Chapter 2: Acquiring Medical Language

studied byStudied by 0 people
0.0(0)
get a hint
hint

Q

1 / 170

encourage image

There's no tags or description

Looks like no one added any tags here yet for you.

171 Terms

1

Q

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

New cards
2

cv

cardiovascular

New cards
3

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)

New cards
4

Objective (Red)

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

New cards
5

Assessment (Yellow)

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

New cards
6

Plan (Green)

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

New cards
7

Review of Systems (ROS)

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

New cards
8

Social History

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

New cards
9

First line of prescription form

Name and strength of the medicine

New cards
10

Second line of prescription form

Marked “Sig,” contains patient’s instructions

New cards
11

Third line of prescription form

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

New cards
12

Fourth line of prescription form

Mentions how many refillls are available for the prescription

New cards
13

Last line of prescription form

Health care provider’s signature

New cards
14

Clinic Note

medical professional documents a visit

New cards
15

HEENT

head, eyes, ears, nose and throat

New cards
16

NKDA

no know drugs allergies

New cards
17

Consult Note

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

New cards
18

Emergency Department Note

ED medical staff documents an emergency department visit

New cards
19

Admission Summary

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

New cards
20

Discharge Summary

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

New cards
21

Operative Report

surgeon documents a surgery in detail

New cards
22

Daily Hospital Note/Progress Note

medical professional documents daily hospital visit

New cards
23

Radiology Report

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

New cards
24

Pathology Report

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

New cards
25

Prescription

medical professional provides directions for a medication

New cards
26

Acute

Started recently, is sharp, or a severe problem

New cards
27

Chronic

Going on for a while

New cards
28

Exacerbation

Getting worse

New cards
29

Abrupt

Suddenly

New cards
30

Febrile

With fever

New cards
31

Afebrile

Without fever

New cards
32

malaise

Not feeling well

New cards
33

Progressive

More and more

New cards
34

Symptom

What a patient feels

New cards
35

Noncontributory

Not related to this specific problem

New cards
36

Lethargic

Decrease in level of consciousness

New cards
37

Genetic

Runs in the family

New cards
38

Hereditary

Runs in the family

New cards
39

Alert

Able to answer questions, responsive, interactive

New cards
40

Oriented

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

New cards
41

Marked

Stands out

New cards
42

Unremarkable

Normal

New cards
43

Auscultation

Listen

New cards
44

Percussion

To hit something and hear resulting sound, feel resulting vibration

New cards
45

Palpation

Feel

New cards
46

Impression

Assessment

New cards
47

Diagnosis

Identification of a problem

New cards
48

Differential diagnosis

List of possible causes of a problem

New cards
49

Benign

Safe

New cards
50

Malignant

Dangerous

New cards
51

Degeneration

Getting worse

New cards
52

Etiology

The cause

New cards
53

Remission

Improving, but not cured

New cards
54

Idiopathic

No specific cause, it just happens

New cards
55

Localized

Stays in a certain part of the body

New cards
56

Systemic/generalized

All over body (or most of it)

New cards
57

Morbidity

Risk for being sick

New cards
58

Mortality

Risk for dying

New cards
59

Prognosis

Chance of getting better or worse

New cards
60

Occult

Hidden

New cards
61

Pathogen

Organism that causes the problem

New cards
62

Lesion

Diseased tissue

New cards
63

Recurrent

To have again

New cards
64

Sequelae

Problem resulting from a disease or injury

New cards
65

Pending

Waiting

New cards
66

Disposition

What happens at the end

New cards
67

Discharge

Flowing of a fluid OR to send home

New cards
68

Prophylaxis

Preventive treatment

New cards
69

Pallitiative

Treating the symptoms but not getting rid of the cause

New cards
70

Observation

Watch, keep an eye on

New cards
71

Reassurance

Tell the patient that the problem is not serious or dangerous

New cards
72

Supportive care

Treat symptoms and make the patient feel better

New cards
73

Sterile

Clean, germ free

New cards
74

Proximal

Towards the center

New cards
75

Distal

Away from the center

New cards
76

Lateral

Out to the side

New cards
77

Medial

Toward the middle

New cards
78

Ventral

The front

New cards
79

Antral

The front

New cards
80

Anterior

The front

New cards
81

Dorsal

The back

New cards
82

Posterior

The back

New cards
83

Cranial

Toward the top

New cards
84

Caudal

Toward the bottom

New cards
85

Superior

Above

New cards
86

Inferior

Below

New cards
87

Prone

Laying down on stomach

New cards
88

Supine

Laying down on back

New cards
89

Dorsum

Top or back of the hand or foot

New cards
90

Plantar

Bottom of foot

New cards
91

Palmar

Palm of the hand

New cards
92

Contralateral

Opposite side

New cards
93

Ipsilateral

Same side

New cards
94

Unilateral

One side

New cards
95

Bilateral

Both sides

New cards
96

Sagittal

Divides body right and left

New cards
97

Coronal

Divided body front and back

New cards
98

Transverse

Divides body top and bottom

New cards
99

CCU

coronary care unit

New cards
100

ECU

emergency care unit

New cards

Explore top notes

note Note
studied byStudied by 13 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 20 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 57 people
Updated ... ago
5.0 Stars(2)
note Note
studied byStudied by 12 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 24 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 164 people
Updated ... ago
4.0 Stars(1)
note Note
studied byStudied by 14 people
Updated ... ago
5.0 Stars(2)
note Note
studied byStudied by 48 people
Updated ... ago
5.0 Stars(1)

Explore top flashcards

flashcards Flashcard99 terms
studied byStudied by 23 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard22 terms
studied byStudied by 3 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard76 terms
studied byStudied by 21 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard100 terms
studied byStudied by 19 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard21 terms
studied byStudied by 79 people
Updated ... ago
3.9 Stars(7)
flashcards Flashcard172 terms
studied byStudied by 67 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard38 terms
studied byStudied by 31 people
Updated ... ago
5.0 Stars(2)
flashcards Flashcard114 terms
studied byStudied by 19 people
Updated ... ago
5.0 Stars(1)