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objective
measurable findings (what the clinician observes)
Assessment
interpretation (the medical diagnosis or clinical impression based on the data)
Plan
what happens next (e.g, treatment, medication, follow-up, tests)
ACUTE vs CHRONIC
Acute (short/new)
Chronic (long-term)
ferbile vs aferbile
Ferbile (feverish)
Aferbile (not feverish)
Malaise
A general, vague feeling of discomfort, illness, uneasiness, or lack of well-being (patients might say âIâm not feeling that wellâ)
Progessive vs Exacerbation
Progressive (conditions getting worse over time)
Exacebation (something is causing that condition to get worse over time)
Symptom
subjective evidence of a disease or condition as perceived by the patient (cannot be seen, felt, or measured by an outside observer (like a doctor or nurse; entirely based on what the patient experiences and reports)
treatment
The management and care of a patient to combat a disease, disorder, or injury
Prevention
Actions or measures taken to stop a disease, injury, or health condition from occurring, progressing, or recurring
Lethargy
State of profound sluggishness, drowsiness, inactivity, of a lack of energy
genetic
Pertaining to, caused by, or relating to genes, heredity, or the transmission of traits from parents to offspring
Heredity
Genetic transmission of physical or mental characteristics, traits, or medical conditions from parents to their offspring
Noncontributory
Used to describe information in a patientâs medical history that is not relevant, significant, or helpful to the patientâs currency diagnosis or treatment
Layers of skin
epidermis, dermis, hypodermis
Epidermis
FIRST (top) layer of skin
Dermis
SECOND (middle) layer of skin
Hypodermis
THIRD (deepest) layer of the skin
Hair follicle
sac within which each hair grows
sebaceous glands
secrete sebum (oil) into the hair follicles where the hair shafts pass through the dermis
sweat glands
The glands that secrete sweat, located in the dermal layer of the skin
Melanocytes
cells that produce melanin
Keratin
Had protein material found in the epidermis, hair, and nails
Melanin
A pigment that gives the skin its color
derm/o
dermat/o
cutane/o
SKIN
adip/o
lip/o
fat
hidr/o
sweat
onych/o
NAILS
seb/o
OIL
pil/o
HAIR
trich/o
hair or hairlike
squam/o
scale
Purpose of medical language
Be clear
Communicate quickly
Provide comfort to patients
Ancient languages used in med term
Geek- first to study anatomy and developed theories about health and disease
Latin- global language of the scientific revolution (dead language - reliable to not change)
Modern Language
German
French
English
Eponyms
word that is derived from a personâs name
(ex. ALzheimerâs DIsease: Named after Dr. Alois Alzhemer, who first described the condition)
Acronyms
letter of the words (MRI, CT, ACL)
What is the order to DECODE a MED TERM
suffixâ>prefixâ>root
Prefix
modifies the root (an affix attached to the beginning of a word, base word, or stem)
root word
Subject (main part of the word)
Suffix
essential meaning (a letter or group of letters added to the end of a base or root word)
BREAKDOWN â> Hypothermia
Hyper (above normal) + therm (Heat or temperature) + ia (condition, state, or disease)
Bradycardia
Brady (slow) + card (Heart) + ia (condition or state)
Tachypnea
Tachy (fast) + pnea (Breathing or breath)
hyrd/o
water
myc/o
fungus
necr/o
death
orth/o
straight
path/o
disease
phag/o
eat, swallow
sten/o
narrowing
troph/o
development, nourishment
xen/o
foreign,strange
SOAP
subjective
objective
assessment
plan
subjective
what the patient tells you (e.g, symptoms, feelings, history, chief complaint)