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Subjective
Medical
| Term | Definition |
|---|---|
| acute | occurs recently, or sharp severe symptoms |
| chronic | a problem that occurs for a while |
| abrupt | occurs suddenly |
| febrile | has a fever |
| afebrile | does not have a fever |
| malaise | not feeling well |
| progressive | worsening of symptoms |
| exacerbation | worsening of a condition |
| symptom | what the patient feels |
| noncontributory | patient’s symptom is not related to the current problem |
| lethargic | a decrease in level of consciousness |
| genetic/hereditary | it runs in the family |
| alert | patient can answer questions; responsive, interactive |
| oriented | patient knows who they are, where they are, and what time it is (current date and time) |
| auscultation | to listen (usually with a stethoscope) |
| percussion | to hit or strike and then listen for the sound; the returned sound indicates the condition of the body |
| palpation | to feel something; how something feels can indicate its condition, be it normal or abnormal |
| unremarkable | normal |
| marked | it stands out |
| objective data | the information gathered by the health care provider. Includes tests, body images, provider observations |
| assessment | gathering and analyzing of the facts about the patient. The facts come from the subjective and objective information |
| impression | another word for assessment |
| diagnosis | using the subjective and objective data to determine the patient’s condition |
| differential diagnosis | based on the subjective and objective data, the health care professional cannot yet determine the diagnosis |
| benign | not cancerous |
| malignant | cancerous |
| degeneration | getting worse |
| etiology | the cause |
| idiopathic | no known cause |
| remission | no longer having the symptoms of a disease; usually used when referring to cancer |
| recurrent | to have again |
| morbidity | risk of being sick or diseased |
| mortality | risk for dying |
| prognosis | chance of getting better or worse |
| localized | one area |
| systemic | over a large area or body system |
| occult | hidden |
| pathogen | organism that causes the disease |
| lesion | diseased tissue |
| sequelae | result of disease or injury; for example, paralysis can be the sequelae of spinal cord injury |
| pending | waiting for |
| plan | the recommendation of action for the patient |
| Disposition | where the patient went at the conclusion of the visit. Examples would be home, hospital, or a nursing home |
| sischarge | to send home |
| prophylaxis | preventative treatment |
| palliative | relieve symptoms, but not cure |
| observation | to watch |
| reassurance | actions that make the patient feel better |
| supportive care | treat symptoms to make the patient feel better |
| sterile | extremely clean, germ-free conditions |
| anatomical position | person standing face forward, arms on side with palms forward |
| proximal | attachment to the trunk |
| distal | upper extremities and lower extremities |
| lateral | relationship to center |
| medial | describes relationship to center |
| ventral/antral/anterior | front when referring to the human |
| dorsal/posterior | back when referring to the human |
| superior | above |
| inferior | below |
| cranial | cranial means head |
| caudal | caudal means tail |
| supine | lying on back |
| prone | lying on belly |
| ipsilateral | same side |
| contralateral | opposite side |
| unilateral | one side |
| bilateral | two sides |
| plantar | sole of foot |
| palmar | palm of hand |
| dorsum | top/back of something |
| coronal plane | divides body into anterior and posterior sides |
| sagittal plane | divides body into right and left |
| transverse plane | divides body into superior and inferior(top/bottom) |
| physician | skilled health care provider who attended and graduated medical school |
| pediatrician | physician with special training in caring for children |
| surgeon | physician qualified to treat patients surgically, that is by means of operation or invasive procedure |
| anesthesiologist | physician with special training in pain sedation and pain control |
| physician assistant | midlevel health care provider who works under the license of a supervising physician |
| nurse practitioner | midlevel healthcare provider, nurse, postgraduate training |
| emergency medical technician | emergency care of a patient before and/or during transport to medical facility |
| speech therapist | evaluating and treating problems with speech and/or swallowing |
| occupational therapist | evaluating and treating problems with performing daily activities at home, work or school |
| physical therapist | impairments including disabilities or recovering from an injury |
| respiratory therapist | trained in treating patients respiratory issues |
| dietician | nutritional status of a patient and developing appropriate diet plan |
| licensed practical nurse | trained and certified to provide basic care to a patient |
| registered nurse | advanced level nurse who has completed an associate or bachelor's degree; assist with care planning and education for the patient |
| medical assistant | basic administrative and clinical tasks under the guidance of a health care provider |
| pathologist | physician with special training in both evaluating the causes and effects of disease and in lab medicine |
| medical lab tech | perform lab testing on bodily fluid |
| phlebotomist | removal of blood from the body for diagnostic or therapeutic purposes |
| radiologist | physician specially trained in evaluating images of the body to diagnose illness injury |
| radiology tech | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| ultrasonagrapher | trained in performing ultrasound imaging on a patient |
| pharmacist | preparing and dispensing medicine |
| pharmacy tech | assist pharmacist with pharmacy related tasks |
| patient service coordinator | handles administrative tasks and coordinates patient care |
| medical transcriptionist | converting the voice recorded dictations of health care providers into text format |
| chief complaint | patients visit |
| history of present illness | patients problem |
| review of systems | description of indiv. body systems in order to discover any symptoms related to the problem |
| past med history | past illnesses |
| past surg history | past surgeries |
| fam history | illnesses that run in family |
| social history | records of habits like smoking, drinking or drug abuse |
Created by:
KENING
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