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Med Term Ch2
Medical Terminology - Chapter 2
| Term | Definition |
|---|---|
| Subjective | how a patient experiences and personally describes his problem as well as personal and family medical histories |
| Objective | the patient's physical exam, and lab findings, and imaging studies performed |
| Assessment | a diagnosis, identification of a problem, or a differential diagnosis |
| Plan | course of action: treatment with medicine or a procedure or additional tests |
| acute | it just started recently OR is a sharp, sever symptom |
| chronic | it has been going on for a while now |
| exacerbation | it is getting worse |
| abrupt | all of a sudden |
| febrile | to have a fever |
| afebrile | to not have a fever |
| malaise | not feeling well |
| progressive | more and more each day |
| symptom | something a patient feels |
| noncontributory | not related to this specific problem |
| lethargic | a decrease in level of consciousness, in a medical record, this is generally an indication that the patient is really sick |
| genetic/hereditary | it runs in the family |
| alert | able to answer questions, responsive, interactive |
| oriented | being aware of wh he is, where he is, and the current time; all three= "x3" |
| marked | it really stands out |
| unremarkable | another way of saying normal |
| auscultation | to listen |
| percussion | to hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument |
| palpation | to feel |
| impression | another way of saying assessment |
| diagnosis | what the health care professional thinks the patient has |
| differential diagnosis | 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; remission does 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 |
| sequela | a problem resulting from a disease or injury |
| pending | waiting for |
| disposition | 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, ICU, normal hospital bed) |
| discharge | unload 1. to send home 2. fluid coming out of a part of the body |
| prophylaxis | preventive treatment |
| palliative | treating the symptoms, but not actually getting rid of the cause |
| observation | watch, eep an eye on |
| reassurance | to tell the patient that the problem is not serious or dangerous |
| supportive care | to treat the symptoms and make the patient feel better |
| sterile | extremely clean, germ-free conditions; especially important during medical procedures and surgery |
| proximal | closer in to the center |
| distal | farther away from the center |
| lateral | out to the side |
| medial | toward the middle/midline |
| ventral/antral/anterieor | front |
| dorsal/posterior | 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 slices right to left |
| coronal | divides the body into slices from front to back |
| transverse | divides the bottom from top to bottom |
| physician | a skilled health care provider who attended and graduated medical school (MD and DO) |
| pediatrician | a physician with special training in caring for children |
| surgeon | a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure |
| anesthesiologist | a physician with special training in pain sedation and pain control |
| physician assistant | a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training |
| nurse practitioner | a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician |
| emergency medical technician | specially trained in the emergency care of a patient before and/or during transport to a medical facility |
| speech therapist | specially trained in evaluating and treating problems with speech and/or swallowing |
| occupational therapist | specially trained in evaluating and treating problems with performing daily activities at home, school, or work |
| physical therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury |
| respiratory therapist | specially trained in treating patient's respiratory issues under the guidance of a healthcare provider |
| dietician | specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan |
| licensed practical nurse licensed vocational nurse | trained and certified to provide basic care to a patient |
| registered nurse | an advanced level nurse who has completed an associate's or bachelor's degree; often assists with patient care planning and patient education |
| medical assistant | trained to carry out basic administrative and clinical tasks under the guidance of a health care provider |
| pathologist | a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
| medical laboratory technician | trained in performing laboratory testing on bodily fluids |
| phlebotomist | trained in the removal of blood from the body for diagnostic or therapeutic purposes |
| radiologist | a physician specially trained in evaluating images of the body to diagnose illness or injury |
| radiology technician | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| ultrasonographer | trained in performing ultrasound imaging on a patient |
| pharmacist | trained and licensed in preparing and dispensing medicine |
| pharmacy technician | trained to assist a pharmacist with pharmacy related tasks |
| patient service coordinator | handles administrative tasks and coordinates patient care |
| medical transcriptionist | trained in converting the voice recorded dictations of health care providers into text format |
| history of present illness | the story of the patient's problem |
| chief complaint | the main reason for the patient's visit |
| 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 patient's past surgeries |
| family history | any significant illnesses that run in the patient's family |
| social history | a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health |
| CCU | critical care unit |
| ECU | emergency care unit |
| ER | emergency room |
| ED | emergency department |
| ICU | intensive care unit |
| PICU | pediatric intensive care unit |
| NICU | neonatal intensive care unit |
| SICU | surgical intensive care unit |
| PACU | post anesthesia care unit |
| L&D | labor & delivery |
| OR | operating room |
| post-op | after surgery |
| pre-op | before surgery |
| (R) | right |
| (L) | left |
| (B) | bilateral |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Ht | height |
| Wt | weight |
| BMI | body mass index (measurement of body fat based on height and weight) |
| I/O | intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output) |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | Prescription |
| H&P | history and physical |
| Hx | history |
| CC | chief complaint |
| HPI | history of present illness |
| ROS | review of system |
| PMHx | past medical history |
| FHx | family history |
| NKDA | no known drug allergies |
| PE | physical exam |
| Pt | patient |
| y/o | years old |
| h/o | history of |
| PCP | primary care provider |
| f/u | follow up |
| SOB | shortness of breath |
| HEENT | head, eyes, ears, nose, and throat |
| PERRLA | pupils are equal, round, and reactive to light and accommodation |
| NAD | no acute distress |
| CV | cardiovascular |
| RRR | regular rate and rhythm (normal sounding heart) |
| CTA | clear to auscultation (normal sounding lungs) |
| WDWN | well developed, well nourished (the patient is growing or has grown appropriately and does not appear to be malnourished) |
| A&O | alert and oriented |
| WNL | within normal limits |
| NOS | not otherwise specified |
| NEC | not elsewhere classified |
| PO | per os (by mouth) |
| NPO | nil per os (nothing by mouth) |
| PR | per rectum |
| IM | intramuscular |
| SC | subcutaneous |
| IV | intravenous |
| CVL | central venous line |
| PICC | peripherally inserted central catheter |
| Sig | signa, Latin for label |
| BID | twice daily, bis in die |
| TID | three times daily, ter in die |
| Q | every x, Q4hr means every 4 hours |
| QD | daily, quaque die, each day |
| QID | four times daily, quater in die |
| QHS | at night, quaque hora somni, each night at the hour of sleep |
| AC | before meals, ante cibum (food) |
| PC | after meals, post cibum (food) |
| prn | as needed, per re nata, as the need arises |
| ad lib | as desired |
Created by:
rodonnell9034
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