all combined

Allergy

hypersensitivity

Artery

Vessel carrying blood from the heart to the tissues

Autonomic

Involuntary

Biofeedback

Development of a person’s ability to control his or her autonomic nervous system

Bipolar disorder

Disorder in which mood swings from euphoric to depression

Catheterization

To insert a catheter into a body structure

Chemotherpy

Killing of cancer cells by administering antineoplastic agents

Chiropractic

Treatment predominately by manipulation of spinal and musculoskeletal structures

Cognitive

thoughts or thinking process

Comorbidity

Presence of two or more illnesses at the same time. There may be an association between the illnesses.

Compulsion

Repetitive behavior with ritualistic characteristics

Debridement

Removal of damaged tissue to promote healing

Decompensation

Deterioration; exacerbation of an illness or condition

Desensitize

Lessen sensitivity by administering the specific antigen in low doses

Dialysis

Removal of toxins from the blood by diffusing over a membrane or filter in patients with renal failure

Disorientation

Confusion

Doppler Study

Use an ultrasonic probe to determine blood flow

Enteral Nutrition

Nutrients for patients with impaired ability to chew/swallow or ingest food, typically delivered by gastric or nasogastric tube

Extracranial

Outside the skull

Extraspinal

Outside the spine

Gait training

Method of restoration of balance, extremity swings, stance

Gastroenterology

Study of the stomach, intestine, esophagus, liver, gallbladder, and pancreas

Genetics

Study of hereditary factors

Grandiosity

Unrealistic concept of self-importance

Hallucination

False sense of perception

Home care

Prescribed medical care provided in a patient’s home

Hydration

To replenish fluids

Immune globulin

Antibodies derived from blood plasma providing short term, protection against certain infections

Infusions

A therapeutic agent introduced into the body by a vein

Injection

A fluid introduced into tissue, cavity or vessel, usually by needle

Loosening of Association

Frequent change of subject, often with minimal relationship

Manipulation

Thrusting movement to achieve realignment of joints or spine

Modality

A therapeutic agent

Neuropsychology

Study and treatment of psychiatric and neurological disorders

On call

Medical personnel with special training and skills available to provide services when summoned

Orientation

Awareness

Orthotic

A custom made mechanical appliance used in orthopedics

Panic Attacks

Intense anxiety; often feels like a loss of control

Parenteral Nutrition

Nutrients delivered intravenously to patients who are postoperative, in shock, or otherwise unresponsive

Prosthetic

An artificial body part

Psychology

Study of behavior, thoughts, feelings

Psychotherapy

Method of treating mental disorders. Treatment may involve education, pharmacology, suggestion, and psychoanalysis

Range of Motion

Natural movement

Reflux

To flow backward

Rehabilitation

Effort to restore to optimal function

Short Term Memory

Ability to recall information for a very brief period

Therapeutic

To promote healing

Toxoids

Substance no longer toxic, but capable of forming antibodies

Vaccine

Preparation (bacteria or virus) of nonpathogenic material but can induce immunity to prevent disease

Vein

Vessel that carries blood to the heart

Venom

A poison transmitted by bites or stings

BP

blood pressure

CC

chief complaint

HEENT

head, eyes, ears, nose, throat

h/o

history of

HPI

history of present illness

Hx

history

NAD

no apparent distress

NKDA

no known drug allergies

PE

physical examination

PERRLA

pupils equal, round, and reactive to light and accommodation (for ex: normal)

PMH

past medical history

pt

patient

R/O

rule out

ROS

review of systems

WNL

within normal limits

Auscultation

Listening for sounds within the body, usually within the chest or abdomen

Chief Complaint

the reason the patient presents for an encounter

Counseling

A discussion with a patient and family concerning diagnosis, prognosis, risk factors, etc.

Critical Care

Care provided for a critical illness or injury, which acutely impairs one or more vital organ systems, and is an imminent or life-threatening condition

Established Patient

A patient who has seen a provider of the exact same specialty and subspecialty in the same group within the past 3 years

Family History

A review of the health status of immediate family, including cause and age of death, if appropriate. Also includes a review of hereditary diseases existing in the family.

History of Present Illness

A chronological description of the onset and progression of the illness for which treatment is being sought.

New patient

A patient who has not been seen by a provider of the exact same specialty and subspecialty in the same group for the past 3 years

Medical Necessity

Reasonable and necessary services to effect cure or a change in the condition for which the patient is being seen

Observation Status

The patient’s condition requires monitoring but the decision to admit to inpatient status has not been made.

Palpation

Examining by placing the hands or fingers on the surface of the body to determine characteristics such as texture, temperature, movement, and consistency

Percussion

Tapping the body lightly but sharply to assess the condition of the underlying tissue by the sounds obtained

Review of Systems

A series of questions regarding the signs and symptoms that are associated with the patient’s chief complaint

Autopsy

Examination of a dead body to determine the cause(s) of death

Bacteriology

Branch of science concerned with the study of bacteria

Cytopathology

The study of the cellular changes in disease

Cytogenetics

A branch of genetics concerned with the study of the structure and function of the cell, especially the chromosomes

Clinical Laboratory

Place where tests are performed on clinical specimens to get information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of disease

Clinical Laboratory Improvement Amendments (CLIA)

Quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results

CLIA Waived Tests

Simple tests that may be performed in non-laboratory settings, such as a physician office

Definitive Identification

Identification of the genus and species of the microorganism

Forensic

Pertaining to or applicable to personal injury, murder, and other legal proceedings

Gross

Examination of the entire specimen without sectioning of the specimen into thin slides to be examined without the use of a microscope

Hematology

The medical specialty pertaining to the anatomy, physiology, pathology, symptomatology, and therapeutics related to blood and blood forming tissues.

Immunology

The study of the immune system, its components and function

In Vivo

Studies performed within the living body

Microbiology

The study of microorganisms, including fungi, protozoa, bacteria, and viruses

Microscopy (Microscopic)

Examination under a microscope of minute objects

Molecular Diagnostics

The measurement of DNA, RNA, proteins, or metabolites to detect genotypes, mutations or biochemical changes

Mycology

The study of fungi, their identification, classification, edibility, cultivation, and biology, including pathogenicity

Necropsy

Examination of a dead body and organs to determine the cause(s) of death (syn: autopsy)

Panel

A group of tests performed together and listed in the code description

Pathology

The medical science and specialty practice concerned with study of diseased tissue and cells

Presumptive Identification

Identification of a microorganism based on the growth patterns, color, success in culturing the specimen in certain media, etc