Medical Tech Vocab

Urine

Description: Liquid waste produced by the kidneys through filtration of blood. Contains water, urea, inorganic salts, and metabolic waste products.

Common diseases/conditions tested:

• Urinary tract infections (UTIs)

• Diabetes mellitus

• Kidney diseases

• Glomerulonephritis

• Preeclampsia

Collection methods:

• First-morning urine

• Random urine specimen

• Clean-catch specimen

• 24-hour urine collection

Stool (Feces)

Solid or semisolid waste remaining after food is digested and absorbed in the gastrointestinal tract.

Common diseases/conditions tested:

• Gastrointestinal infections (bacterial, viral, parasitic)

• Colorectal cancer (occult blood testing)

• Inflammatory bowel disease (IBD)

Collection: Collect in an appropriate clean container and avoid contamination.

Sweat

Fluid secreted by sweat glands containing water, sodium, chloride, and other electrolytes.

Common condition tested:

• Cystic fibrosis

Collection: Standardized sweat test performed by trained personnel.

Pleural Fluid

Fluid found between the membranes surrounding the lungs.

Common diseases/conditions tested:

• Pleural effusion

• Pneumonia

• Tuberculosis (TB)

• Lung cancer

• Heart failure

Collection procedure: Thoracentesis.

Synovial Fluid

Description: Viscous fluid found in joint cavities that reduces friction during movement.

Common diseases/conditions tested:

• Septic arthritis

• Gout

• Rheumatoid arthritis

Collection procedure: Arthrocentesis.

Saliva

Description: Secretion from salivary glands containing water, electrolytes, enzymes such as amylase, and immunoglobulins.

Common tests:

• Cortisol testing

• Selected viral infection tests

• Drug screening or monitoring

Collection: Saliva is collected in a designated container according to test instructions.

Cerebrospinal Fluid (CSF)

Description: Clear, colorless fluid that surrounds and protects the brain and spinal cord.

Common diseases/conditions tested:

• Meningitis

• Encephalitis

• Multiple sclerosis

• Subarachnoid hemorrhage

Collection procedure: Lumbar puncture (spinal tap).

Peritoneal Fluid

Fluid within the abdominal cavity surrounding the abdominal organs.

Common diseases/conditions tested:

• Inflammation

• Cirrhosis and ascites

• Intra-abdominal cancers

• Bowel perforation

Collection procedure: Paracentesis.

Amniotic Fluid

Clear, yellowish fluid surrounding the fetus in the amniotic sac during pregnancy.

Common conditions tested:

• Chromosomal abnormalities, including Down syndrome

• Neural tube defects

• Fetal lung maturity

Collection procedure: Amniocentesis.

Pericardial Fluid

Fluid contained within the sac surrounding the heart.

Common diseases/conditions tested:

• Pericarditis

• Cardiac tamponade

• Pericardial effusion, which may be malignant or infectious

Collection procedure: Pericardiocentesis.

Sputum

Description: Thick mucus or phlegm coughed up from the lower respiratory tract, including the trachea and bronchi.

Common diseases/conditions tested:

• Pneumonia

• Tuberculosis (TB)

• Chronic obstructive pulmonary disease (COPD)

Collection: Cough a deep respiratory specimen into an appropriate sterile container. Saliva alone is not an adequate substitute.

Biopsy

A tissue sample or collection of cells extracted from the body for microscopic examination.

Common diseases/conditions investigated:

• Cancers and tumors

• Selected infections

• Hepatitis-related tissue disease

• Autoimmune disorders

Collection: Tissue is obtained using an appropriate biopsy procedure.

Semen

Male reproductive fluid containing spermatozoa suspended in seminal plasma rich in nutrients and enzymes.

Common tests/conditions:

• Infertility

• Post-vasectomy verification

• Male reproductive tract infections

Collection: Collected in a designated container following laboratory instructions.

Gastric Juice

Strongly acidic fluid produced by gastric glands containing hydrochloric acid (HCl), pepsinogen, and mucus.

Common diseases/conditions tested:

• Gastritis

• Peptic ulcer disease

• Helicobacter pylori infection

Collection: Obtained through an appropriate gastric sampling procedure.

Cervical/Vaginal Swabs

Cellular and mucosal samples collected from the cervix or vaginal walls.

Common diseases/conditions tested:

• Cervical cancer and precancerous lesions (Pap smear)

• Human papillomavirus (HPV)

• Bacterial vaginosis

• Candidiasis (yeast infection)

• Sexually transmitted infections, including chlamydia and gonorrhea

Collection: Use the appropriate swab and collection technique for the requested test.

Blood

Description: Circulating bodily fluid consisting of plasma and cellular elements, including red blood cells, white blood cells, and platelets.

Common diseases/conditions tested:

• Anemia

• Infections and sepsis

• Leukemia

• Cardiovascular disease

• Metabolic and endocrine disorders

• Kidney and liver dysfunction

Collection: Usually collected by venipuncture or another approved method.

SAMPLE

SAMPLE is used to collect the patient’s history and background information.

SAMPLE - S

S = Signs and Symptoms

• What you observe and what the patient reports.

• Includes vital signs.

SAMPLE - A

A = Allergies

• Food allergies

• Medication allergies

• Environmental allergies

SAMPLE - M

M = Medications

• Prescription medications

• Supplements

• OTC (over-the-counter) medications

SAMPLE - P

P = Past Pertinent Medical History

• Previous surgeries

• Medical conditions

• Cancer history

• Family history

SAMPLE - L

L = Last Oral Intake

• What the patient last ate or drank.

• When the patient last ate or drank.

SAMPLE - E

E = Events Leading Up to the Incident

• What happened before the illness, injury, or complaint.

OPQRST — CHIEF COMPLAINT ASSESSMENT

O = Onset

• When did it start?

• What were you doing when it started?

P = Provocation/Palliation

• What makes it worse?

• What makes it better?

Q = Quality

• What does it feel like?

• Examples: sharp, dull, aching, throbbing, or pulling.

R = Region/Radiation

• Where is the pain?

• Does it spread or move anywhere else?

S = Severity

• How bad is it on a scale of 1–10?

T = Time

• How long has it lasted?

• Is it constant or does it come and go?

LOC — LOSS OF CONSCIOUSNESS

 A temporary loss of awareness or responsiveness.

During assessment, determine whether it occurred and gather information about the event.

 CUPS — TRIAGE CATEGORIES

C = Critical

• Immediately life-threatening condition.

U = Unstable

• Serious condition that may deteriorate rapidly.

P = Potentially Unstable

• Condition that may worsen and requires assessment and monitoring.

S = Stable

• No current signs of immediate instability.

MOI — MECHANISM OF INJURY

 The way an injury occurred.

Examples:

• Fall

• Motor vehicle collision

• Sports injury

• Other traumatic event

DCAP-BTLS — TRAUMA ASSESSMENT

D = Deformities

• Abnormal shape or position of a body part.

C = Contusions

• Bruises caused by injury.

A = Abrasions

• Scrapes on the skin.

P = Punctures/Penetrations

• Injuries where an object pierces the skin or enters tissue.

B = Burns

• Tissue injuries caused by heat, chemicals, electricity, or other sources.

T = Tenderness

• Pain or sensitivity when an area is examined.

L = Lacerations

• Cuts or tears in tissue.

S = Swelling

• An increase in tissue size, often caused by injury or inflammation.