medical records + med term definitions

chief complaint

the most relevant medical complaint

symptoms

medical complaints

how to obtain signs during physical examination?

palpation, auscultation, perfection, inspection

what are the 9 components of a medical record?

chief complaint, symptoms, signs, presumptive diagnosis, complementary exams and medical procedures, surgical procedures, definitive/final diagnosis, prognosis, treatment

components of complementary exams and medical procedures?

clinical laboratory tests, microbiology lab tests, medical procedures— meant to complete the study

purpose of surgical procedures?

to complete the study in order to reach out to the correct diagnosis

what is definitive/final diagnosis?

name of the disease

what is prognosis?

what to expect from a particular medical condition or disease: good, poor, reserved

what are the two types of treatment?

medical/conservative and surgical

paracentesis

abdominal tap to remove excess of abdominal fluid

thoracentesis

chest drainage

amniocentesis

a prenatal procedure that involves removing a small amount of amniotic fluid by a needle from a pregnant woman’s uterus

mastopexy

a plastic surgery that fasten breasts in a pixed position to correct sagging

angiorrhaphy

suture of blood vessels

tracheotomy

an incision of the trachea through the skin and muscles in th neck that overlie the trachea

lithotripsy

surgical crushing of a calculus

hematoma

collection of blood

encephalopathy

disease of the brain

calcipenia

deficiency of calcium

dysmeonrrhoea

painful menstruation

myoglobinaemia

myoglobin in blood

anaemia

without blood (reduced oxygen carrying capacity of blood)

polycythaemia

many red cells in the blood (pathological increase in the number of red cells in the blood)

stasis

not moving

cholestasis

bile not flowing consistently

amoebiasis

individual infected with amoeba

atelectasis

collapse of the small airways as a result of blokcage

emetic

induce vomiting

antiemetic

reduce vomiting or nausea

embolism

condition where there is an emboli that has been broken off from a thrombus

priapism

sustained erection of penis

hemiparesis

half the body is weak

paraparesis

weakness in bottom part of body going down

dysphagia

difficulty of eating/swallowing

aphagia

unable to eat at all

dysphasia

difficulty speaking

dysarthria

difficulty articulating (informing) words

expressive dysphasia

unable to express oneself in words

receptive dysphasia

unable to understand words spoken

dyspnoea

difficulty breathing

apnoea

unable to breathe

tachypnoea

rapid breathing

bradypnoea

slow breathing

atrophy

wasted; malnourishment

hypertrophy

increase in size of cells

dystrophy

abnormal situation of growth/development

haematuria

blood in urine

anuria

no urine produced

pyuria

pus in urine

hypovolaemia

low blood volume