Medical Terminology and Health Records

Comprehensive practice flashcards matching vocabulary terms and definitions from Chapters 1 and 2 on medical language origins, word components, clinical health documentation, SOAP format, anatomical orientations, and medical abbreviations.

Medical Language

A specialized language used by health care professionals that allows them to be clear, communicate quickly, and provide comfort to patients.

Eponym

A word source derived from the name of a person who discovered or was associated with it, such as Lou Gehrig's disease (ALS) or Gabriello Fallopio.

Ultima

The last syllable of a medical word.

Penult

The almost-last (second-to-last) syllable in a medical word.

Antepenult

The syllable immediately before the penult (third-to-last syllable), where pronunciation emphasis usually falls in medical terms.

Root

The foundation or subject of a medical term that functions like a noun in the language of medicine.

Suffix

A word part attached to the end of a medical term that gives essential meaning to the term.

Prefix

A word part added to the beginning of a medical term when needed to further modify the root.

Combining Vowel

A vowel (most commonly the letter 'o') used to join a root to a suffix beginning with a consonant or to join two roots together.

Combining Form

The combination of a word root and a combining vowel (such as cardi/o or gastr/o).

Diminutive Suffix

A category of simple suffix (such as -icle, -ole, -ule, or -ula) that transforms a term's meaning into a smaller version of the structure.

-cele

A complex suffix describing a symptom, disease, or condition meaning hernia, or a bulging of tissue into an area where it does not belong.

-lysis

A suffix describing a symptom, disease, or condition meaning to loosen or break down.

-desis

A complex suffix indicating treatment meaning binding or surgical fixation.

-stomy

A complex suffix indicating treatment meaning the surgical creation of an opening.

-centesis

A complex suffix meaning a puncture test procedure.

SOAP Method

An acronym and organizational system for four types of medical information documented in health records: Subjective, Objective, Assessment, and Plan.

Subjective (SOAP)

The portion of a medical note consisting of information stated by the patient or caregiver (such as pain, sadness, or nausea) that cannot be empirically validated.

Objective (SOAP)

The data collected directly by the health care provider that can be seen, felt, heard, and validated, including vital signs, physical exam findings, and lab tests.

Assessment (SOAP)

The clinical analysis and interpretation of subjective and objective data performed by a health care provider to reach a diagnosis or differential diagnosis.

Plan (SOAP)

The course of action recommended by the provider regarding the patient's current health status, including orders for medication, surgery, and further tests.

Acute vs. Chronic

A sudden onset of symptoms or condition versus a problem persisting over a long period of time.

Abrupt

A subjective description of symptoms starting suddenly without warning.

Febrile vs. Afebrile

Having a fever versus having no fever.

Malaise

A general feeling of being 'yucky' or 'out of sorts.'

Progressive vs. Exacerbation

A condition that worsens continuously over time versus a situation where something specific triggers a sudden worsening.

Noncontributory

A detail or finding that does not have an effect on or contribute to the patient's disease.

Lethargic

A state characterized by a lack of energy and loss of interest.

Auscultation

An objective diagnostic technique of listening to sounds produced within the body.

Palpation

An objective physical examination technique of feeling structures of the body with the hands.

Percussion

An objective physical examination method of tapping on a surface to determine the underlying structure through sound.

Differential Diagnosis (DDx)

A list of the most likely causes of a patient's condition when a single cause is not immediately evident (often referred to as 'rule out' or R/O).

Idiopathic

Describing a disease or condition that arises spontaneously or has an unknown cause.

Morbidity

The condition of being diseased, or having an illness or loss of function in the body or mind.

Mortality

The state of being subject to death.

Prognosis

The health care provider's reasoned assessment as to how long a disease process will last or the patient's expected life duration.

Occult

Hidden or abnormal for the area in which it is found, such as occult blood in a stool sample.

Sequelae

A condition or symptoms that are the consequence of a previous disease or injury.

Disposition

What happens to the patient at the conclusion of a clinical visit or hospital course (e.g., discharged home, admitted to surgery).

Prophylaxis

Medical or health care measures taken for preventative care against disease.

Palliative Care

Relief-providing, symptom-focused care that is not curative, originated in the 1950s by Dame Cecily Saunders.

Anatomical Planes

Reference planes dividing the human body: the transverse plane (horizontal, top from bottom), sagittal plane (vertical, right from left), and coronal/frontal plane (vertical, front from back).

Anatomical Directional Opposites

Relative positional terms: proximal (closer to the trunk) vs. distal (further from the trunk); medial (closer to the center) vs. lateral (further from the center); superior (above) vs. inferior (below); anterior/ventral (toward front) vs. posterior/dorsal (toward back).

Cranial vs. Caudal

Cranial means toward the head (indicating an anterior position in the context of the trunk, head, and neck), whereas caudal means toward the tail (indicating a posterior position).

Supine vs. Prone

Lying on the back facing upward (supine) versus lying face downward (prone).

Ipsilateral vs. Contralateral

Ipsilateral means located on or controlling the same side of the body, whereas contralateral means located on or controlling the opposite side of the body.

Unilateral vs. Bilateral

Pertaining to or affecting only one side of the body versus both sides of the body.

Dorsum, Palmar, and Plantar

Dorsum refers to the back of the hand or top of the foot; palmar refers to the anterior surface/palm of the hand; plantar refers to the sole of the foot.

Pronation, Supination, Dorsiflexion, and Plantar Flexion

Pronation is rotational movement where the radius crosses over the ulna, supination returns radius and ulna parallel; dorsiflexion moves the foot upward, and plantar flexion points the foot downward.

Angular and Rotational Body Movements

Movements including flexion and extension (bending and straightening joints), abduction and adduction (moving away from and toward the midline), circumduction (circular limb movement), and rotation (turning around an axis).

Pathologist

A physician with special training in evaluating the causes and effects of disease and in laboratory medicine.

Phlebotomist

A clinical professional trained in the removal of blood from the body for diagnostic or therapeutic purposes.

Medical Transcriptionist

A healthcare clinical support professional trained in converting voice-recorded dictations of providers into written text format.

Review of Systems (ROS)

A structured description of individual body systems conducted to discover any symptoms not directly related to the patient's main problem.

PERRLA

An exam finding abbreviation indicating that pupils are equal, round, and reactive to light and accommodation.

CTA

An abbreviation used in respiratory physical examination meaning 'clear to auscultation.'

NPO

An order abbreviation derived from the Latin phrase 'nil per os,' meaning 'nothing by mouth.'

PRN

A prescription and administration timing abbreviation meaning 'as needed.'