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Medical Terminology

Chapters 1-6 general terms

chief complaint the main reason for the patients visit
history of present illness the story of the patients problem
review of systems description of individual body systems in order to discover any symptoms not directly related to the main problem
past medical history other significant past illnesses, like high blood pressure, asthma, or diabetes
past surgical history any of the patients past surgeries
family history any significant illnesses that run in the patients family
social history a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
acute (S) it just started recently or is a sharp, severe symptom
chronic (S) it has been going on for a while now
exacerbation (S) it is getting worse
abrupt (S) all of a sudden
febrile (S) to have a fever
afebrile (S) to not have a fever
malaise (S) not feeling well
progressive (S) more and more each day
symptom (S) something a patient feels
noncontributory (S) not related to the specific problem
lethargic (S) a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick
genetic / hereditary (S) it runs in the family
alert (O) able to answer questions; responsive; interactive
oriented (O) being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all 3 is "oriented x 3"
marked (O) it really stands out
unremarkable (O) another way of saying normal
auscultation (O) to listen
percussion (O) to hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument
palpatation (O) to feel
impression (A) another way of saying assessment
diagnosis (A) what the health care professional thinks the patient has
differential diagnosis (A) a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
benign (A) safe
malignant (A) dangerous; a problem
degeneration (A) to be getting worse
etiology (A) the cause
remission (A) to get better or improve; most often used when discussing cancer; remission does not mean cure
idiopathic (A) no known specific cause; it just happens
localized (A) stays in a certain part of the body
systemic/ generalized (A) all over the body (or most of it)
morbidity (A) the risk for being sick
mortality (A) the risk for dying
prognosis (A) the chances for things getting better or worse
occult (A) hidden
pathogen (A) the organism that causes the problem
lesion (A) diseased tissue
recurrent (A) to have again
sequelae (A) a problem resulting from a disease or injury
pending (A) waiting for
disposition (P) what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU, normal hospital bed)
discharge (P) literally to unload. 1)to send home. 2)fluid coming out of a part of the body
prophylaxis (P) preventive treatment
palliative (P) treating the symptoms, but not actually getting rid of the cause
observation (P) watch, keep an eye on
reassurance (P) to tell the patient that the problem is not serious or dangerous
supportive care (P) to treat the symptoms and make the patient feel better
sterile (P) extremely clean, germ-free conditions, especially important during medical procedures and surgery
proximal closer to the center
distal farther away from the center
lateral out to the side
medial toward the middle
ventral / antral/ anterior the front
dorsal / posterior the back
cranial toward the top
caudal toward the bottom
superior above
inferior below
prone lying down on belly
supine lying down on back
contralateral opposite side
ipsilateral same side
unilateral one side
bilateral both sides
dorsum the top of the hand or foot
plantar the sole of the foot
palmar the palm of the hand
sagittal divides the body into a right and left side
coronal divides the body into front and back
transverse divides the body into top and bottom
Created by: lluckey3