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Medical terminology

health records

TermDefinition
SOAP subjective,objective, assessment, plan
abrupt all in a sudden
acute it just started recently or is a sharp, severe symptom
afebrile to not have a fever
chronic it has been going on for a while now
exacerbation it is getting worse
febrile to have a fever
genetic/ hereditary runs in the family
lethargic a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick
malaise not feeling well
noncontributory not related to this specific problem
progressive more and more each day
symptom something a patient feels
alert able to answer question; responsive; interactive
auscultation to listen
marked it really stands out
oriented being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is "oriented x 3"
palpation to feel
percussion to hit something and listen to the resulting sound or feel for the resulting vibration
unremarkable normal
impression assessment
diagnosis what the health care professional thinks the patient has
differential diagnosos a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
benign safe
malignant dangerous, a problem
degeneration to be getting worse
etiology the cause
remission to get better or improve; most often used when discussing cancer; remissiondoes not mean cure
idiopathic no known specific cause; it just happens
localized stays in a certain part of the body
systemic/ generalized all over the body or most of it
morbidity the risk for being sick
mortality the risk for dying
prognosis the chances for things getting better or worse
occult hidden
pathogen the organism that causes the problem
lesion diseased tissue
recurrent to have again
sequelae a problem resulting from a disease or injury
pending waiting for
discharge literally, to unload; it has two meanings: 1. to send the patient home 2. fluid coming out of a part of the body
disposition what happened to the patient at the end of the visit
observation watch, keep an eye on
palliative treating the symptoms but not actually getting rid of the cause
prophylaxis preventive treatment
reassurance to tell the patient that the problem is not serious or dangerous
sterile extremely clean, germ-free condition
supportive care to treat the symptoms and make the patient feel better
distal farther away from the center
proximal closer to the center
lateral out to the side
medial toward the middle
dorsal, posterior the back
ventral, antral, anterior the front
caudal toward the bottom
cranial toward the top
prone lying down on belly
supine lying down on back
contralateral opposite side
ipsilateral same side
bilateral both sides
unilateral one side
dorsum the top of the hand or foot
palmar the palm of the hand
plantar the sole of the foot
coronal divides the body into slices from front to back
sagittal divides the body in slices right to left
transverse divides the body from top to bottom
Created by: lalla