Chapter 2: Acquiring Medical Language

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171 Terms

1

Q

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

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2

cv

cardiovascular

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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)

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4

Objective (Red)

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

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5

Assessment (Yellow)

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

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6

Plan (Green)

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

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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

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8

Social History

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

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9

First line of prescription form

Name and strength of the medicine

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10

Second line of prescription form

Marked “Sig,” contains patient’s instructions

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11

Third line of prescription form

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

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12

Fourth line of prescription form

Mentions how many refillls are available for the prescription

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13

Last line of prescription form

Health care provider’s signature

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14

Clinic Note

medical professional documents a visit

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15

HEENT

head, eyes, ears, nose and throat

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16

NKDA

no know drugs allergies

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17

Consult Note

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

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18

Emergency Department Note

ED medical staff documents an emergency department visit

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19

Admission Summary

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

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20

Discharge Summary

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

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21

Operative Report

surgeon documents a surgery in detail

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22

Daily Hospital Note/Progress Note

medical professional documents daily hospital visit

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23

Radiology Report

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

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24

Pathology Report

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

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25

Prescription

medical professional provides directions for a medication

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26

Acute

Started recently, is sharp, or a severe problem

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27

Chronic

Going on for a while

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28

Exacerbation

Getting worse

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29

Abrupt

Suddenly

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30

Febrile

With fever

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31

Afebrile

Without fever

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32

malaise

Not feeling well

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33

Progressive

More and more

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34

Symptom

What a patient feels

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35

Noncontributory

Not related to this specific problem

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36

Lethargic

Decrease in level of consciousness

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37

Genetic

Runs in the family

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38

Hereditary

Runs in the family

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39

Alert

Able to answer questions, responsive, interactive

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40

Oriented

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

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41

Marked

Stands out

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42

Unremarkable

Normal

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43

Auscultation

Listen

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44

Percussion

To hit something and hear resulting sound, feel resulting vibration

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45

Palpation

Feel

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46

Impression

Assessment

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47

Diagnosis

Identification of a problem

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48

Differential diagnosis

List of possible causes of a problem

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49

Benign

Safe

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50

Malignant

Dangerous

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51

Degeneration

Getting worse

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52

Etiology

The cause

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53

Remission

Improving, but not cured

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54

Idiopathic

No specific cause, it just happens

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55

Localized

Stays in a certain part of the body

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56

Systemic/generalized

All over body (or most of it)

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57

Morbidity

Risk for being sick

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58

Mortality

Risk for dying

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59

Prognosis

Chance of getting better or worse

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60

Occult

Hidden

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61

Pathogen

Organism that causes the problem

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62

Lesion

Diseased tissue

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63

Recurrent

To have again

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64

Sequelae

Problem resulting from a disease or injury

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65

Pending

Waiting

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66

Disposition

What happens at the end

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67

Discharge

Flowing of a fluid OR to send home

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68

Prophylaxis

Preventive treatment

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69

Pallitiative

Treating the symptoms but not getting rid of the cause

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70

Observation

Watch, keep an eye on

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71

Reassurance

Tell the patient that the problem is not serious or dangerous

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72

Supportive care

Treat symptoms and make the patient feel better

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73

Sterile

Clean, germ free

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74

Proximal

Towards the center

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75

Distal

Away from the center

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76

Lateral

Out to the side

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77

Medial

Toward the middle

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78

Ventral

The front

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79

Antral

The front

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80

Anterior

The front

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81

Dorsal

The back

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82

Posterior

The back

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83

Cranial

Toward the top

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84

Caudal

Toward the bottom

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85

Superior

Above

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86

Inferior

Below

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87

Prone

Laying down on stomach

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88

Supine

Laying down on back

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89

Dorsum

Top or back of the hand or foot

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90

Plantar

Bottom of foot

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91

Palmar

Palm of the hand

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92

Contralateral

Opposite side

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93

Ipsilateral

Same side

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94

Unilateral

One side

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95

Bilateral

Both sides

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96

Sagittal

Divides body right and left

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97

Coronal

Divided body front and back

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98

Transverse

Divides body top and bottom

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99

CCU

coronary care unit

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100

ECU

emergency care unit

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