Chapter 2: Acquiring Medical Language

Q

every x (e.g. Q4hr mean every 4 hours or Q3 days means every 3 days)

cv

cardiovascular

Subjective (Blue)

information received by the health care professional that is in the patient’s own words (e.g. how long the problem has been occurring, the quality of the problem, and factors that may make the problem better or worse)

Objective (Red)

data collected during the medical visit (e.g. physical exam, laboratory results, and imaging studies all contribute to the data)

Assessment (Yellow)

diagnosis or possible diagnosis by the health care provider who determines the assessment using all the information during the medical visit

Plan (Green)

treatment or follow-up for the patient (e.g. medication, physical therapy, or a procedure)

Review of Systems (ROS)

description of individual body systems in order to discover any symptoms not related to the main problem or chief complaint

Social History

a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health

First line of prescription form

Name and strength of the medicine

Second line of prescription form

Marked “Sig,” contains patient’s instructions

Third line of prescription form

Marked “Dispense,” tells the pharmacist how much medicine to give the patient

Fourth line of prescription form

Mentions how many refillls are available for the prescription

Last line of prescription form

Health care provider’s signature

Clinic Note

medical professional documents a visit

HEENT

head, eyes, ears, nose and throat

NKDA

no know drugs allergies

Consult Note

physician (usually a specialist) provides an expert opinion on a more challenging problem

Emergency Department Note

ED medical staff documents an emergency department visit

Admission Summary

hospital medical professional documents the admission of a patient to the hospital

Discharge Summary

medical professional describes when and why the patient was admitted; documents a longer stay

Operative Report

surgeon documents a surgery in detail

Daily Hospital Note/Progress Note

medical professional documents daily hospital visit

Radiology Report

radiologist explains reason for image, how image was performed, what was seen on image, radiologist’s asssessment; sometimes a recommendation

Pathology Report

pathologist provides reasons for test, what was seen on the test and an assessment

Prescription

medical professional provides directions for a medication

Acute

Started recently, is sharp, or a severe problem

Chronic

Going on for a while

Exacerbation

Getting worse

Abrupt

Suddenly

Febrile

With fever

Afebrile

Without fever

malaise

Not feeling well

Progressive

More and more

Symptom

What a patient feels

Noncontributory

Not related to this specific problem

Lethargic

Decrease in level of consciousness

Genetic

Runs in the family

Hereditary

Runs in the family

Alert

Able to answer questions, responsive, interactive

Oriented

Aware of who they are, where they are and the current time

Marked

Stands out

Unremarkable

Normal

Auscultation

Listen

Percussion

To hit something and hear resulting sound, feel resulting vibration

Palpation

Feel

Impression

Assessment

Diagnosis

Identification of a problem

Differential diagnosis

List of possible causes of a problem

Benign

Safe

Malignant

Dangerous

Degeneration

Getting worse

Etiology

The cause

Remission

Improving, but not cured

Idiopathic

No specific cause, it just happens

Localized

Stays in a certain part of the body

Systemic/generalized

All over body (or most of it)

Morbidity

Risk for being sick

Mortality

Risk for dying

Prognosis

Chance of getting better or worse

Occult

Hidden

Pathogen

Organism that causes the problem

Lesion

Diseased tissue

Recurrent

To have again

Sequelae

Problem resulting from a disease or injury

Pending

Waiting

Disposition

What happens at the end

Discharge

Flowing of a fluid OR to send home

Prophylaxis

Preventive treatment

Pallitiative

Treating the symptoms but not getting rid of the cause

Observation

Watch, keep an eye on

Reassurance

Tell the patient that the problem is not serious or dangerous

Supportive care

Treat symptoms and make the patient feel better

Sterile

Clean, germ free

Proximal

Towards the center

Distal

Away from the center

Lateral

Out to the side

Medial

Toward the middle

Ventral

The front

Antral

The front

Anterior

The front

Dorsal

The back

Posterior

The back

Cranial

Toward the top

Caudal

Toward the bottom

Superior

Above

Inferior

Below

Prone

Laying down on stomach

Supine

Laying down on back

Dorsum

Top or back of the hand or foot

Plantar

Bottom of foot

Palmar

Palm of the hand

Contralateral

Opposite side

Ipsilateral

Same side

Unilateral

One side

Bilateral

Both sides

Sagittal

Divides body right and left

Coronal

Divided body front and back

Transverse

Divides body top and bottom

CCU

coronary care unit

ECU

emergency care unit