Question | Answer |
abstruseness | incomprehensible, unfathomable |
accommodation | automatic adjustment of the eye to distinct vision at different distances |
anemia | quantitative deficiency of the protein hemoglobin |
arcane | understood by very few; mysterious; secret |
arthritis | inflammation of a joint |
asthma | a paroxysmal, often allergic disorder of respiration |
atrophic | decreasing in size of a body part owing to disease, injury, or lack of use |
auscultation | listening to sounds within the body as a method of diagnosis |
belligerent | pugnacious, truculent, combative |
bruit | abnormal sound or murmur heard on auscultation |
cancer | malignant and invasive growth or tumor |
cardiovascular | pertaining to the heart and blood vessels |
herniation | rupture in muscle tissue through which a bodily structure protrudes |
CHIEF COMPLAINT (heading) | The statement of the patient's presenting complaint |
chiropractor | a practitioner in treatment that manipulates body structures (esp. the spine) to relieve low back pain, headache or high blood pressure |
chronic | lasting for a long period of time or marked by frequent recurrence |
clubbing | ends of toes and fingers become wide and thick; a symptom of heart or lung disease |
cyanosis | blueness of the skin |
decubitus | An attitude assumed in lying down |
defecate | to void excrement from the bowels through the anus |
diabetes mellitus | a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin |
diaphragmatic | of the diaphragm, a membranous part that divides or separates. |
diarrhea | an intestinal disorder characterized by abnormal frequency and fluidity of fecal evacuations |
disk space | the space between vertebrae occupied by an intervertebral disk as seen on radiographs |
DISPOSITION (heading) | a patient's destination after discharge from a hospital? |
dysuria | painful urination |
ecchymosis | a bruise |
edema | excessive accumulation of fluid in tissue spaces or a body cavity |
enuresis | lack of control of urination; urinary incontinence |
epilepsy | a disorder of the central nervous system with loss of consciousness and convulsions |
erythema | redness of the skin caused by dilatation and congestion of the capillaries |
excursions | range of movements regularly repeated in performance of a function |
exostosis | the abnormal formation of a bony growth on a bone or tooth |
extraocular movements | eye movements |
FAMILY HISTORY (heading) | Includes the age and state of health of each member of the patient's immediate family and selected data about other relatives |
flexion/extension films | x-rays commonly used to identify abnormalities in intervertebral motion |
foramen | a natural opening or perforation through a bone or a membranous structure |
fundus | the base of a hollow organ or that part of the organ farthest from its opening |
gallbladder | a pear-shaped organ located below the liver that serves as a storage place for bile; cholecyst |
gastrointestinal | of or relating to the stomach and intestines |
genitalia | the external organs of the reproductive system |
genitourinary | of or related to the genital and urinary organs or their functions |
great trochanter | one of two processes near the head of the femur |
guaiac-negative | stool that is negative for occult blood |
heart attack | sudden interruption or insufficiency of the supply of blood to the heart; myocardial infarction |
heart disease | structural or functional abnormality of the heart, or blood vessels supplying the heart, that impairs its normal functioning |
heart sounds | the noises enerated by the beating heart and the resultant flow of blood through it |
HEENT (heading) | head, eyes, ears, nose, and throat |
hematemesis | the vomiting of blood |
hemiparesis | partial paralysis restricted to one side of the body |
hemoptysis | expectoration of blood, due usually to hemorrhage from the mucous membrane of the lungs |
HISTORY OF PRESENT ILLNESS (hpi) (heading) | Contains all historical details leading up to and pertaining to the patient's current status |
hypertension | a common disorder in which blood pressure remains abnormally high - a reading of 140 over 90 or greater |
hypochondriac | regions of the upper abdomen beneath the lower ribs and lateral to the epigastric region |
hyposthenuria | the secretion of urine of low specific gravity due to inability of the kidney to concentrate the urine normally |
incontinence | inability to control excretory functions |
insulin | a hormone produced in the pancreas that regulates the amount of sugar in the blood |
intercostal space | between the ribs |
kidney disease | nephropathy |
melena | black, tarry stool or vomit resulting from a hemorrhage along the digestive tract |
mental illness | abnormal behavior or an inability to function socially |
murmur (heart) | an abnormal sound produced by the blood passing through deformed cardiac valves. |
myocardial infarction | heart attack |
neuromuscular | having the characteristics of both nervous and muscular tissue |
noncontributory | making no contribution to a medical diagnosis |
organomegaly | visceromegaly; abnormal enlargement of the viscera |
osteoma | a slow growing benign tumor consisting of bone tissue; usually on the skull or mandible |
palpation | to examine or explore by touching |
PAST HISTORY (heading) | a concluding survey of all medical information not covered in any previous section of the history |
pathophysiology | the functional changes associated with a disease or syndrome. |
peptic ulcer disease | painful sores or ulcers in the lining of the stomach or the duodenum |
percussion | striking or tapping of the surface of a part of the body for diagnostic or therapeutic purposes |
peripheral edema | edema (swelling from fluid accumulation in body tissues) in the limbs |
pneumonia | disease marked by inflammation of the lungs, caused by viruses, bacteria, or other microorganisms or by physical and chemical irritants |
polyuria | an excessive quantity of urine |
precordial | in front of the heart |
predisposes | provides an inclination or susceptibility |
presacral | anterior to or preceding the sacrum (the triangular-shaped bone lying between the 5th lumbar vertebra and the coccyx) |
provisional diagnosis | not 100% sure of the diagnosis because more information is needed |
differential diagnosis | more than one possibility for what the diagnosis is |
psychiatric | relating to he practice of psychiatry (diagnosing and treating mental disorders.) |
pulsations | throbs or rhythmical beats, as of the heart |
carotid arterial pulsations | arterial pulsations in neck of blood flowing away from the heart to the head |
jugular venous pulsations | venous pulsations in the neck of blood flowing to the heart from the head |
pulse | the regular throbbing of the arteries, caused by the successive contractions of the heart |
carotid pulse | located in the neck (carotid artery) |
dorsalis pedis pulse | located on top of the foot (dorsalis pedis artery) |
femoral pulse | located in the thigh (femoral artery) |
peripheral pulse | pulse measured in the limbs |
popliteal pulse | located above the knee in the popliteal nasal, found by holding the bent knee |
tibialis posterior pulse | located on the medial side of the ankle |
respiratory | pertaining to respiration |
REVIEW OF SYSTEMS (heading) | a system-by-system review of the body functions |
rheumatic fever | disease occurring chiefly in children and young adults characterized by fever, inflammation, pain, and swelling in and around the joints, inflammatory involvement of the pericardium and valves of the heart |
sacrum | the triangular segment of the spinal column that forms part of the pelvis |
SOCIAL HISTORY (heading) | personal information about the patient's past or present life that, although nonmedical, may have a bearing on health |
splitting (heart sound) | the presence of two components in the first or second heart sound complexes |
stethoscope | an instrument used in auscultation |
stoic | one who is seemingly indifferent to or unaffected by joy, grief, pleasure, or pain |
stroke | apoplexy; cerebrovascular accident; a blockage or hemorrhage of a blood vessel leading to the brain |
symmetric | affecting corresponding parts simultaneously |
systolic ejection murmur | a heart murmur heard at systole, usually due to mitral or tricuspid regurgitation or to aortic or pulmonary obstruction |
thrombophlebitis | inflammation of a vein caused by the formation of a blood clot. |
tuberculosis | an infectious disease of humans and animals caused by the tubercle bacillus |
ulcer | a sore on the skin or a mucous membrane, accompanied by the disintegration of tissue, the formation of pus, etc. |
urinate | to pass or discharge urine |
Valsalva maneuver | forcing of air into middle ear |
varicosities | a varicose enlargement or swelling |
venous hum | brief or continuous noise originating from the neck veins that may be confused with cardiac murmurs |
VITAL SIGNS (heading) | pulse, respiration, temperature, blood pressure |
waxed | increased in extent, quantity, intensity, power, etc |
waned | decreased in strength, intensity, etc. |