Medical Terminology

Medical Terminology: The language of medicine is a universal language used by healthcare professionals to document the services and procedures they perform.

  • Derived from ancient Greeks & Romans

Root: The base of a word. The word part holding the fundamental meaning of the medical term ,and each medical term contains at least one root or base word.

  • A word can have more than one root

  • A root may be used for different meanings based on the body system referred to

  • Combining Vowels: attached to root words to link the root word with the suffix or link one root word to another. 

  • Prefix: A prefixed is attached to the beginning of a word to modify or alter its meaning.

    • Not all medical terms contain a prefix.

    • Often indicate location, time, or number.

  • Suffix: subfigure, or fasten underneath. A suffix is attached to the end of a word to modify its meaning.

    • Not all medical terms have a suffix

    • Frequently indicate the procedure, condition, disorder, or disease

    • Often used for diagnostic or surgical procedures

    • Include medical specialties

    • Suffix Conditions: -ia, -ism, -sis, and -y

    • Suffix Medical Specialties: -ian, -iatrics, -iatry, -ics, -ist, and -logy

    • Suffix Diseases: -itis, -oma, -megaly, -pathy

Anatomy: The human body contains multiple organ systems.

Organ System: A collection of body parts depending on one another to achieve a common objective

  • Integumentary - The largest organ. Skin, hair, and nails. External protection covering body.

  • Musculoskeletal - Muscles, ,joins, tendons, and ligaments providing movement, form, strength, and protection. Skeletal & Muscular system protects vital organs and provides structure to the body.

  • Cardiovascular - Heart and the blood vessels. Work together to move blood throughout the body. Blood provides nutrients and oxygen to all organs and tissues within the body.

  • Lymphatic - Lymph vessels, lymph nodes. bone marrow, thymus, thoracic duct, spleen. Collects excess fluid from the interstitial spaces (spaces between tissues) and returns it to the heart. This is the body's immune system - houses lymphocytes (white blood cells)

  • Respiratory - Nose, nasal cavity, pharynx, larynx, trachea, bronchi, smaller branches, lungs, and alveoli. Exchanges carbon dioxide for oxygen, breathing. Also referred to as pulmonary system. Keeps blood supplied with oxygen.

  • Digestive - Aka Gastrointestinal system. GI tract and its ancillary organs make up the digestive system. Begins at the mouth, ends at the anus. Oral cavity, esophagus, liver, stomach, small intestines, large intestines, rectum, and anus.

    • GI (Gastrointestinal) aka Alimentary Tract

    • Winds through body and encompasses many structures and organs

    • Breaks down food (mechanically and chemically) into miniscule or molecular size for absorption into the blood stream and use at the cellular level.

  • Urinary - Two kidneys, two ureters, a bladder, and a urethra. Produces urine for excretion of metabolic wastes and fluid and electrolyte balance. Provides transportation and temporary storage of urine prior to urination.

  • Reproductive -

    • Male - Male genital system.

      • External: Testes, epididymis, scrotum, and penis.

      • Internal: prostate gland, seminal vesicles, Cowper's glands, and penis. Tubes and ducts that sperm travel through to leave the body is comprised of vas deferens, ejaculatory duct, and urethra.

    • Female - Female genital system.

      • External: Vulva, labia majora and minora, clitoris, external opening of the vagina (introitus), opening of the urethra (urinary meatus), Skene's glands, Bartholin's glands.

      • Internal: vagina, uterus, two fallopian tubes, and two ovaries

  • Nervous - Brain, sensory receptors, spinal cord, and nerves. Enormous network of nerve fibers traversing the body. Composed of central and peripheral portions. Controls the body's response to internal and external changes.

    • Brain & Spinal Cord are Central Nervous System (CNS)

    • Cranial & spinal nerves are Peripheral Nervous System (PNS)

  • Organs of Sense -

    • Eye = Sight

    • Ear = hearing. Works in tandem with the auditory nerves sending auditory impulses to the temporal lobes of the cerebrum. They form the auditory apparatus.

  • Endocrine -  Glands located throughout the body producing various hormones that regulate bodily processes in coordination with the nervous system. Pineal gland, pituitary gland, thyroid gland, thymus, adrenal gland, pancreas, ovaries, and testes.

    • Neuroendocrine System = Nervous System + Endocrine System

  • Hematologic - Hemic system involves the blood

  • Immune - Body's defense mechanism

Anatomical Position & Planes - The standard body position. Upright, forward facing, with arms by the side and palms facing forward. Feet are parallel and slightly apart.

  • Anterior (ventral) - Toward the front of the body

  • Posterior (dorsal) - Toward the back of the body

  • Medial - Toward the midline of the body

  • Lateral - Toward the side of the body

  • Proximal - Nearer to the point of attachment or to a given reference point

  • Distal - Farther from the point of attachment or from a given reference point

  • Superior (cranial) - Above, toward the heard

  • Inferior (Caudal) - Below, toward the lower end of the spine

  • Superficial (external) - Closer to the surface of the body

  • Deep (internal) - Closer to the center of the  body

  • Supine - Lying face up

  • Prone - Lying face down

Radiological Planes - the body is often cut along a flat surface called a plane.

  • Sagittal - Cuts through the body from font to back and divides the body into right and left sections

  • Midsagittal - Cuts through the midline of the body from front to back and divides the body into equal right and left sections

  • Frontal (coronal) - Cuts at a right angle to the midline, from side to side, and divides the body into front (anterior) and back (posterior) sections

  • Transverse (horizontal)(axial) - Cuts horizontally through the body and separates the body into upper (superior) and lower (inferior) sections

Structure of the Human Body:

  1. Cells

  2. Tissues

  3. Organs

  4. Systems

Cells - Basic unit of all living things. Human anatomy is composed of cells varying in size and shape according to function.

  • Cell membrane forms the boundary of a cell

  • Cytoplasm makes up the body of a cell

  • Nucleus is the small, round structure in the center of a cell.

  • Chromosomes are in the nucleus of the cell. Contain genes that determine hereditary characteristics

Cell Membrane - Surrounds and protects individual cell.

Nucleus - Small, round structure within the cell containing chromosomes and nucleoplasm (deoxyribonucleic acid - DNA & ribonucleic acid - RNA)

Chromosome - Linear strand made of DNA carrying genetic information

Cytology - Study of cells including the formation, structure, and the function of cells

RNA (Ribonucleic Acid) - Contained within the nucleus, is transcribed from DNA by enzymes and plays a crucial role in protein synthesis.

Gene - Specific segment of base pairs in chromosomes; functional unit of heredity

Mitosis - cells divide and multiply to form two cells

Tissue - A group of similar cells performing a specific task.

  • Muscle tissue produces movement

  • Nerve tissue conducts impulses to and from the brain

  • Connective tissue connects and supports various body structures: Adipose (fat) and Osseous (Bone). 4 types:

    • Proper

    • Cartilage

    • Bone

    • Blood

  • Epithelial tissue is found in the skin and lining of the blood vessels, respiratory, intestinal, urinary tracts, and other body systems

Organs  - Two or more kinds of tissue, together performing special body functions.

Organ Systems - groups of organs working together to perform complex body functions.

Body Cavities - 5 cavities with an orderly arrangement of organs

  1. Cranial Cavity (Dorsal Cavity): Space inside skull, or cranium, containing brain

  2. Spinal (vertebral canal) Cavity (Dorsal Cavity): Space inside the spinal column containing the spinal cord

  3. Thoracic/Chest Cavity (Ventral Cavity): Space containing heart, lungs, esophagus, trachea, bronchi, and thymus

  4. Abdominal Cavity (Ventral Cavity): Space containing lower portion of esophagus, stomach, intestines (excluding rectum & colon), kidneys, liver, gallbladder, pancreas, spleen, and ureters.

    1. Divided into 4 sections:

      1. RUQ - Right Upper Quadrant

      2. LUQ - Left Upper Quadrant

      3. RLQ - Right Lower Quadrant

      4. LLQ - Left Lower Quadrant

  5. Pelvic Cavity (Ventral Cavity): Space containing urinary bladder, certain reproductive organs, part of large intestine and rectum

Membranes - Line the internal spaces of organs and tubes opening to the outside, and line body cavities . 5 types:

  1. Mucous Membranes - Line interior walls of the organs and tubes opening to the outside of the body.

    1. Ex: digestive, respiratory, urinary, and reproductive sytems

    2. Lined with epithelium overlaying a layer of connective tissue called lamina propria.

    3. Involved in absorption and secretion

    4. Not every mucous membrane secretes mucous 

  2. Serous Membranes - Line cavities including the thoracic cavity and internal organs (heart)

    1. Layer of epithelium overlaying a layer of loose connective tissue

    2. Support internal organs and compartmentalize the large cavities to hinder spread of infection

    3. Membrane for lungs = pleura

    4. Membrane for heart = pericardium

    5. Membrane for abdominal cavity = peritoneum

  3. Synovial Membranes - Line cavities and are composed of connective tissue. Secrete synovial fluid into the joint cavity, this lubricates the ends of bones so they can move freely.

  4. Meninges - 3 connective tissue membranes within the dorsal cavity to protect brain and spinal cord. Outer to inside layers:

    1. Dura Mater (Outer)

    2. Arachnoid Mater (middle)

    3. Pia Mater (inside)

  5. Cutaneous Membrane - Forms outer covering of the body that consists of stratified squamous epithelium attached to a thicker underlying layer of connective tissue called the cutaneous membrane AKA Skin.

Physiology - The study of how the human body operates

  • Chemistry, physics, foundation of basic biological processes, like how molecules react in cells and how organ systems work together.

Pathology - The study of disease.

  • Determines the disease cause and understands the processes of its development (pathogenesis), the structural changes associated with the disease process (morphological alterations), and the functional effects of those changes.

Homeostasis - Physiological balance. An organism's normal state.

Pathophysiology - Disrupted physiology due to disease.

  • Determining the illness's source (etiology)

  • Understanding the processes of its development (pathogenesis)

  • Structural changes associated with the disease process (morphological changes), and functional outcomes of these changes

Disease - Any adverse change from an organism's normal structural, functional, or social condition that is accompanied by specific signs and symptoms and changes in function from physical damage.

AKA - DISORDER; MORBIDITY: ILLNESS

4 Types:

  1. Infectious Disease: caused by organisms, like bacteria, viruses, fungi, or parasites

  2. Deficiency Disease: resulting from a dietary deficiency of minerals, vitamins, essential nutrients, like proteins or carbohydrates

  3. Genetic Disease: When a change to a gene (pathogenic variant) affects your genes or when you have the wrong amount of genetic material

  4. Physiological Disease: When the body malfunctions and causes illness, such as diabetes, glaucoma, or asthma1

Communicable - Spreads from person to another through things like contact with blood & bodily fluids, breathing in an airborne virus, or being bitten by an insect

Noncommunicable - Noninfectious health condition that cannot be spread from person to person to person

Medical Treatment:

Curative - to cure a patient of disease or illness

Palliative - To alleviate symptoms of a disease or illness

Preventative - To avoid or mitigate the onset or development of a disease or illness

Medical Record - Anytime you are seen by a medical provider, the visit or service is documented in a medical record

  • Evaluation & Management (E/M) Documentation

    • Service related to the entire body. Not specific.

    • Visual evaluation, Palpation (touch) examination, Auscultation (listening), & Percussion *creating sounds from tapping on body areas to examine - vibrations help identify abnormalities

    • Abbreviations used during E/M Documentation

  • Operative reports - A note produced by a healthcare professional for procedures they provide

    • Must be written or dictated immediately after procedure performed and must contain a detailed summary of findings throughout the Surgery

      • Procedure performed

      • Specimens removed

      • Pre- and post-operative diagnoses

      • Names of the primary performing surgeon and assistants

    • Divided into 4 sections -

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      • indications for surgery - provides brief history outlining reasons for procedure (medical necessity)

      • detail/body of procedure - specific details of Sx

        • This will determine the CPT Code

      • findings - completion of surgery. Estimated blood loss and patient status upon completion.

  • Radiology reports

  • Laboratory reports

 

Medical Records format - SOAP:

  • Subjective

  • Objective

  • Assessment

  • Plan

 

Medical Coder - The primary responsibility of a medical coder is to interpret the medical record documentation into alpha numeric codes