29.2 Medical Terms in General Medicine, Abbreviations, Symbols & Critiquing Requests and Reports
Key Takeaways
- A radiographic request must be checked for patient identity, the clinical indication, the exact body part and side, the projections required, pregnancy status and the requesting clinician's identity before any exposure is made.
- Left and right must be verified against the written request and the patient's own account, and anatomical lead markers must be placed in the primary beam at exposure — never added digitally afterwards.
- The abbreviations most dangerous in radiology are those denoting laterality and dose, so departments increasingly require left and right to be written in full rather than abbreviated.
- A diagnostic report is read in four parts: the clinical indication, the technique, the findings, and the impression or conclusion, and the impression is the section that answers the clinical question.
- The technologist critiques the request but does not diagnose: an ambiguous, unsigned, clinically unjustified or wrong-side request must be clarified with the requesting clinician before the examination proceeds.
29.2 Medical Terms in General Medicine, Abbreviations, Symbols & Critiquing Requests and Reports
The second Medical Terminology sub-topic carries 7 items and three competencies: explain medical terms referring to certain infectious diseases, diseases of various body systems, and obstetrics; organize according to its applicable terms for various radiological instruments and equipment; and critique orders, requests, and diagnostic reports. The third of these is a genuine professional skill, not a vocabulary drill: it is the checkpoint at which wrong-patient and wrong-side examinations are stopped.
1. Disease Terminology by Body System
| System | Terms you will meet on requests |
|---|---|
| Respiratory | Pneumonia, pleural effusion, empyema, pneumothorax, haemothorax, atelectasis, bronchiectasis, emphysema, chronic obstructive pulmonary disease, pulmonary tuberculosis (PTB), pleural thickening, bronchopneumonia, pulmonary oedema |
| Cardiovascular | Cardiomegaly, congestive heart failure, myocardial infarction, atherosclerosis, aneurysm, dissection, deep vein thrombosis, pulmonary embolism, hypertension |
| Gastrointestinal | Gastritis, peptic ulcer disease, gastro-oesophageal reflux disease, achalasia, hiatal hernia, ileus, intestinal obstruction, volvulus, intussusception, diverticulosis, diverticulitis, appendicitis, cholelithiasis, cholecystitis, pancreatitis, cirrhosis, ascites |
| Urinary | Nephrolithiasis, hydronephrosis, pyelonephritis, cystitis, urinary retention, renal failure, urethral stricture, vesicoureteric reflux |
| Musculoskeletal | Fracture, dislocation, subluxation, osteoarthritis, rheumatoid arthritis, gout, osteomyelitis, osteoporosis, osteomalacia, Paget disease, osteosarcoma, avascular necrosis, spondylolisthesis, scoliosis, kyphosis, lordosis |
| Nervous | Cerebrovascular accident (stroke), intracranial haemorrhage, hydrocephalus, meningitis, encephalitis, epilepsy, herniated nucleus pulposus, spinal cord compression |
| Endocrine | Diabetes mellitus, goitre, thyrotoxicosis, hypothyroidism, acromegaly, Cushing syndrome |
Infectious disease terms with imaging relevance
Pulmonary tuberculosis remains a high-volume indication in the Philippines and is examinable in its own right: upper-lobe and apical predominance, cavitation, fibrosis with volume loss and tracheal deviation, miliary pattern, pleural effusion, and calcified granuloma with ipsilateral hilar node calcification (Ranke complex) in healed primary disease. Other frequently seen terms include pneumonia, dengue with plasma leakage and pleural effusion, leptospirosis, typhoid, hepatitis, HIV-associated opportunistic infection, sepsis, cellulitis, abscess, osteomyelitis and septic arthritis.
Modifiers you must be able to apply: acute (rapid onset, short course) versus chronic (long duration); localised versus systemic; communicable versus non-communicable; endemic (constantly present in a population), epidemic (a sudden increase above expected) and pandemic (across countries or continents); nosocomial or healthcare-associated (acquired in a health facility); iatrogenic (caused by medical care); idiopathic (of unknown cause); congenital (present at birth) versus acquired.
Obstetric and gynaecological terms
| Term | Meaning |
|---|---|
| Gravida / para | Number of pregnancies / number of deliveries past viability |
| Nulliparous, primiparous, multiparous | Never delivered, delivered once, delivered more than once |
| Antepartum, intrapartum, postpartum | Before, during and after delivery |
| Gestational age | Duration of pregnancy, conventionally from the first day of the last menstrual period |
| Ectopic pregnancy | Implantation outside the uterine cavity |
| Placenta praevia / abruptio placentae | Placenta covering the internal os / premature separation of the placenta |
| Oligohydramnios / polyhydramnios | Too little / too much amniotic fluid |
| Amenorrhoea, dysmenorrhoea, menorrhagia, metrorrhagia | Absent, painful, excessive and irregular menstruation |
| Cephalopelvic disproportion | Fetal head too large for the maternal pelvis |
| Dystocia | Difficult labour |
| Salpingitis, endometriosis, leiomyoma (fibroid) | Common gynaecological indications for imaging |
Every one of these terms should trigger the pregnancy-status question before any ionising examination.
2. Terminology for Radiological Instruments and Equipment
The TOS asks you to organise these terms, so group them by function.
| Group | Terms |
|---|---|
| Beam production and control | X-ray tube, anode, cathode, filament, focal spot, collimator, beam-restricting device, cone, filter, generator, transformer, autotransformer, rectifier, timer, automatic exposure control |
| Image reception | Cassette, intensifying screen, grid, Bucky, photostimulable phosphor plate, flat-panel detector, thin-film transistor array, image intensifier, charge-coupled device |
| Measurement | Dosimeter, thermoluminescent dosimeter, optically stimulated luminescence dosimeter, film badge, pocket ionisation chamber, Geiger-Muller counter, scintillation detector, densitometer, sensitometer, penetrometer (step wedge) |
| Positioning and immobilisation | Bucky table, upright Bucky, sponge, sandbag, compression band, head clamp, positioning wedge, paediatric immobiliser, cephalostat |
| Protection | Lead apron, thyroid shield, gonadal shield, leaded glasses, mobile lead screen, bucky slot cover, lead-lined door, control booth barrier |
| Contrast and injection | Barium sulphate suspension, iodinated contrast, power injector, cannula, catheter, guidewire, introducer sheath, three-way stopcock |
| Cross-sectional and specialist | Gantry, detector array, slip ring, superconducting magnet, gradient coil, radiofrequency coil, transducer, gamma camera, collimator (nuclear), linear accelerator, multileaf collimator, simulator |
| Informatics | PACS, RIS, HIS, DICOM, HL7, modality worklist, workstation, archive, teleradiology |
3. Abbreviations and Symbols
Positioning and projection
| Abbreviation | Meaning | Abbreviation | Meaning |
|---|---|---|---|
| AP / PA | Anteroposterior / posteroanterior | LAT | Lateral |
| RAO / LAO | Right / left anterior oblique | RPO / LPO | Right / left posterior oblique |
| CC | Craniocaudal (mammography) | MLO | Mediolateral oblique |
| SMV | Submentovertical | CR | Central ray (also computed radiography — context decides) |
| SID / OID | Source-to-image / object-to-image distance | KUB | Kidneys, ureters, bladder |
| CXR | Chest x-ray | IVU / IVP | Intravenous urography / pyelography |
| HSG | Hysterosalpingography | VCUG / MCU | Voiding cystourethrography / micturating cystourethrogram |
| ERCP | Endoscopic retrograde cholangiopancreatography | DSA | Digital subtraction angiography |
| UGIS | Upper gastrointestinal series | BE | Barium enema |
Clinical and charting
| Abbreviation | Meaning | Abbreviation | Meaning |
|---|---|---|---|
| Hx / Dx / Rx / Tx / Px | History / diagnosis / prescription or treatment / treatment / prognosis or patient | c/o | Complains of |
| NPO | Nothing by mouth (nil per os) | PRN | As needed (pro re nata) |
| BID / TID / QID / OD / HS | Twice / three times / four times daily; once daily; at bedtime | STAT | Immediately |
| IV / IM / SC / PO / PR | Intravenous / intramuscular / subcutaneous / by mouth / per rectum | BP / HR / RR / T | Blood pressure, heart rate, respiratory rate, temperature |
| SOB / DOB | Shortness of breath / difficulty of breathing | LMP | Last menstrual period |
| CBC / BUN / GFR | Complete blood count / blood urea nitrogen / glomerular filtration rate | PTB | Pulmonary tuberculosis |
| Fx | Fracture | s/p | Status post |
| WNL | Within normal limits | NAD | No abnormality detected |
Symbols
| Symbol | Meaning | Symbol | Meaning |
|---|---|---|---|
| @ | at | # | number or fracture (context) |
| > / < | greater than / less than | = | equals |
| Δ | change | ↑ / ↓ | increased / decreased |
| ♀ / ♂ | female / male | c with a bar | with |
| s with a bar | without | / | per |
The danger list
Certain abbreviations cause harm and are increasingly prohibited:
- "L" and "R" or "lt" and "rt" for laterality. The safest departmental policy is that left and right are written in full on the request. Wrong-side imaging is one of the commonest reportable radiology errors worldwide.
- "U" for units (mistaken for a zero), "QD" and "QOD" (mistaken for each other), trailing zeros such as 1.0 mg (read as 10 mg), and absent leading zeros such as .5 mg (read as 5 mg).
- Site-specific abbreviations invented locally, which no visiting or locum staff member can decode.
The professional rule: if you cannot decode an abbreviation with certainty, you clarify it with the requesting clinician. You do not guess.
4. Critiquing the Request Before Exposure
This is the competency that protects patients. Work the checklist every time.
| Check | What you are confirming |
|---|---|
| 1. Patient identity | At least two identifiers — full name and date of birth or hospital number — obtained from the patient, not read to them |
| 2. Clinical indication | A real clinical question. "For check-up" or a blank indication is not justification |
| 3. Body part and projections | Exactly which part, and which projections; ambiguity resolved before exposure |
| 4. Laterality | Left or right, confirmed against the request and the patient's own account of their symptoms |
| 5. Pregnancy status | Asked and documented for every female of childbearing potential |
| 6. Prior imaging | Has this study already been done? Would a prior study answer the question without a new exposure? |
| 7. Preparation | Fasting, bowel preparation, hydration, bladder status, renal function and metformin status for contrast studies |
| 8. Allergy and comorbidity | Contrast allergy, asthma, renal impairment, diabetes, anticoagulation, implanted devices for MRI |
| 9. Requester identity and signature | A named, contactable, appropriately qualified requesting clinician |
| 10. Justification | Does the expected benefit exceed the radiation detriment? If not, do not expose |
When you must stop and clarify: the side is missing or contradicts the patient's story; the indication is blank or nonsensical; the request is unsigned; the patient is or may be pregnant and the examination is not urgent; the requested study cannot answer the clinical question; or the patient's account differs materially from the request. Escalating a request is not obstruction — under both RA 7431 and radiation-protection principles, the exposure is only lawful if justified.
Markers. Anatomical lead markers must be placed within the collimated field and exposed with the image. Adding "L" or "R" digitally afterwards is falsification of the record and is indefensible if the image is later used in a medico-legal context.
5. Reading a Diagnostic Report
A radiological report has a predictable structure. Read it in this order.
| Section | Contains | Why the technologist reads it |
|---|---|---|
| Clinical indication / history | Why the study was requested | Confirms the study matched the question |
| Technique | What was performed — projections, contrast agent and volume, phases, dose metrics | Confirms the record matches what you did |
| Comparison | Prior studies used | Explains references to interval change |
| Findings | Systematic description of what is seen | The observational record |
| Impression / conclusion | The radiologist's synthesis and answer to the clinical question, and any recommendation | The section that answers the question |
Vocabulary to recognise in a report: unremarkable and no acute cardiopulmonary abnormality (normal); suggestive of, consistent with, cannot be excluded (graded certainty); interval change, stable, resolved, progression (comparison with priors); recommend correlation with, recommend further imaging (the next step); incidental finding (unrelated to the indication).
Critiquing a report within scope means checking that the technique section accurately reflects what was performed, that the correct patient and side are named, that a stated projection was actually taken, and that a critical finding has been communicated. It never means disputing the interpretation, which lies outside the radiologic technologist's scope of practice under RA 7431.
A critical or unexpected finding — tension pneumothorax, free intraperitoneal air, misplaced line or tube, suspected aortic dissection, unstable spinal fracture — must be brought to the radiologist's attention immediately, not at the end of the list. That single behaviour saves more lives than any refinement of technique.
A request for a knee radiograph states the indication as 'pain' with no side specified, and the patient reports that both knees are sore but the left is worse. What is the correct action?
Which section of a radiological report answers the clinical question that prompted the examination?
A radiograph is produced without an anatomical lead marker in the collimated field. What is the correct remedy?
Which abbreviation practice is most strongly discouraged in modern radiology because of its association with serious patient harm?