Week 2: Chapter 1 - Intro to Medical Terminology

Building Medical Terms from Word Parts:

word root
- ie: wood root = “cardi” (meaning heart)
  - cardiogram ( record of the heart)
prefix
- ie: prefix = “peri-” (meaning around)
  - pericardium (around the heart)
suffix
- ie: suffix = “-itis” (meaning inflammation)
  - carditis (inflammation of the heart)
combining vowel
- ie: “o”
  - cardi-o-my-o-pathy (heart muscle disease)

Word Root

root word: foundation of term
gives general sense of word’s meaning
refers to body system, part OR describe an action
medical terms can have more than one root or none
- ie: osteoarthritis
  - two word roots = osteo, arthri
  - suffix = -itis
- ie: hyperthrophy
  - prefix = hyper-
  - suffix = trophy
  - no word root

Combining Vowels

combining vowels: make possible to combine several words
usually “o”
- sometimes “i” or ““e”
used between two word roots OR between word root and suffix that starts with consonant
NOT used if suffix begins with a vowel
- ie: arthritis, not arthroitis
IS used if suffix begins with consonant
- ie: arthroscope, not arthrscope
used between two word roots, even if second word root begins with vowel
- ie: gastroenteritis, not gastrenteritis
Common combining forms:
- when writing word root by itself, combining form is typically used
  - written in form “word root/combining vowel”
- ie: cardi/o: heart
  - arthr/o: joint
  - gastr/o: stomach
  - bi/o: life
  - carcin/o: cancer
  - cis/o: to cut
  - dermat/o: skin
  - enter/o: small intestine
  - gynec/o: female
  - hemat/o: blood
  - immun/o: immunity or protection
  - laryng/o: voice box
  - nephr/o: kidney
  - neur/o: nerve
  - ophthalm/o: eye
  - ot/o: ear
  - path/o: disease
  - pulmon/o: lung
  - rhin/o: nose

Prefixes

prefixes: added to beginning of term
add meaning to term, such as:
- location of organ, number of parts, time (frequency)
  - ie:
    - sub- = below
    - mono- = one
    - post- = after
not all medical terms have prefixes
when written by itself, add hyphen
ie:
- a- / an- = without
- anti- = against
- auto- = self
- brady- = slow
- de- = without
- dis- = apart from
- dys- = painful, difficult, abnormal
- endo- = within, inner
- epi- = above
- au- = normal
- ex- = outward
- extra- = outside of
- hetero- = different
- homo- = same
- hyper- = excessive
- in- = not, inward
- inter- = between
- intra- = within
- macro- = large
- micro- = small
- neo- = new
- non- / un- = not
- para- = beside, abnormal, two like parts of a pair
- per- = through
- peri- = around
- post- = after
- pre- / pro- = before
- pseudo- = false
- re- = again
- retro- = backward, behind
- sub- = under
- syn- = together
- tachy- = fast
- trans- = across
- ultra- = beyond
ie of number prefixes:
- bi- = two
- hemi = half
- mono- = one
- multi- / poly- = many
- nulli- = none
- pan- = all
- quadri- / tetra- = four
- semi- = partial, half
- tetri- = three

Suffixes

suffixes: added to end of term
- add meaning to term, such as:
  - condition
    - ie: -algia = pain
  - disease
    - -itits = inflammation
  - procedure
    - -ectomy = surgical removal
  - all medical terms have suffix - only mandatory word part
  - when written by itself, add hyphen before (precedes suffix)
    - -algia / -dynia = pain
    - -logy =
    - -cyte = cell
    - -cele = protrusion
    - -ectasis = dilation
    - -gen = that which protrudes
    - -genesis = produces
    - -genic = producing
    - -ia = condition
    - -iasis = abnormal condition
    - -ism = state of
    - -itis = inflammation
    - -logical = pertaining to study of
    - -logist = one who studies
    - -logy = study of
    - -lytic = descruction
    - -malacia = abnormal softening
    - -megaly = enlarged
    - -oma = tumor, mass
    - -opsy = view of
    - -osis = abnormal condition
    - -pathy = disease
    - -plasm = formation
    - -plegia = paralysis
    - -ptosis = drooping
    - -rrhage = abnormal flow
    - -rrhagia = abnormal flow condition
    - -rrhexis = rupture
    - -sclerosis = hardening
    - -stenosis = narrowing
    - -therapy = treatment
    - -trophy = development
adjective suffixes: used to change a root into a complete word
- translate to “pertaining to”
- new word created by adding suffix can be used to modify another word
  - ie:
    - -ac
    - -al
    - -an
    - -ar
    - -ary
    - -atic
    - -ael
    - -iac
    - -ic
    - -ical
    - -ile
    - ine
    - -ior
    - -nic
    - -ory
    - -ose
    - -ous
    - -tic
- ie:
  - gastr/o = stomach
  - -ic = pertaining to
    - gastr + -ic = gastric: pertaining to stomach
  - gastric ulcer: ulcer found in stomach
Surgical Suffixes examples:
- -centesis: puncture to withdraw fluid
- -ectomy = surgical removal
- -ostomy = surgically create an opening
- -otomy = cutting into
- -pexy = surgical fixation
- -plasty = surgical repair
- -rrhaphy = suture
- -tome = instrument to cut

Procedural suffixes examples:
- -gram = record
- -graphy = process of recording
- -meter = instrument for measuring
- -metry = process of measuring
- -scope = instrument for viewing
- -scopic = pertaining to visually examining
- -scopy = process of visually examining

Word Building

word building: putting words together to form new terms
- begins with knowing meaning of word parts and selecting correct ones
- must remember rules regarding location of each word part
  - ie:
    - prefix: hypo- = below or under
    - word root: derm/o = skin
    - suffix: -ic = pertaining to
      - combine to form a term = hypodermic (pertaining to under the skin)

Interpreting Medical Terms

interpreting terms: translating terms, dividing terms into word parts
- ie: gastroenterology (study of stomach and small intestine)
  - gastr / o / enter / o / logy
    - gastr = stomach
    - o = combining vowel
    - enter = small intestine
    - o = combining vowel
    - -logy = study of

Pronunciation

pronunciation differs according to place and education
ask for spelling
stressed syllables are in capital letters
- ie: pericarditis (per ih car D Y E tis)

Spelling

only one correct way to spell a term
changing one letter can change meaning of word
- ie: adduction (moving away) vs. adduction (moving towards)
  - ileum (small intestine) vs. ilium (hip bone)

Singular and Plural Endings

greek and latin words have different rules than english language
- General rules for plurals:
  - Word ends in:
    - -a
      - singular: vertebra
      - plural: vertebrae
    - -ax
      - singular: thorax
      - plural: thoraces
    - -ex / -ix
      - singular: appendix
      - plural: appendices
    - -is
      - singular: metastasis
      - plural: metastases
    - -ma
      - singular: scaroma
      - plural: sarcomata
    - -nx
      - singular: phalanx
      - plural: phalanges
    - -on
      - singular: ganglion
      - plural: ganglia
    - -um
      - singular: ovum
      - plural: ova
    - -us
      - singular: nucleus
      - plural: nuclei
    - -y
      - singular: biopsy
      - plural: biopsies

Abbreviations

commonly used in medical fields to save time but can be confusing
if confused, spell out term
do not use own personal abbreviations

The Medical Record:

medical record details:
- patient’s day to day
- type and time of services provided
- patient response to treatment
- all personnel with patient contact complete appropriate reports
medical record department ensures all documents are present, complete, signed and in order
EMR: electronic medical record (software program)
- can be analyzed and monitored to detect / prevent potential errors
- easily accessed and shared between healthcare providers
- reduces repeating tests unnecessarily
- reduces inadvertent medication errors
common elements of medical record:
- history and physical:
  - written by admitting physician
  - details patient’s history, exam results, initial diagnosis, and plan of treatment
- physician’s order:
  - ordered by the doctor
  - provides a complete list of care, medications, tests, and treatments
- nurse’s notes:
  - completed by nursing staff to record the patient’s care throughout the day
  - includes vitals, treatment specifics, patient’s response to treatment, and patient’s condition
- physician’s progress notes:
  - physician’s daily record of patient’s condition
  - generally incudes results of physical exam, summary of test results, updating assessments and diagnoses, and further plans of treatment
- Consultation reports:
  - given by a specialist when the physician asks for a patient evaluation
- Ancillary Reports:
  - from various treatments and therapies (PT, OT, speech therapists, respiratory therapists, dietitians, social services workers, etc.)
  - may include rehabilitation, social services, respiratory therapy, dietetics
- Diagnostic reports:
  - include results of all diagnostic testing performed on the patient
  - often written by lab or medical imaging department
- Informed consent:
  - document signed voluntary by the patient or responsible party
  - clearly describes purpose, methods, procedures, benefits, and risks of procedure
  - intent: make procedure clear to the patient
- Operative report:
  - from surgeon detailing an operation
  - includes pre- and post-operative diagnosis, specific details of procedure, and how the patient tolerated the procedure
Anesthesiologist Report:
- provides details of any drugs given to patient during surgery
- includes patient response to anesthesia an vital signs
Pathologist’s Report:
- report given by a pathologist who studies tissue removed from the patient
Discharge summary:
- outlines patient’s entire hospital stay
  - includes condition at admission, admitting diagnosis, test results or treatment, patient’s response, final diagnosis and follow up plan

Healthcare Settings

Acute care or general hospital: provides serves to diagnose or treat diseases for short period of time
specialty care hospital: provide care for specific type of disease
- ie: psychiatric hospital or children’s hospital
nursing home / long term care facilities: provide longterm car for pt who need extra time to recover before going home or care for those who cannot care for themselves
urgent care centers: walk-in clinics that provide immediately needed care not requiring serves of ER
- often used by pts who cannot get appt with PCP or do not have PCP
ambulatory care center / surgical centers / outpatient clinics: provide services to patients who do not need overnight care or offer simple surgeries, therapies, or diagnostic testing
physician’s office: individual or group of doctors that provide diagnostic and treatment services in an office setting
health maintenance organization (HMO): group of PCPs, specialists, and other healthcare professionals that provide a wide range of services in a pre-paid system
home health care: agencies that provide nursing, therapy, personal care, or housekeeping services in pt’s home
Rehabilitation centers: provide physical and occupational therapy in inpatient and outpatient settings
hospices: organized groups of health workers that provide supportive treatment to terminally ill patients and their families
- do not need certain time to live - only need to be diagnosed with terminally ill disease

Confidentiality

any info or record relating to pt is considered privileged
healthcare workers have moral and legal responsibility to keep all info private
proper auth must be signed by pt before any info can be released
Health Insurance Portability and Accountability Act (HIPAA): (1996) set federal standards for protecting records and medical information

Medication

brand name: A company's trademark name for a drug