Chapter 1

Medical Terminology and Medical History

Acronym

uses the first letter of each word

Abbreviation

shortened form of a word

Greek and Latin Roots

between prefix and suffix

SOB

short of breath *Never pronounced as a word

BUN

B-U-N *Never pronounced as a word

AIDS

acquired immunodeficiency syndrome

Ac

acute

prn

as needed

A-fib

atrial fibrilation

BMI

body mass index

Ca2+

calcium

COPD

chronic obstructive pulmonary disorder

-penia

deficient, low

Dz

diseasedstate

gtt

drops

phagia

eating (generally non-human, often cells)

ECG/EKG

Electrocardiogram

-tachy

fast

GI

gastrointestinal

GTT

glucose tolerance test

HBV

hepatitis B virus, Hep-B

Hx

History

poly

many

MI

myocardial infarction

NSAID

nonsteroidal anti-inflammatory drug

NPO, npo

nothing by mouth

path

pathology

Px

prognosis

Si

signs

-stasis

stop

SIDS

sudden infant death syndrome

Sx

symptoms

micro

tiny

-octomy

cut into

-ectomy

cut out

TB

tuberculosis

UTI

urinary tract infection

V-tach

ventricular tachycardia

WBC

white blood cell

cc

chief complaint

HPI

history of present illness

PMHx

past medical history

FHx

family history

SHx

social history

ROS

review of systems

Alg

allergies

NKDA

no known drug allergies

immuno

immunizations

PE

physical exam

Meds

Medications

A/P

assessment and plan

cyte / cyt

cell (of or relating to a cell)

-emia

blood (of or relating to blood)

hemo

blood (of or relating to blood)

mastia

breasts (of or relating to breasts)

metric

measurement

-osis

state, usually referring to a disease state

-pexy

fixation of an anatomical structure

-plasty

molding or shaping; reconstruction

pnea

breath or respiration (of or relating to the breath)

-rrhea

flow; flowing

-scopy

using an instrument to view

turia

of or relating to the urine

uria

of or relating to the urine

a

without

ana-

up or against

andro-

masculine

angina

pain or pressure (in the chest)

anthropo-

humankind (both men and women)

cephal

head (of or related to the head)

corpus

body

cutaneous

of or related to the skin

dia-

through

dys-

bad (or difficult)

epi-

upon; on top of

exo (-ec-)

outside of; exterior; out

gyn / gyno

feminine; female

hyper-

higher than normal; elevated/excessive

hypo-

lower than normal, decreased/deficient

leuko-

white

ortho-

straight or ordered; aligned

litho-

stone

peri-

near; around

rhin / rhino

nose (of or related to the nose)

thorax

chest

oligo

few; very little

-lytic

burst open

entero

intestines

7 Attributes of a Symptom

1. Location

2. Quality

3. Quantity or Severity

4. Timing

5. Setting of Occurrence

6. Remitting/Exacerbating Factors

7. Associated Manifestations

Review of Systems (ROS)

documents presence or absence of common symptoms related to each major body system

Ethical Considerations

Nonmaleficence: “first, do no harm”

Beneficence: “do good” for the patient

Autonomy: patients have the right to determine what is in their own best interest

Confidentiality: we are obligated not to tell others what we learn from our patients

Intake Forms

forms that the patient fills out when they arrive for their first visit at the location

SOMR

Source Oriented Medical Records: organized by the source of the information

POMR

Problem-Oriented Medical Record: organization of the medical chart based on relevance of the documents to a specific problem or treatment

SOAP Note

S: Subjective Information - patients own words

O: Objective Information - measurable values

A: Assessment and/or diagnosis of patient - based on both subjective and objective information

P: Plan for Treatment

SOAPER

S: Subjective Information - patients own words

O: Objective Information - measurable values

A: Assessment and/or diagnosis of patient - based on both subjective and objective information

P: Plan for Treatment

E: Educating the patient

R: Response of the patient to the education and care provided

CHEDDAR

C: Chief Complaint

H: History of all relevant information

E: Examination of relevant information

D: Details of complaint and observed problems

D: Drugs, with dosages, currently being taken

A: Assessment based off diagnostics

R: Returning visit for follow up, if needed

Physical Examination Methods

1. Auscultation: listening with stethoscope for wheezing, rubs, bowel sounds, bruits, rales, rhonchi, and other adventitious sounds

2. Percussion: tapping with intent of differentiating solid from hollow structures, organs, tissues, and masses

3. Visual Inspection: identifying symmetry, erythema, or other visual signs

   1. Palpation: toughing and feeling - softness, tenderness, induration, nodularity

c (with line over top)

with

B/O

because of