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 |