medical terms 2 Word Scramble
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| Term | Definition |
| EHR | Electronic Health Record |
| roadmap | The information contained in a patient's records serves as a __________ to their health history detailing previous illnesses and treatments, continuing medical problems, history of family illness, and any current meds. |
| Subjective, Objective, Assessment, Plan (SOAP) | the four general parts of a medical note |
| Subjective | the patient's personal story of health issue: reason for visit, description of problem, timing, previous problems/surgeries, family health issues, current meds/allergies |
| acute | started recently or sharp and severe symptom |
| chronic | has been going on for a while |
| 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, usually means really sick in medical records |
| genetic/hereditary | runs in the family |
| chief complaint | the main reason for a patient's visit |
| history of present illness | the story of the patient's problem |
| review of symptoms | description of individual body symptoms 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 |
| clinic note | document of a visit in an office setting. always follows the SOAP method |
| consult note | a note from a visit to a specialist or consultant |
| emergency department note | a note given to emergency departments in need of information on a patient |
| admission summary | a summary of a patient's physical details upon being admitted to a hospital |
| discharge summary | a note that details when and why a patient was admitted to the hospital, what happened, how the patient felt, and a follow-up plan. |
| operative report | a report after each surgery explaining the procedure, the events that transpired, and patient's outcome |
| daily hospital note/progress note | a document made every day a patient is in a hospital, usually covers how their condition has changed since the day before. |
| radiology report | a note explaining the reason for ordering a radiologic image, how image was performed, and what was seen on the image, and the reviewing radiologist's assessment |
| pathology report | mirrors the same style as a radiology note, but for pathology |
| prescription | a note that doesn't follow SOAP format, it's the plan. |
| CCU | coronary 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 and delivery |
| OR | operating room |
| post-op | after surgery |
| pre-op | before surgery |
| alert | able to answer questions, responsive |
| oriented | being aware of who they are, where they are, and the current time |
| marked | it stands out |
| unremarkable | normal |
| auscultation | to listen |
| percussion | to hit something and listen to the resulting sound or feel for resulting vibration |
| palpation | to feel |
| impression | assessment |
| diagnosis | what the health care professional thinks the patient has |
| differential diagnosis | list of conditions 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 |
| remission | to get better or improve, most often used when discussing cancer |
| idiopathic | no known specific cause, just happens |
| localized | stays in a certain part of the body |
| systemic/generalized | all over the body or most of the body |
| prognosis | the chances for things getting better or worse |
| occult | hidden |
| 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, used at end of ED notes to reference where patient went after visit |
| discharge | to send home, or fluid coming out of part of body |
| palliative | treating the symptoms but not the cure |
| observation | watch, keep an eye on |
| reassurance | 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 |
| proximal | closer to the center |
| distal | farther from center |
| lateral | out to the side |
| medial | toward the middle |
| ventral | the front |
| dorsal | the back |
| cranial | towards top |
| caudal | towards 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 hand or foot |
| plantar | sole of foot |
| palmar | palm of hand |
| saggital | divides body from left and right |
| coronal | divides body front and back |
| transverse | divides body top to bottom |
| physician | skilled healthcare provider who attended and graduated medical school |
| pediatrician | physician with special training for children |
| surgeon | physician qualified to treat patients surgically by means of operation or invasive procedure |
| anesthesiologist | physician with special training on pain sedation and pain control |
| epidemiologist | specialist in study of causes and distribution of diseases in populations and the use of this data will enhance public health |
| physician assistant (PA) | midlevel healthcare provider who works under the license of a supervising physician, requires postgraduate training |
| nurse practitioner (NP) | nurse with postgraduate training that serves as midlevel healthcare provider, works under supervising physician |
| emergency medical technician | specially trained in evaluating and treating problems with speech and/or swallowing |
| occupational therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from injury |
| respiratory therapist | trained in treating patients respiratory issues under guidance of a healthcare provider |
| dietician | trained in evaluating the nutritional status of a patient and developing diet plan |
| licensed practical nurse (LPN) | trained and certified to provide basic care to a patient |
| registered nurse (RN) | advanced level nurse who has completed an associate's or bachelor's degree, assists with patient care planning and patient education |
| medical assistant | trained to carry out basic administrative and clinical tasks under guidance of a healthcare provider |
| pathologist | 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 | physician 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 healthcare 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 voice recorded dictations of healthcare providers into text format |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Ht | height |
| Wt | weight |
| BMI | body mass index |
| I/O | intake/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 systems |
| 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, reactive to light and accomadations |
| NAD | no acute distress |
| CV | cardiovascular |
| RRR | regular rate and rhythm |
| CTA | clear to auscultation |
| WDWN | well developed well nourished |
| 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 | instructions |
| BID | twice daily |
| TID | three times daily |
| Q | every x (every x hours) |
| QD | daily |
| QID | four times daily |
| QHS | at night |
| AC | before meals |
| PC | after meals |
| prn | as needed |
| ad lib | as desired |
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