Chapter 1: Intro to Medical Terms, Anatomy, Pathophysiology, and the Medical Record Flashcards
1
Q
what are medical terms/words comprised of?
A
root word, prefix, suffix (but like kinda. i can explain)
2
Q
Root word
A
- the base of the word
- holds the basic meaning of the word
- each medical term has at least 1 root word
- prefix, suffix, and/or combining vowels accompany it
3
Q
combining vowels
A
- attached to root words
- link to suffix or root word to the other
- most common vowels I and O
- sometimes they are dropped when suffix starts with vowel
- always placed between two root words even when second root word starts with a vowel
4
Q
A
5
Q
Prefix
A
- not all words have it
- attach to beginning to modify the meaning
- often indicates location, time, or number
6
Q
Ec-, Ecto-
A
out; outside
7
Q
End/o-
A
in; within
8
Q
Epi-
A
outer; above, on
9
Q
Ab-
A
away from
10
Q
Mes/o-
A
Middle
11
Q
Ad-
A
toward; near
12
Q
Per-
A
through
13
Q
Trans-
A
through; across
14
Q
Infra-
A
below
15
Q
Inter-
A
between
16
Q
Sub-
A
beneath; under
17
Q
Ante-
A
before; forward
18
Q
Pre-
A
before; in front of
19
Q
Post-
A
after; behind
20
Q
Mon/o
A
one; single
21
Q
Bi-
A
two, twice
22
Q
Tri-
A
three
23
Q
Quadri-
A
four
24
Q
Poly-
A
many, much
25
Suffix
- comes from latin word subfigure
- attach to end of word to modify the meaning
- not all medical terms have it
26
Common Suffixes meaning "condition of"
-ia, -ism, -sis, and -y
27
Common Suffixes to show medical specialties
-ian, -iatrics, -iatry, -ics, -ist, -logy
28
Common Suffixes for disease
-itis, -oma, -megaly, -pathy
29
-itis
inflammation suffix
30
-oma
tumor suffix
31
-megaly
enlargement suffix
32
-pathy
"disease of" suffix
33
Common Suffixes for diagnostic procedures
-gram, -graphy, -meter, -scope, -scopy
34
-gram
record of data
35
-graphy
act of recording data
36
-meter
instrument for measuring
37
-scope
instrument for reviewing or examining
38
-scopy
examination of
39
Common Suffixes for Surgery
-centesis, -desis, -ectomy, -pexy, -plasty,
-rhaphy, -stomy, -tome, -tomy, -tripsy
40
-centesis
meaning puncture tap
41
-desis
meaning binding or fusion
42
-ectomy
meaning excision; surgical removal
43
-pexy
meaning surgical fixation
44
-plasty
meaning plastic repair, plastic surgery, reconstruction
45
-rhaphy
meaning surgical repair; suture
46
-stomy
meaning surgical creation of an opening
47
-tome
meaning instrument for incising; cutting
48
-tomy
meaning incision; cutting
49
-tripsy
meaning crushing
50
Plural Endings
singular to plural
a --> ae
en --> ina
ex, ix, yx --> ices
is --> es
ma --> mata
nx (anx, inx, ynx) --> nges
on --> a
um --> a
us --> i
51
Organ Systems
-groups of organs working together to perform complex body functions
- human body contains multiple organ systems
- collection of body parts depending on one another to achieve a common objective
52
Name the organ systems
Integumentary
Respiratory
Musculoskeletal
Digestive
Cardiovascular
Urinary
Lymphatic / Immune
Reproductive (Male & Female)
Endocrine
Hematologic
Organs of Sense
53
Integument
meaning outer covering
54
Muscul/o
meaning muscles
55
Skeletal
meaning bones
56
Lymph/o
meaning lymphocyte
57
Lymphocyte
white blood cells
58
Spir/o
breathing
59
Gastr/o
stomach
60
entero/o
small and large intestine
61
What is the Anatomical Position?
- standard body position
- upright, facing forward, arms by sides, palms facing forward, parallel feet slightly apart
62
Anterior (Ventral)
toward front of the body
63
Posterior (Dorsal)
toward the back of the body
64
Medial
toward midline of the body
65
Lateral
toward side of the body
66
Proximal
nearer to a point of attachment or to a given reference point
67
Distal
farther from a point of attachment or to a given reference point
68
Superior (Cranial)
above; toward head
69
Inferior (Caudal)
below; toward the lower end of the spine
70
Superficial (External)
closer to the surface of the bdoy
71
Deep (Internal)
closer to the center of the body
72
Supine
lying face up
73
Prone
lying face down
74
Planes
- for radiological studies, the body is often cut along a flat surface
75
Sagittal
- cuts through body from front to back
- divides body into right and left sections
76
Midsagittal
- cuts through midline of body from front to back
- divides the body into EQUAL right and left sections
77
Frontal (Coronal)
- cuts at a right angle from side to side
- divides the body into front and back sections
78
Transverse (Horizontal/Axial)
- cuts horizontally through the body
- divides the body into supper and lower sections
79
Categories of the human body structure
- cells, tissues, organs, and systems
- each structure is a highly organized unit of small structures
80
Cells
- basic unit of living things
- vary in size and shape according to function
81
Cell Structures
- cell membrane
- cytoplasm
- nucleus
- chromosomes
82
Cell Membrane
forms the boundary of an individual cell
83
Cytoplasm
makes up the body of the cell
84
Nucleus
small, round, structure in the center of the cell. contains chromosomes and nucleoplasm
85
Chromosomes
- located in the nucleus
- they contain genes that determine hereditary characteristics
- linear strand made of DNA carrying genetic info
86
Tissues
group of similar cells performing a specific task
87
Types of Tissues
- muscle, nerve, connective, epithelial
88
Muscle Tissue
produces movement
89
Types of Muscle Tissue
skeletal, smooth, cardiac
90
Nerve Tissue
conducts impulses to and from the brain
91
Connective Tissue
- connects and supports various body structures such as adipose (fat) and osseous (bone)
92
Types of Connective Tissue
cartilage, bone, blood, connective tissue proper
93
Epithelial Tissue
found in the skin and lining of blood vessels, respiratory system, intestinal system, urinary tracts, and other body systems
94
Types of Epithelial Tissue / Principal Shapes
squamous (scaly), columnar, cuboidal
95
Organs
two or more kinds of tissue performing special body functions together
96
Integumentary System
- provides external protective covering over the body
- includes hair, skin, nails
97
Musculoskeletal System
- Skeleton protects organs and provides structure to the body. Blood cells form here.
-Muscles provide movement of the body
98
Immune System
body's defense system that houses the Lymphatic System
99
Lymphatic System
- crucial part of the immune system
- includes bone marrow, thymus, lympathic vessels, thoracic duct, spleen, and lymph node. Also lymphocytes
100
Respiratory System (Pulmonary)
- allows breathing and keeps blood supplied with oxygen while removing carbon dioxide
- includes nasal cavity, pharynx, larynx, trachea, bronchi, and lungs
101
Digestive System
- breaks down food for fuel to the body
- includes oral cavity, esophagus, liver, stomach, small intestines, big intestines, rectum, and anus
102
Nervous System
- controls the body response to internal and external changes
- includes brain, sensory receptors, spinal cord, and nerves
103
Endocrine System
- consists of pineal gland, pituitary gland, thyroid gland, thymus, adrenal gland, pancreas, ovaries, and testes
- system's glands secrete hormones that regulate bodily processes in coordination with nervous system
104
Neuroendocrine System
Used to refer to both Endocrine and Nervous systems as they work together
105
Cardiovascular System
- moves blood throughout the body
- includes heart and blood vessels
- helps oxygenate organs and systems
106
Male Reproductive System
- system of tubes and ducts that sperm travel through to leave the body comprised of the vas deferens, ejaculatory duct, and urethra
107
External Male Reproductive Organs
testes, penis, scrotum, epididymis
108
Internal Male Reproductive Organs
prostate glands, seminal vesicle, Cowper's gland
109
Female Reproductive System
creates hormones and responsible for fertility, menstruation, and sexual activity
110
External Female Reproductive Organs
vulva, labia majora, labia minora, clitoris, external opening to vagina (introitus), opening of urethra or urinary meatus, Skene's gland (either side of meatus), Bartholin's glands (either side of introitus)
111
Internal Female Reproductive Organs
vagina, uterus, two fallopian tubes, two ovaries, mammary glands, uterine tube
112
Organs of Sense
Eye: organ of sight
Ear: organ of hearing
113
Hematologic System
involves the blood; responsible for the production, circulation, and function of blood and its components
114
DNA
- deoxyribonucleic acid
- a molecule that carries the genetic instructions for the development, functioning, growth, and reproduction of all known organisms and many viruses.
115
RNA
- ribonucleic acid
- contained within the nucleus, transcribed from DNA by enzymes
- plays a crucial role in protein synthesis
116
Gene
- specific segment of base pairs in chromosomes
- functional unit of heredity
117
Mitosis
a cell divides and multiplies to form two cells
118
Body Cavities
- the body is not a solid structure, it has 5 cavities each contains an orderly arrangement of internal organs
- Two umbrella cavities: dorsal and ventral
119
Dorsal Cavity
- contains the cranial cavity and spinal (vertebral) cavity
120
Cranial Cavity
space inside skull or cranium that contains the brain
121
Spinal (vertebral) Cavity
space inside the spinal column containing the spinal cord
122
Ventral Cavity
contains the Thoracic (chest) Cavity, Abdominal Cavity, and Pelvic Cavity
123
Thoracic (chest) Cavity
space containing the heart, lungs, trachea, esophagus, bronchi, and thymus
124
Abdominal Cavity
space containing the lower portion of the esophagus, the stomach, intestines (excluding the sigmoid colon and rectum), kidneys, liver, gallbladder, pancreas, spleen, and ureters
- divided into four sections/quadrants: RUQ, RLQ, LUQ, LLQ
125
Pelvic Cavity
space containing the urinary bladder, certain reproductive organs, part of the large intestine, and rectum
126
Membranes
- line internal spaces of organs and tubes opening to the outside and line body cavities
- there are five types of membranes
127
Five Types of Membranes
mucous, serous, synovial, meninges, cutaneous
128
Mucous Membrane
- lines interior walls of organs and tubes opening to the outside of the body (i.e. digestive organs)
- lined with epithelium
- involved in absorption and secretion
- composed of epithelium overlaying a layer of connective tissue called lamina propria
- not every mucous membrane secretes mucous
129
Serous Membrane
- lines cavities (i.e. thoracic) and internal organs (i.e. heart)
- consists of a layer of simple squamous epithelium overlaying a layer of loose connective tissue
- supports internal organs and compartmentalizes large cavities to hinder spread of infection
- named according to organ associated with
-pleura, pericardium, peritoneum
130
Pleura
serous membrane in lungs
131
Pericardium
serous membrane in heart
132
Peritoneum
serous membrane lining abdominal cavity
133
Synovial Membrane
- lines joint cavities and are composed of connective tissue
- secrete synovial fluid into the joint cavity to lubricate ends of bones so they can move freely
134
Meninges
- type of membrane
- composed of 3 connective tissue membranes found within dorsal cavity and serve as a protective covering of brain and spinal cord
- outer layer to inside layer: dura mater, arachnoid mater, pia mater
135
What are the 3 layers that make up the meninges?
outer to inner layer
- dura mater
- arachnoid mater
- pia mater
136
Cutaneous Membrane
- forms outer covering of body
- consists of a thin outer layer of stratified squamous epithelium attached to a thicker underlying layer of connective tissue
- its fucking skin
137
Physiology
- study of how the human body operates
- helps us understand what occurs in a health and non-healthy body
138
Pathology
- study of disease
- determines the etiology, pathogenesis, morphological alterations, and the functional effects of those changes
139
Etiology
disease cause
140
Pathogenesis
process of disease development
141
Morphological Alterations
structural changes associated with the disease process
142
Homeostatis
an organism's normal state represents a physiological balance in terms of chemical, physical, and functional activities
143
Pathiophysiolgy
- study of how a disease or injury effects the body's functions
144
Disease (disorder, morbidity, illness)
- 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
- four main types of disease
- two classes of disease
145
Main Types of Disease
- infectious
- deficiency
- genetic
- physiological
146
Classes of Disease
- communicable
- non-communicable
147
Communicable Disease
spread person to person with contact with blood, bodily fluids, breathing airborne, bitten by insect
148
Non-Communicable
Not contagious/infectious, does not spread
149
Infectious Disease
disorders caused by organisms like bacteria, viruses, fungi, or parasites
150
Deficiency Disorder
Resulting from dietary deficiency of minerals, vitamins, essential nutrients, like proteins and carbohydrates
151
Genetic Disease
when a change to a gene (pathogenic variant) affects your genes or when you have the wrong amount of genetic material
152
Physiological Illness
when the body malfunctions and causes illnesses, such as diabetes, glaucoma, or asthma
153
Medical Treatment
- management and care of a patient's disease/disorder is dependent on this
- helps improve health
- treatment is divided into three categories
154
Categories of Medical Treatment
curative, palliative, and preventive
155
Curative Treatment
to cure a patient of a disease or illness
156
Palliative Treatment
to alleviate symptoms of a disease or illness
157
Preventive Treatment
to avoid or mitigate the onset or development of a disease or illness
158
The Medical Record
- all medical visits/services are documented here
- medical coder interprets this into alpha numeric codes
159
Types of Medical Records
Evaluation and Management Documentation (E/M), Operative Reports, Laboratory Reports, Radiology Reports are the most common
160
Evaluation and Management Documentation
- not specific to one medical specialty or one body system or anatomical area
- usually consists of patient evals, observations, examinations, inspections
161
Physician Methods of Patient Evals
involves observation and inspection, palpation, auscultation, percussion
162
Physician Methods of Patient Evals: Observation + Inspection
- visual eval
- mannerisms, appearance, behavior, skin, and symmetry of body
163
Physician Methods of Patient Evals: Palpation
- examination of body by tough
- body parts are palpated to feel/look for organ size and condition
164
Physician Methods of Patient Evals: Auscultation
- listening to body sounds
165
Physician Methods of Patient Evals: Percussion
- creating sounds from tapping on body areas to examine body organs and body cavities
- vibrations of sound help to identify abnormalities
166
BP
Blood pressure
167
CC
chief complaint
168
HEENT
head, eyes, ears, nose, throat
169
h/o
history of
170
HPI
history of present illness
171
Hx
history
172
NAD
no apparent distress
173
PE
physical exam
174
PERRLA
pupils equal, round, and reactive to light and accommodation. AKA normal
175
PMH
past medical history
176
pt
patient
177
R/O
rule out
178
ROSq
Review of Systems
179
WNL
within normal limits
180
ROM
range of motion
181
const.
constitution (but like only sometimes; context clues)
182
Structure of office visits
CC: reason for visit
Hx: how patient describes symptoms and which prompted the visit
PE: focused on area of CC
Assessment and Plan: determination/diagnosis (A), relieve or resolve symptoms (P)
183
S.O.A.P.
- most common format in medical records
- Subjective: CC + Hx
- Objective: PE
- Assessment: Dx
- Plan: Tx
184
The Operative Report
- note produced by provider for procedures
- completed immediately after performed surgery
- contains detailed summary of findings throughout surgery including: the procedure, any specimens removed, pre- and post-operative diagnoses, name of primary surgeon and any assistants
- divided into four main sections
185
Sections of the Operative Report
- header, indications for surgery, detail/body of procedure, findings
186
Operative Report: Header
Helps identify the following:
- patient name
- date of surgery
- preoperative Dx
- postoperative Dx
- procedure performed
- primary surgeon
- assistant surgeon(s)
- anesthesia administered
- anesthesiologist
187
Operative Report: Indications for Surgery
- medical necessity
- brief history outlining reason for procedure
188
Operative Report: Details/Body of Procedure
- specific surgery details
- determines CPT codes used to convey the surgical services performed
189
Operative Report: Findings
- final section of report
- findings upon completion of surgery
- estimated blood loss documented here
- status of patient upon surgery completion
- provides details of the whole surgery; begins with prep and approach, continues to explain findings, removal of any specimens for analysis, and/or intraoperative complications
190
Operative Report: "Time-Out"
- verify patient and procedure
