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Medical Terminology
Chapters 1-6 general terms
| Term | Definition |
|---|---|
| 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
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