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Medical Terms Often Seen in Medical Documents Related to Traumatic Injury:
Often, after an injury, you read the doctor’s report to see what he says your injury is/was, and it may seem like it was written in Latin. They don’t use everyday terms to describe your injury in their medical records and reports. I’ve compiled a list, and will update it periodically, of injuries and terms used for those injuries, along with an explanation of what that terminology typically means – along with a few examples.
The best way to understand what is wrong with you is to talk with your medical provider / doctor. Medical terms are used on reports – and often they seem to speak for themselves, but usually its best to ask your doctor directly what the terms mean that have been written down – especially if you don’t completely understand what was written.
Term Seen in Medical Reports in Injury Cases:
- ACL Tear – Anterior Cruciate Ligament tear in the knee. Knee ligament tear of ligament needed for stability in knee.
- Acute injury – Back sprain or strain
- Adrenal – Example: Adrenal hemorrhage
- Amnestic – Example: Concussion – amnestic to event
- Anterior –
- Example: Bone bruises of the anterior aspect of medial and lateral femoral condyles
- Example: Subcortical fracture anterior medial aspect of the medial femoral condyle
- Example: C2-3 – 3-4mm disc herniation slightly contacts the right anterior spinal cord
- Anterolateral – Example: Anterolateral proximal tibia
- Anterolisthesis – Example: Anterolisthesis Mild grade I
- Arthritis – Example: Severe arthritis in knee
- Aspiration – Example: Aspirated about 40 cc of cloudy appearing synovial fluid
- Bilateral – Example: Paraspinal muscle spasm bilateral paracervical and lumbar spine
- Blepharochalasis – (inflamation of eyelid)
- Blowout – Example: Localized blowout fracture of left orbital floor
- Blunt – Example: Blunt trauma chest-wall pain
- Bone bruises – Example: Bone bruises of the anterior aspect of medial and lateral femoral condyles
- Bone Spurs –
- Branch Blocks – Example: Cervical injections & branch blocks
- Brevis Tendons – Example: Mild tenosynovitis to the intersection of the extensor carpi radialis longus and brevis tendons at the dorsal aspect of the wrist
- Bruised lung
- Bulging –
- Example: L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- Example: Small Disc Bulge at L5-S1
- Example: Bulging lumbar discs on CT exam C2-3 – Example: C2-3 – 3-4mm disc herniation slightly contacts the right anterior spinal cord
- Carpal Canal – Example: Inflammatory change in carpal and Guyon’s canal
- Carpal Navicular – Example: Fracture carpal navicular left wrist
- Carpal Tunnel Syndrome
- Carpi Radialis – Example: Mild tenosynovitis to the intersection of the extensor carpi radialis longus and brevis tendons at the dorsal aspect of the wrist
- Cervical –
- Example: Cervical Sprain, Cervical Strain
- Example: Cervical injections & branch blocks
- Cervical fracture
- Cervical Injections – Example: Cervical injections & branch blocks
- Cervical lordosis –
- Example: Reversal of the cervical lordosis
- Example: Straightening of cervical lordosis
- Example: Abnormal straightening of cervical lordosis
- Cervicobrachial Syndrome
- Collateral – Example: Sprain medial collateral ligament
- Complications – Example: Risk of complications
- Concussion –
- Example: Post concussion syndrome
- Example: Neuropsychological evaluation concussion
- Example: Concussion – amnestic to event
- Condyles –
- Example: Bone bruises of the anterior aspect of medial and lateral femoral condyles
- Example: Subcortical fracture anterior medial aspect of the medial femoral condyle
- Consciousness – Example: Loss of consciousness
- Contusion –
- Example: Marrow contusion
- Example: Seatbelt chest contusion
- Example: Renal contusion
- Example: Pulmonary contusions
- Example: Lung contusion
- CT exam – Example: Bulging lumbar discs on CT exam
- Curvature convex – Example: Mild lumbar curvature convex to the left
- Diabetes issues
- Differential Diagnosis
- Diffusely – Example: Diffusely tender under the knee
- Diplopia (double vision)
- Disc –
- Example: L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- Example: Small Disc Bulge at L5-S1
- Example: Bulging lumbar discs on CT exam
- Discal – Example: Left paracentral discal substance protrusion/herniation
- Discectomy – Example: Laminectomy/Discectomy
- Dislocation
- Dorsal –
- Example: Mild tenosynovitis of extensor digitorum/indicis tendons dorsal to the wrist
- Example: Mild tenosynovitis to the intersection of the extensor carpi radialis longus and brevis tendons at the dorsal aspect of the wrist
- Ecchymotic – Example: Abrasion ecchymotic (purple bruising)
- Edema –
- Example: Edema left eye
- Example: Edema (fluid) in knee from trauma
- Effacing – Example: L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- Effusion – Example: Examination of rt knee shows large joint effusion
- Elevated – Example: Elevated signal in shoulder
- Entrapment – Example: Inferior herniation of extraconal fat and possible entrapment of left inferior rectus
- Epicondylitis – Example: Lateral epicondylitis (tennis elbow)
- Examination – Example: Examination of rt knee shows large joint effusion
- Extension – Example: range of motion is 10 degrees full extension and around 80 degrees flexion
- Extensor Carpi Radialis Longus – Example: Mild tenosynovitis to the intersection of the extensor carpi radialis longus and brevis tendons at the dorsal aspect of the wrist
- Extensor Digitorum / Indicis Tendons – Example: Mild tenosynovitis of extensor digitorum/indicis tendons dorsal to the wrist
- Extraconal – Example: Inferior herniation of extraconal fat and possible entrapment of left inferior rectus
- Facial – Example: facial-head-nasal abrasions
- Femoral –
- Example: bone bruises of the anterior aspect of medial and lateral femoral condyles
- Example: Subcortical fracture anterior medial aspect of the medial femoral condyle
- Fenestration – Example: Acquired fenestration or tear of the TFC complex associated with escape of joint fluid in the inferior radioulnar recess
- Flexion –
- Example: Pronounced with flexion
- Example: Range of motion is 10 degrees full extension and around 80 degrees flexion
- Fibula
- Fracture –
- Example: Localized blowout fracture of left orbital floor
- Example: Subcortical fracture anterior medial aspect of the medial femoral condyle
- Example: Fracture carpal navicular left wrist
- Example: Cervical fracture
- Functional Capacity evaluation –
- Gamekeepers Fracture –
- Guyon’s Canal – Example: Inflammatory change in carpal and Guyon’s canal
- Headaches
- Hemorrhage – Example: Adrenal hemorrhage
- Herniation – Examples:
- Back or Neck: C2-3 – 3-4mm disc herniation slightly contacts the right anterior spinal cord
- Orbital: Orbital floor Fx fissure w soft tissue swelling and herniation of fat into the defect
- L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- Left paracentral discal substance protrusion/herniation
- Horns – Example: Grade 1 changes to posterior horns of menisci – but not torn
- Hypermobility – Example: Hypermobility suggestive of cervical strain
- Impingement – Example: Impingement left shoulder
- ICH
- Inferior –
- Example: Inferior herniation of extraconal fat and possible entrapment of left inferior rectus
- Example: Acquired fenestration or tear of the TFC complex associated with escape of joint fluid in the inferior radioulnar recess
- Inferior Radioulnar Recess – Example: Acquired fenestration or tear of the TFC complex associated with escape of joint fluid in the inferior radioulnar recess
- Inflammatory or Inflammation – Example: Inflammatory change in carpal and Guyon’s canal
- Infrahilar – Example: Right infrahilar stranding
- Injections – Example: Cervical injections & branch blocks
- Intersection of the Extensor Carpi Radialis Longus – Example: Mild tenosynovitis to the intersection of the extensor carpi radialis longus and brevis tendons at the dorsal aspect of the wrist
- Interspinious ligamentous regions
- Intervertebral disc syndrome
- Kidney Laceration – Example: Kidney laceration
- Knee injury –
- Example: MCL tear, probably grade 3
- Example: ACL tear
- Example: Edema (fluid) in knee from trauma
- Example: Hinge knee brace
- L2-3Â – Example: L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- L3-4Â – Example: L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- L4-5Â – Example: L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- L5-S1Â –
- Example: L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- Example: Small Disc Bulge at L5-S1
- Laceration –
- Example: Liver laceration grade II
- Example: Kidney laceration
- Laminectomy – Example: Laminectomy/Discectomy
- Lateral –
- Example: Lateral list of thoracic spine suggestive of muscle spasm
- Example: Bone bruises of the anterior aspect of medial and lateral femoral condyles
- Example: Lateral epicondylitis (tennis elbow)
- Ligament –
- Example: Sprain medial collateral ligament
- Example: ACL
- Liver laceration –
- Example: Liver laceration grade II – http://en.wikipedia.org/wiki/Liver_injury – covers 10-50% of surface area, 1-3cm in depth
- Localized – Example: Localized blowout fracture of left orbital floor
- Lumbago
- Lumbar –
- Example: Paraspinal muscle spasm bilateral paracervical and lumbar spine
- Example: Bulging lumbar discs on CT exam
- Lumbar Strain –
- Lumbosacral
- Lung contusion
- Marrow – Example: Marrow contusion
- Maxillary – Example: Maxillary sinus hemorrhage left
- Maximum Medical Improvement (MMI)Â –
- MCL Tear – Example: MCL tear, probably grade 3
- Medial –
- Example: Bone bruises of the anterior aspect of medial and lateral femoral condyles
- Example: Subcortical fracture anterior medial aspect of the medial femoral condyle
- Example: Sprain medial collateral ligament
- Medial Collateral Ligament – Example: Sprain medial collateral ligament
- Menisci – Example: Grade 1 changes to posterior horns of menisci – but not torn
- Morbidity – Example: Morbiditiy and mortality all rated as high risks
- Mortality – Example: Morbiditiy and mortality all rated as high risks
- MRIÂ – Example: MRI right knee
- Muscle Soreness
- Muscle spasm –
- Example: Paravertebral muscle spasm
- Example: Paraspinal muscle spasm parascapular musculature
- Example: Paraspinal muscle spasm bilateral paracervical and lumbar spine
- Example: Paracervical muscle spasms
- Example: Paralumbar muscle spasms
- Myalgia – Example: Post traumatic myalgia
- Myofacial
- Nasal – Example: Facial-head-nasal abrasions
- Navicular – Example: Fracture carpal navicular left wrist
- Neck – Example: Radiating neck pain
- Neuromuscular reeducation
- Neuropsychological evaluation concussion
- Orbital floor Fracture fissure
- Pain –
- Example: Thoracic Spine Pain
- Example: Pain on palpatation,
- Example: Radiating neck pain
- Example: Pain management
- Pain management
- Palpatation – Example: Pain on palpatation,
- Paracentral – Example: Left paracentral discal substance protrusion/herniation
- Paracervical –
- Example: Paraspinal muscle spasm bilateral paracervical and lumbar spine
- Example: Paracervical muscle spasms
- Paralumbar – Example: Paralumbar muscle spasms
- Parascapular – Example: Paraspinal muscle spasm parascapular musculature
- Paraspinal –
- Example: Paraspinal muscle spasm parascapular musculature
- Example: Paraspinal muscle spasm bilateral paracervical and lumbar spine
- Paraspinous lumbar tenderness –
- Paraspinous thoracic tenderness –
- Parasthesia (tingling/numbness)
- Paravertebral – Example: Paravertebral muscle spasm
- Physical capabilities exam
- Physical therapy – Example: Physical therapy using pulmonary toilet to clear airways
- Pneumothorax
- Post Concussion – Example: Post concussion syndrome
- Posterior – Example: Grade 1 changes to posterior horns of menisci – but not torn
- Post Traumatic – Example: Post traumatic myalgia
- Protrusion – Example: Left paracentral discal substance protrusion/herniation
- Proximal – Example: Anterolateral proximal tibia
- Pulmonary –
- Example: Pulmonary contusions
- Example: Physical therapy using pulmonary toilet to clear airways
- Radiating – Example: Radiating neck pain
- Radiulnar Recess – Example: Acquired fenestration or tear of the TFC complex associated with escape of joint fluid in the inferior radioulnar recess
- Range of motion decreased
- Example: range of motion is 10 degrees full extension and around 80 degrees flexion
- Rectus – Example: Inferior herniation of extraconal fat and possible entrapment of left inferior rectus
- Renal – Example: Renal contusion
- Respiration – Example: Painful respiration
- Sacroilliac – Example: Sacroilliac joint sprain/strain
- Scoliosis – Example: Congenital
- Shoulder – Example: Impingement left shoulder
- SI Joint – Example: Subluxation of the SI joint
- Signal – Example: Elevated signal in shoulder
- Signal intensity –
- Example: Lumbar MRI: Hyperintense signal intensity on stir imaging is seen in the interspinious ligamentous regions
- Sinus hemorrhage
- Snoring respirations –
- Soft tissue
- Spasm – Example: Paravertebral muscle spasm
- Spinal Cord – Example: C2-3 – 3-4mm disc herniation slightly contacts the right anterior spinal cord
- Spine –
- Example: Thoracic Spine Pain
- Example: Paraspinal muscle spasm bilateral paracervical and lumbar Spine –
- Sprain –
- Example: Sprain back acute
- Example: Sacroilliac joint sprain/strain
- Example: Sprain medial collateral ligament
- Sternum – Example: Chest – mid-sternum
- Stir imaging – Example: Lumbar MRI: Hyperintense signal intensity on stir imaging is seen in the interspinious ligamentous regions
- Strain –
- Example: Strain back acute
- Example: Sacroilliac joint sprain/strain
- Stranding – Example: Right infrahilar stranding
- Subcortical – Example: Subcortical fracture anterior medial aspect of the medial femoral condyle
- Subluxation – Example: Subluxation of the SI joint
- Swelling –
- Syndrome – Example: Post concussion syndrome
- Synovial Fluid – Example: Aspirated about 40 cc of cloudy appearing synovial fluid
- Tenderness – Example: Positive tenderness in lumbar or thoracic
- Tendonitis – Example: Tendonitis in wrist
- Tenosynovitis –
- Example: Mild tenosynovitis of extensor digitorum/indicis tendons dorsal to the wrist
- Example: Mild tenosynovitis to the intersection of the extensor carpi radialis longus and brevis tendons at the dorsal aspect of the wrist
- TFC Complex Tear – Example: Acquired fenestration or tear of the TFC complex associated with escape of joint fluid in the inferior radioulnar recess
- Thecal Sac – Example: L2-3 – slight bulging 1-2mm, L3-4 2-3 mm bulging slightly effacing thecal sac, L4-5 3-4 mm disc bulging, L5-S1 4mm disc herniation
- Thoracic Spine –
- Example: Lateral list of thoracic spine suggestive of muscle spasm
- Example: Thoracic Spine Pain
- Tibia – Example: Anterolateral proximal tibia
- Trauma –
- Example: Blunt trauma chest-wall pain
- Example: Edema (fluid) in knee from trauma
- Example: Post traumatic myalgia
- Ventral subarachnoid space – Example: narrowing of the ventral subarachnoid space at approx C5-6 level
- Verbal stimulus –
- Whiplash –
- Wrist –
- Example: Fracture carpal navicular left wrist
- Example: Tendonitis in wrist
- Example: Acquired fenestration or tear of the TFC complex associated with escape of joint fluid in the inferior radioulnar recess
- Example: Mild tenosynovitis of extensor digitorum/indicis tendons dorsal to the wrist
- Example: Mild tenosynovitis to the intersection of the extensor carpi radialis longus and brevis tendons at the dorsal aspect of the wrist
- Example: Inflammatory change in carpal and Guyon’s canal
- Xray – Example: xrays of right hip and knee
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