History and physical
written or dictated by admitting physician; details patient’s history, results of physician’s examination, initial diagnoses, and physician’s plan of treatment
physician’s orders
complete list of care, medications, tests, and treatments physician orders for patient
Nurse’s notes
record of patients care throughout the day; includes vital signs, treatment specifics, patient’s response to treatment and patient’s condition
consultation reports
reports given by specialists whom physician and asked to evaluate patient
Ancillary reports
reports from various treatments and therapies patient has received, such as rehabilitation, social services, and respiratory therapy
Diagnostic reports
results of diagnostic tests performed on patients, principally from clinical lab and medical imaging
Informed consent
document voluntarily signed by patient or a responsible party that clearly describes purpose, methods, procedures, benefits, and risk of diagnostic or treatment procudure
operative report
report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical procedure itself, and how patient tolerated procedure
anesthesiologist’s report
relates details regarding substances given to patient, patient’s response to anesthesia and vital signs during surgery
pathologist’s report
report given by pathologist who studies tissue removed from patient
discharge summary
comprehensive outline of patient’s entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient’s response, final diagnosis, and follow-up plans
Chemical name
Describes the molecular structure of a drug
Generic name
the official name of a drug (Ibuprofen)
Brand name
proprietary name or trademark name of a drug (Advil)
muscular, epithelial, connective, nervous
tissue types
skeletal muscle
muscular tissue subtype that connects muscle to bone; voluntary movement
smooth muscle
muscular tissue subtype that surrounds internal organs; involuntary movement
cardiac muscle
muscular tissue subtype that pumps the hear; involuntary movement
connective tissue
cartilage and tendons are an example of what tissue type
neurons
nervous tissue is composed of
epithelial tissue
lines internal organs and serves as a covering for the skin
sagittal plane
divides body into right and left portions
frontal plane
divides body into front and back halves
transverse plane
divides body into top and bottom
skin
largest organ of the body
protecting, hosing nerve receptors, secreting fluids, regulate body temp
purpose of skin
sweat and sebaceous
two types of skin glands
epidermis
skin layer composed of stratified squamous epithelium cells, no blood supply, no connective tissue
melanocytes
special cells that produce the black pigment melanin
dermis
another name for the corium, middle layer of skin, means “true skin”, has excellent blood supply, composed of connective tissue and collagen fibers
subcutaneous layer
a continuous layer of fat that separates the dermis from deeper tissue, composed of lipocytes, acts as insulation
epidermal
pertaining to above skin
hypodermic
pertaining to below skin
intradermal
pertaining to within skin
dermal
pertaining to skin
hyperhidrosis
abnormal condition of excessive sweat
anhidrosis
abnormal condition of no sweat
erythroderma
condition of having reddened or flushed skin
melanoderma
increased skin pigmentation
leukoderma
having skin that appears white because normal skin pigment is absent
erythroderma
red skin
axial skeleton, appendicular skeleton
two division of the human skeleton
head, neck, spin, chest, and trunk
axial skeleton includes the bones of what parts of the body
pectoral girdle, upper extremities, pelvic girdle, and lower extremities
appendicular skeleton contains bones from what parts of the body
closed fracture
fracture in which there is no open skin wound; also called simple fracture
colles’ fracture
common type of wrist fracture
comminuted fracture
fracture in which bone is shattered, splintered, or crushed into many smaller pieces or fragments
compound fracture
fracture in which bone has broken through skin; also called open fracture
compression fracture
fracture involving loss of height of a vertebral body; may be result of trauma, but in older people, especially women, may be caused by condition like osteoporosis
fracture, FX, Fx
broken bone
greenstick fracture
fracture in which there is an incomplete break
impacted fracture
fracture in which bone fragments are pushed into each other
oblique fracture
fracture at an angle to bone
pathologic fracture
fracture caused by diseased or weakened bone
spiral fracture
fracture in which fracture line spirals around shaft of bone; can be caused by twisting injuring and is often slower to heal than other types of fractures
stress fracture
slight fracture caused by repetitive, low-impact forces, like running
transverse fracture
complete fracture that is straight across bone at right angles to long axis of bone
abduction
movement away from midline of body
adduction
movement toward midline of the body
flexion
act of bending or being bent
extension
movement that brings limb into or toward a straight condition
dorsiflexion
backward bending, as of hand or foot
plantar flexion
bending sole of foot; pointing toes downward
eversion
turning outward
inversion
turning inward
pronation
to turn downward or backward
supination
turning the palm or food upward
elevation
to raise body part
depression
downward movement, opposite of elevation
circumduction
movement in a circular direction from central point
opposition
moving thumb away from palm
rotation
moving around a central axis
endocardium
inner layer of the heart lining the heart chambers
myocardium
thick muscular middle layer of the heart
epicardium
outer layer of the heart
pericardium
the heart is enclosed within a double-layered pleural sac called?
SA node
pacemaker, where the electrical impulses begin. Wave of electricity travels through the atria, causing them to contract
arteries
large, thick-walled vessels that carry the blood away from the heart
aorta
largest artery; carries oxygenate blood to all the body systems
arterioles
smallest of the arteries; deliver blood to the capillaries
capillaries
network of tiny blood vessels; allows diffusion of the oxygen and nutrients from the blood into the body tissues
veins
carry blood back to the heart
veins
do arteries of veins have thinner walls?
superior and inferior vena cava
the two largest veins
venules
smallest of veins
angiitis
inflammation of vessel
embolus
obstruction of blood vessel by blood clot that has broken off from thrombus
infarct
area of tissue within an organ that is going through necrosis
cardiomegaly
enlarged heart
fibrillation
extremely serious arrythmia characterized by abnormal quivering
aneurysm
weakness in wall of artery resulting in localized widening artery
hypertension
high blood pressure
phlebitis
inflammation of vein
auscultation
listening to sounds by stethoscope
angiogram
X-ray record of vessel taken during angiography
electrocardiogram
record of procedure using ultrasound to visualize internal cardiac structures
CABG
open heart surgery in which blood vessel from another location in body is grafted to route blood around blocked coronary artery
CAD
insufficient blood supply to heart muscle due to obstruction of one or more coronary arteries
CCU
coronary care unit
CHF
condition of heart in which there is reduced outflow of blood from left side of heart because left ventricle myocardium has become too weak to efficiently pump blood