Lecture 2: The Medical Record and Diagnostic Imaging

Flashcards covering key vocabulary related to the medical record, patient history components, vital signs, physical examination techniques, diagnostic imaging, and medical terminology from Lecture 2.

Chief Complaint (CC)

The reason why the patient is seeking medical attention, subjectively notated in their own words, written in quotations, and not translated into medical terminology.

History of Present Illness (HPI)

A chronological narrative of the patient's subjective complaint(s), typically obtained using open-ended questions and frameworks like OPQRST or OLD CARTS.

OPQRST

A mnemonic used in history of present illness: Onset, Provocation/Palliation, Quality, Region & Radiation, Severity, Time.

OLD CARTS

A mnemonic used in history of present illness: Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Time, Severity.

Medical History

A component of patient history that includes diseases/diagnoses with their diagnosed dates.

Surgical History

A component of patient history that includes procedures, locations, and dates of surgeries.

Medications

A component of patient history that lists prescription (dose, route, frequency) and over-the-counter/herbal supplements.

Allergies

A component of patient history that lists food, medication, or environmental allergies with reported reactions.

Vaccinations

A component of patient history that includes childhood, boosters, and yearly vaccines received.

Social History

A component of patient history that includes information on alcohol, smoking, illicit substances, occupation, and living situation.

Family History

A component of patient history that includes inheritable conditions, cancer, and heart disease among family members.

Review of Systems (ROS)

A subjective review of each body system, highlighting pertinent positive or negative responses related to the current chief complaint/history of present illness.

Vital Signs

Objective measurements including temperature, heart rate, blood pressure, respiratory rate, and oxygenation.

Hypothermia

A condition of low body temperature (<35 deg C).

Normothermia

A condition of normal body temperature.

Hyperthermia

A condition of high body temperature (>38.0 deg C).

Thermoregulation

The maintenance of body temperature.

Tachycardia

A condition of fast heart rate, over 100 beats per minute (BPM).

Bradycardia

A condition of slow heart rate, under 60 beats per minute (BPM).

Arrhythmia/Dysrhythmia

A condition of abnormal heart rhythm.

0 (Pulse strength)

An absent pulse.

1+ (Pulse strength)

A thready/weak pulse.

2+ (Pulse strength)

A normal pulse.

3+ (Pulse strength)

A bounding pulse.

Hypotension

Low blood pressure (<100/60 mmHg).

Hypertension

High blood pressure (>140/90 mmHg).

Normotensive

Having normal blood pressure.

SBP (Systolic Blood Pressure)

The force exerted on arterial walls during systole (contraction phase of the heart beat).

DBP (Diastolic Blood Pressure)

The force exerted on arterial walls during diastole (relaxation phase of the heart beat).

Tachypneic/Tachypnea

A condition of rapid breathing (>20 breaths per minute).

Bradypneic/Bradypnea

A condition of slow breathing (<12 breaths per minute).

Hypoventilation/Hyperventilation

Pertaining to the amount of ventilation of lungs, either too little or too much.

Apnea

Cessation of breathing.

Hypoxia

Low or deficient oxygen in the tissues.

Hypoxemia

Low oxygen in the blood.

Anoxia

A condition of being without oxygen.

Inspection

The first step in examining a patient or body part, involving observation of general appearance, mental status, posture, skin, body language, and gait.

Palpation

Utilizing the sense of touch with fingertips to examine characteristics of body parts like location, size, texture, temperature, and tenderness.

Percussion

Utilizing fingers to tap a portion of the body to assess underlying tissue/structure for the presence of fluid or air, based on sound differences.

Auscultation

Listening to sounds of specific body areas (e.g., heart, lungs, abdomen) using a stethoscope to determine normal vs. abnormal sounds.

Alert and oriented x3

A patient assessment indicating awareness of person, place, and time.

Turgor (skin)

The ability for skin to return to place freely, used to assess hydration during a physical exam.

Enophthalmos

A condition where the eyeball is sunken back into the orbit.

Exophthalmos

A condition where the eyeball protrudes forward from the orbit.

Complete Blood Count (CBC)

A laboratory test that shows the makeup of blood components, counting red blood cells, white blood cells, and platelets.

Basic/Complete Metabolic Panel (BMP/CMP)

A laboratory test that indicates kidney and liver function, including electrolytes and function enzymes.

Urine Analysis (UA)

A laboratory test that measures various components of urine such as pH, specific gravity, bilirubin, glucose, ketones, protein, blood, bacteria, nitrites, and leukocytes.

Urine Culture

A laboratory test that specifies the type of bacteria present in urine and outlines which antibiotics it is sensitive to for effective treatment.

-gram

A suffix meaning 'record' (e.g., electrocardiogram).

-graphy

A suffix meaning 'process of recording' (e.g., angiography).

-lucent

A suffix meaning 'to shine' or transparent to radiation (e.g., radiolucent).

-opaque

A suffix meaning 'obscure' or impenetrable to radiation (e.g., radiopaque).

Scan

An image of an area, organ, or tissue of the body obtained by an imaging study.

X-Ray

A 2-D view of bones and cartilage, not showing ligaments or tendons, obtained in specific positions described utilizing directional terms.

Radi/o

A prefix meaning 'x-rays'.

Radiolucent

Pertaining to substances that allow x-rays to pass through easily, appearing dark on an x-ray.

Radiopaque

Pertaining to substances that obstruct the passage of x-rays, appearing white on an x-ray.

Anteroposterior (AP)

A directional term for an x-ray view where the x-ray beam travels from the front of the body to the back.

Posteroanterior (PA)

A directional term for an x-ray view where the x-ray beam travels from the back of the body to the front.

Lateral (X-ray view)

A directional term for an x-ray view taken from the side of the body.

Oblique (X-ray view)

A directional term for an x-ray view taken at an angle.

Prone

A body position where the patient is lying face down.

Supine

A body position where the patient is lying face up.

Recumbent

A body position where the patient is lying down (e.g., dorsal recumbent).

Ultrasound/Sonography

An imaging technique that produces images by sound waves/vibrations as they echo off body parts.

Son/o

A prefix meaning 'sound'.

Echo-

A prefix meaning 'a repeated sound'.

Ultra-

A prefix meaning 'beyond'.

CT Scan (Computed Tomography Scan)

An X-ray scan that works with a computer to give cross-sectional (3D) images of a specific area, showing depth.

Contrast material

Radiopaque material (e.g., Barium, Iodine) injected or ingested to better visualize certain structures like vessels during imaging.

MRI (Magnetic Resonance Imaging)

An imaging technique that utilizes a magnetic field and radio waves to produce detailed views along planes of the body, focusing on soft tissues.

Sagittal plane

A body plane that divides the body or an organ into right and left portions.

Coronal plane

A body plane that divides the body or an organ into anterior (front) and posterior (back) portions.

Transverse plane

A body plane that divides the body or an organ into superior (upper) and inferior (lower) portions.

Nuclear Medicine Scans

Diagnostic procedures that use radioactive substances to evaluate organ/tissue function and diagnose disease.

PET Scan (Positron Emission Tomography Scan)

A nuclear medicine scan that uses radioactive isotopes, a special camera, and a computer to evaluate organ/tissue function, highlighting cells with quicker metabolic functions (e.g., tumors).

Diagnosis

The identification of an illness/disease/problem, utilizing information from a patient's history, subjective, and objective data.

Differential Diagnosis

A list of possible causes/diseases/illnesses that could explain a patient's symptoms.

Plan (Medical)

The comprehensive plan of care for a patient, including decisions on further imaging, lab tests, treatment, and medication.

Disposition

The decision on where a patient will need to go for further medical care (e.g., follow-up, admit to hospital, intensive care unit).