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Medical terminology
health records
| Term | Definition |
|---|---|
| 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
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