Meaning |
|---|---|---|---|
| ileum | part of the small intestine | ilium | hip bone |
| perineal | the perineum (pelvic floor) | peroneal | the fibula side of the lower leg (peroneal nerve) |
| dysphagia | difficulty swallowing | dysphasia | difficulty with speech or language |
| hypertension | high blood pressure | hypotension | low blood pressure |
| mucus (noun) | the secretion | mucous (adjective) | mucous membrane |
| humerus | upper-arm bone | humorous | funny |
| palpation | examining by touch | palpitation | a racing or irregular heartbeat |
| prostate | a gland | prostrate | lying face down |
| callus | thickened skin; new bone at a fracture | callous | unfeeling |
| abduction | movement away from the midline | adduction | movement toward the midline |
| aural | relating to the ear | oral | relating to the mouth |
| cirrhosis | liver scarring | xerosis | dry skin |
Decide by context: a leg injury points to peroneal; a hip fracture to ilium. When context cannot decide and the word matters, check the medical records exhibits or ask through the agency (Chapter 12).
Research and confidentiality
- References: a medical dictionary, a drug reference, and the anatomy word parts in Section 18.1.
- Build a word list from the medical records, IME reports and the doctor's curriculum vitae if provided.
- Doctors' names: verify through the practice's website or the state medical board's license lookup (Chapter 13).
- Confidentiality: medical testimony often contains protected health information. Handle it under the confidentiality rules and any protective order, and remember that a transcriber working for a HIPAA covered entity may be a business associate (Chapter 2).
Worked example
Audio: the MRI showed a herniation at L five S one with radiculopathy down the left leg so I prescribed gabapentin three hundred milligrams and referred her for an epidural
Transcript:
A. The MRI showed a herniation at L5-S1 with radiculopathy
down the left leg, so I prescribed gabapentin, 300 milligrams,
and referred her for an epidural.
MRI is spoken as letters; L5-S1 is the level; gabapentin is generic, so lowercase; 300 milligrams uses figures for the dose and spells out the unit the doctor said.
A doctor testifies that the patient was prescribed "Percocet" and later "oxycodone." How should the two drug names be capitalized?
Both capitalized, because all drug names are proper nouns
Both lowercase, because medications are common nouns
Percocet capitalized as a brand name; oxycodone lowercase as a generic name
PERCOCET and OXYCODONE in capitals for emphasis
In a deposition about a fall that injured the witness's lower leg, the doctor mentions the "per-o-NEE-al nerve." Which spelling fits the context?
perineal
peritoneal
peroneal
parenteral
A witness says, "They did an M-R-I in the emergency room." How should this be transcribed?
They did an MRI in the emergency room.
They did an magnetic resonance imaging in the ER.
They did an M.R.I. in the E.R.
They did a MRI in the emergency room.
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