Basic Medical Terminology

General Examination Techniques

1. Inspection – Observing the body visually for signs of illness, such as color, shape, and movement.

2. Palpation – Feeling the body with hands to assess temperature, tenderness, texture, and underlying masses.

3. Percussion – Tapping the body to evaluate the underlying structure; used to assess areas like lungs or abdomen for dullness, resonance, or tympany.

4. Auscultation – Listening to internal body sounds, such as heart, lung, and bowel sounds, often using a stethoscope.

Vital Signs & Basic Measurements

1. Heart Rate (HR) – Pulse rate, often checked at the radial or carotid artery.

2. Blood Pressure (BP) – Measured in mmHg; systolic over diastolic pressure.

3. Respiratory Rate (RR) – Breaths per minute, assessing rhythm and depth.

4. Temperature (T) – Body temperature, usually taken orally, tympanically, or rectally.

5. Oxygen Saturation (SpO2) – Measured with a pulse oximeter, indicating oxygen levels in the blood.

Common Terms for Physical Findings

Skin

1. Pallor – Pale skin, often suggesting anemia or poor circulation.

2. Cyanosis – Bluish discoloration, especially of lips and fingers, indicating low oxygen.

3. Jaundice – Yellowing of skin or eyes, usually from liver dysfunction.

4. Erythema – Redness of the skin due to increased blood flow.

5. Rash – General term for skin eruptions that could signify various conditions.

Head & Neck

1. PERRLA – Pupils Equal, Round, Reactive to Light and Accommodation; describes normal eye function.

2. Conjunctival Pallor – Pale color of the conjunctiva, suggesting anemia.

3. Jugular Venous Distension (JVD) – Enlarged jugular veins; may indicate right heart failure.

4. Goiter – Enlargement of the thyroid gland, often visible in the neck.

Chest & Cardiovascular

1. Tachycardia – Rapid heart rate, generally >100 beats per minute.

2. Bradycardia – Slow heart rate, generally <60 beats per minute.

3. Heart Murmur – An abnormal heart sound that can indicate turbulent blood flow or valve issues.

4. Gallop – Extra heart sounds, often S3 or S4, suggesting heart failure.

5. Peripheral Edema – Swelling of the extremities, typically due to fluid retention.

Lungs & Respiratory

1. Rales (Crackles) – Crackling sounds during inspiration; may indicate fluid in the lungs.

2. Wheezing – High-pitched sounds on expiration; commonly associated with asthma.

3. Rhonchi – Coarse, rattling sounds, usually due to mucus in the airways.

4. Dyspnea – Difficulty or labored breathing.

5. Orthopnea – Shortness of breath that occurs when lying flat, often due to heart failure.

Abdomen

1. Tenderness – Pain elicited on palpation, indicating potential inflammation or infection.

2. Distension – Swelling or enlargement of the abdomen.

3. Guarding – Tensing of abdominal muscles, often due to pain or discomfort.

4. Rebound Tenderness – Pain upon release of pressure, suggestive of peritoneal irritation (e.g., appendicitis).

5. Hepatomegaly – Enlarged liver, which can be palpated in the right upper quadrant.

Musculoskeletal

1. ROM (Range of Motion) – Assessing joint flexibility or limitations.

2. Crepitus – A grating or crackling sound or sensation in a joint, often due to cartilage wear.

3. Deformity – Structural abnormality of a bone or joint.

4. Effusion – Accumulation of fluid in a joint, often due to inflammation or injury.

Neurological

1. Gait – The pattern of walking; observed for stability, balance, and coordination.

2. Reflexes – Checking deep tendon reflexes to assess neurological function.

3. Paresthesia – Numbness or tingling sensation, indicating possible nerve issues.

4. Aphasia – Impairment in language ability, often due to stroke or brain injury.

5. Ataxia – Lack of muscle coordination, which can indicate neurological disorders.

Other Descriptive Terms

1. Hypotension – Abnormally low blood pressure.

2. Hypertension – High blood pressure, a risk factor for cardiovascular disease.

3. Normocephalic – A normally shaped head.

4. Afebrile – No fever present.

5. Febrile – Having a fever, often indicative of infection.

Here’s a detailed guide on common laboratory tests and EKG terms to support you in assisting with documentation and understanding patient assessments.

Laboratory Tests

Lab tests are typically categorized based on what they measure and which systems they evaluate.

1. Complete Blood Count (CBC)

   - Hemoglobin (Hb) – Measures oxygen-carrying protein in red blood cells; low levels can indicate anemia.

   - Hematocrit (Hct) – Percentage of blood volume occupied by red blood cells; assesses anemia or dehydration.

   - White Blood Cell Count (WBC) – Measures immune cells; high levels may indicate infection, while low levels may suggest immunosuppression.

   - Platelet Count (PLT) – Number of platelets; crucial for blood clotting; abnormalities can indicate bleeding disorders or bone marrow issues.

   - Differential – Breaks down WBC into types (e.g., neutrophils, lymphocytes), giving insight into infections, inflammation, or immune response.

#### 2. Basic Metabolic Panel (BMP)

   - Sodium (Na) – Electrolyte important for nerve and muscle function; imbalances may indicate dehydration or kidney issues.

   - Potassium (K) – Vital for heart and muscle function; high or low levels can lead to cardiac issues.

   - Chloride (Cl) – Works with other electrolytes to maintain fluid balance; helps assess acid-base balance.

   - Bicarbonate (HCO3) – Reflects acid-base status, often used in respiratory and metabolic disorders.

   - Blood Urea Nitrogen (BUN) – Measures waste in the blood, indicating kidney function.

   - Creatinine – Waste product measured to assess kidney function; high levels suggest kidney impairment.

   - Glucose – Blood sugar level; helps diagnose and monitor diabetes.

#### 3. Comprehensive Metabolic Panel (CMP)

   - Includes all BMP components, plus:

   - Albumin – Protein produced by the liver; low levels may indicate liver or kidney disease.

   - Total Protein – Combined levels of albumin and globulins; used to assess nutritional status.

   - Alkaline Phosphatase (ALP) – Enzyme related to liver and bone; elevated in liver disease or bone disorders.

   - Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST) – Enzymes that indicate liver cell damage.

   - Bilirubin – Waste product from red blood cells; high levels cause jaundice and suggest liver dysfunction.

#### 4. Lipid Panel

   - Total Cholesterol – Total amount of cholesterol in the blood; high levels increase heart disease risk.

   - Low-Density Lipoprotein (LDL) – "Bad" cholesterol; high levels increase risk for atherosclerosis.

   - High-Density Lipoprotein (HDL) – "Good" cholesterol; high levels are protective against heart disease.

   - Triglycerides – Type of fat in the blood; high levels can increase heart disease risk.

#### 5. Thyroid Function Tests

   - Thyroid Stimulating Hormone (TSH) – Hormone from the pituitary that stimulates the thyroid; high levels indicate hypothyroidism, low levels indicate hyperthyroidism.

   - Free T4 (Thyroxine) – Main hormone produced by the thyroid; altered levels suggest thyroid disorders.

   - Free T3 (Triiodothyronine) – Another thyroid hormone; often used when hyperthyroidism is suspected.

#### 6. Coagulation Panel

   - Prothrombin Time (PT) – Time it takes blood to clot; used to monitor blood-thinning medications and assess bleeding disorders.

   - International Normalized Ratio (INR) – Standardized PT; essential for patients on anticoagulants like warfarin.

   - Partial Thromboplastin Time (PTT) – Another clotting measure; used for patients on heparin and in diagnosing clotting disorders.

#### 7. Urinalysis (UA)

   - Appearance and Color – Provides initial information on hydration and possible kidney or liver issues.

   - Specific Gravity – Indicates urine concentration, helping assess hydration status.

   - pH – Urine acidity; can indicate metabolic or kidney issues.

   - Protein, Glucose, Ketones – Abnormal levels suggest kidney disease, diabetes, or metabolic disorders.

   - Microscopic Analysis – Looks for red or white blood cells, bacteria, or crystals, indicating infections or kidney stones.

#### 8. Arterial Blood Gases (ABG)

   - pH – Acidity level of the blood; helps assess acid-base balance.

   - PaO2 (Partial Pressure of Oxygen) – Measures oxygen level in the blood.

   - PaCO2 (Partial Pressure of Carbon Dioxide) – Reflects respiratory function.

   - HCO3 (Bicarbonate) – Reflects metabolic component of acid-base balance.

#### 9. Other Specialized Tests

   - C-Reactive Protein (CRP) – A marker of inflammation; high levels may indicate infection, inflammation, or cardiovascular disease.

   - Erythrocyte Sedimentation Rate (ESR) – Another inflammation marker; often elevated in autoimmune and chronic inflammatory conditions.

   - Hemoglobin A1c – Measures average blood glucose over 2-3 months; essential for diabetes monitoring.

### Electrocardiogram (EKG/ECG) Terminology

An EKG records the heart’s electrical activity. Here’s an overview of key terms used to describe normal and abnormal findings.

#### EKG Components

1. P Wave – Represents atrial depolarization (atrial contraction).

2. QRS Complex – Reflects ventricular depolarization (ventricular contraction).

3. T Wave – Indicates ventricular repolarization (ventricular relaxation).

4. U Wave – Occasionally seen; may indicate electrolyte imbalance if prominent.

5. PR Interval – Time from the start of the P wave to the start of the QRS complex; represents atrial to ventricular conduction.

6. QT Interval – Time from the beginning of the QRS complex to the end of the T wave; prolonged QT can lead to dangerous arrhythmias.

#### Common Abnormalities

1. Sinus Tachycardia – Fast heart rate, originating from the sinus node (>100 beats per minute).

2. Sinus Bradycardia – Slow heart rate (<60 beats per minute).

3. Atrial Fibrillation (AFib) – Irregular, often rapid heart rate due to chaotic electrical activity in the atria.

4. Atrial Flutter – Regular but rapid atrial contractions; creates a “sawtooth” pattern on the EKG.

5. Premature Ventricular Contractions (PVCs) – Extra beats originating from the ventricles; may appear as wide, irregular QRS complexes.

6. Ventricular Tachycardia (VT) – Fast, regular heart rhythm originating in the ventricles; life-threatening if sustained.

7. Ventricular Fibrillation (VF) – Chaotic ventricular activity; requires immediate defibrillation.

8. ST Elevation – Indicates myocardial infarction (heart attack); seen in ST-segment elevation MI (STEMI).

9. ST Depression – May indicate ischemia or a non-STEMI heart attack.

10. Bundle Branch Block (BBB) – A block in electrical conduction through the bundle branches; can be left (LBBB) or right (RBBB) and seen as a widened QRS.

#### EKG Leads and Perspectives

1. Limb Leads – Leads I, II, III, aVR, aVL, and aVF; provide different angles of the heart.

2. Precordial Leads – V1-V6; placed on the chest to view the heart’s electrical activity from various perspectives.

3. 12-Lead EKG – A full EKG setup showing the heart from 12 different perspectives, providing comprehensive information on heart rhythm and health.