medical history and physical exam

abrasion

scraping or rubbing away of skin or mucous membrane

abscess

localized collection of pus in any body part

alopecia

hair loss

analgesic

medication/treatment that relieves pain

anomaly

marked deviation from normal

asymptomatic

without symptoms

arthralgia

joint pain

ataxia

failure of muscular coordination

atopy

characterized by a tendency to be hyperallergic

auscultation

act of listening for sounds within the body

benign

noncancerous; not progressive

blood chemistry profile

analysis of chemical components of the patient's blood

carotid

principal artery of the neck

cheilitis

inflammation of the lip

chief complaint

subjective description of the symptoms that caused the patient to seek medical attention

clinical diagnosis

diagnosis made on the basis of knowledge obtained from the medical history and physical examination

consultation

report written by consulting physician on the request of the patient's primary physician

contusion

bruise

decubitus

lying down

dermis

second layer of skin

diagnosis

identification of a disease or condition by a scientific evaluation of physical signs, symptoms, laboratory tests, and procedures

diaphoresis

profuse perspiration

differential diagnosis

distinguishing between two or more diseases with similar symptoms by comparing their signs and symptoms

dysphonia

voice impairment; difficulty in speaking

edema

abnormal accumulation of fluid in intercellular spaces; swelling

emesis

vomiting

epidermis

first (top) layer of skin

eschar

hard black crust produced by a thermal burn

erythema

redness on the skin

exanthema

measles like eruption or rash that may be due to a virus or allergic reaction to a drug

extraocular

outside of the eye

femoral (pulse)

pulse of the femoral artery felt in the groin

fibrosis

abnormal formation of fibrous tissue (scar tissue)

flaccid

weak, soft, flabby, poor muscle tone

ganglion

a knot, group of nerve cell bodies outside the central nervous system

hematoma

a collection of blood trapped in the tissues of the skin or an organ

hematuria

presence of blood in the urine

hemoptysis

spitting up of blood or blood-tinged sputum

hepatosplenomegaly

enlargement of the liver and spleen

Impression/Diagnosis

section of the report in which the physician indicates diagnostic conclusions

incontinent

inability to control urination

keloid

abnormally large, thickened scar

laboratory diagnosis

diagnosis arrived at after the study of laboratory findings

laceration

tear in the skin

lacrimation

secretion and discharge of tears

lumbar puncture

spinal tap

melanin

pigment granules that give color to the skin and protect the body from injurious ultraviolet light rays

malaise

general feeling of bodily discomfort

murmur

auscultatory sound, particularly a periodic, short-duration sound of cardiac or vascular origin

nocturia

excessive urination at night

palpation

feeling with fingers of hands to determine the physical characteristics of organs or tissues

paresis

partial or incomplete paralysis

Past History

information that includes any childhood or adult diseases, surgical procedures, accidents, pregnancies, deliveries, and allergies

percussion

using fingertips to tap the surface of the body in order to produce sound

Physical Examination

physician's objective assessment of the patient, using auscultation, palpation, percussion, and visualization

postmortem

after death

Present Illness

information provided by patient as to when the symptoms were first noticed, the extent and intensity, and the patient's opinion about what caused the symptoms

primary symptoms

symptoms directly related to a disease

primigravida

pregnant for the first time

prognosis

prediction of course and end of disease

progress note

brief note from a physician documenting a patient's progress

pruritus

itching

ptosis

dropping of the upper eyelid

purpura

large bruises in the skin

Review of Systems

exchange between doctor and patient to determine presence of absence of signs and symptoms

scleroderma

chronic disease caused by infiltration of fibrous tissue resulting in 'hard skin'

sebaceous glands

oil glands located in the dermis

secondary symptoms

symptoms that are the result of a disease process

shunt

to bypass, as an example use of a catheter to drain fluid

Social History

information summarizing the patient's lifestyle and environment to determine whether something about these factors are contributing to the problem

sputum

matter ejected from the trachea, bronchi, and lungs via the mouth

syncope

temporary loss of consciousness

tinnitus

a noise (ringing) in the ear

tympanic membrane

eardrum

urticaria

hives

verruca

wart; type of viral skin infection

vertigo

dizziness

vesicle

small sac containing liquid

vital signs

pulse rate, respiration rate, body temperature, blood pressure

xanthoma

distinct yellow growth caused by deposits of fat in the skin; usually reflects increased fatty materials in the bloodstream