hlth 354 ch 2

a&p, health records

subjective

1st part of the note. Patient data and what they tell the healthcare worker. What seems to be the problem/ reason for the visit

acute

just started, very sharp, severe symptom

chronic

going on for a while now

exacerbation

getting worse

abrupt

all of a sudden

febrile

to have a fever

afebrile

no fever

malaise

not feeling well

progressive

more and more each day

symptom

something the patient feels

noncontributory

not related to this specific problem

lethargic

a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick

genetic/hereditary

it runs in the family

objective

collecting data, lab data, any physical exams

alert

able to answer, responsive, interactive

orientated

focuses on physical diagnosis, interpretation of diagnostic imaging, and understanding the anatomical basis of emergency medicine and general surgery

marked

really stands out

unremarkable

being normal

auscultation

to listen

percussion

to hit something and listen to the resulting sound or feel for the resulting vibration

palpation

to feel

assessment

analysis of the problem or any possible cause of the problem —> differential diagnosis

impression

another word for assessment

diagnosis

what the doctor thinks the patient has

differential diagnosis

a list of conditions the patient may have based on the symptoms exhibited and the results of the exam

benign

safe

malignant

dangerous, a problem

degeneration

getting worse

remission

getting better, improve (usually when talking about cancer) DOES NOT mean cure

idiopathic

no known cause, just happens

localized

stays in a certain part of the body

systematic, generalized

all over the body (or most of it)

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

pathogen

an organism that causes disease

morbidity

the risk of being sick

mortally

risk for dying

etiology

the cause

plan

course of action to help fix the problem. That could be with medicine, nutrition changes, a procedure etc.

disposition

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

literally, to unload; it has two meanings:

1. to send home (to unload the patient from the health care setting to home)
2. fluid coming out of a part of the body (your body unloading a fluid)

palliative

treating the symptoms, but not actually getting rid of the cause

observation

to keep an eye on, watch

reassurance

to 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; especially important during medical procedures and surgery

prophylaxis

preventive treatment

proximal

closer to the point of attachment (come from the word “close”)

distal

farther from the trunk of the body. (comes from the word “far”)

lateral

out to the side

medial

towards the midline

ventral/antral/anterior

the front the word ventral means stomach

dorsal (posterior)

toward or at the back of the body; behind

cranial

toward the top

caudal

towards the bottom

superior

above

inferior

below

prone

lying down on belly

supine

lying on the back

contralateral

opposite side

ipsilateral

same side

unilateral

one sided

bi lateral

both sides

dorsum

the top of the hand or foot

plantar

sole of foot

palmar

palm of hand

saggital

divides body from left to right

coronal

divides the body into sides from front to back

transverse

divides both into upper and lower parts

physician

a skilled health care provider who attended and graduated medical school. In American there's an MD and a DO kind

pediatrician

physician specializing in the treatment of babies and children

surgeon

a physician who specializes in surgery either by invasive procedure or operation

anesthesiologist

doctor who administers anesthesia to patients undergoing surgery pain sedation and control

epidemiologist

a specialist in the study of outbreaks of disease within a population group, using the data to enhance public health

physician assistant

a mid level health care worker that works under the supervision of a physician. Needs grad school

nurse practitioner (np)

a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician

emergency medical technician (emt)

specially trained in the emergency care of a patient before and/or during transport to medical facility

speech therapist

specially trained in evaluating and treating problems with speech and/or swallowing

occupational therapist (ot)

specially trained in evaluating and treating problems with performing daily activities at home, school, or work

respiratory therapist (rt)

specially trained in treating patient's respiratory issues under the guidance of a health care provider

dietician

specially trained to evaluate nutritional status of a patient and developing a plan

licensed practical nurse (lpn) and licensed vocational nurse (lvn)

trained and certified to provide basic care to a patient

registered nurse (rn)

an advanced level nurse who has completed an associate's or bachelor's degree; often assists with patient care planning and patient education

medical assistant

trained to carry out basic administrative and clinical tasks under the guidance of a health care provider

pathologist

a 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

a physician trained in evaluating images to diagnose diseases or injury

radiology technician

trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider

ultrasonographer

trained in performing ultrasound imagining on a patient

pharmacist

trained and licensed in preparing and dispensing medicine

patient service coordinator

handles administrative tasks and coordinates patient care

medical transcriptionist

trained in converting the voice recorded dictations of health care providers into text formal

chief complaint

the main reason for the patient’s visit

sections of a health record: history of present illness

the story of the patient’s problem

review of systems

description of individual body systems in order to discover any symptoms not directly related to the main problem