Chapter 2 Flashcards
General subjective terms
Acute
Sudden onset problem
General subjective terms
chronic
long time problem
General subjective terms
abrupt
all of a sudden
General subjective terms
febrile
to have a fever
General subjective terms
afebrile
to not have a fever
General subjective terms
malaise
not feeling well
General subjective terms
progressive
worsens with time
General subjective terms
exacerbation
it is getting worse
General subjective terms
symptom
physical or mental feature indicating disease
General subjective terms
noncontributory
doesn’t have an effect on disease
General subjective terms
lethargic
no energy, loss of interest
General subjective terms
genetic/hereditary
it runs in the family
General objective terms
alert
responsive, interactive
General objective terms
oriented
aware of their surroundings, themselves, and the time
General objective terms
marked
it really stands out
General objective terms
unremarkable
another way of saying normal
General objective terms
auscultation
to listen
General objective terms
percussion
to hit something and listen to the resulting sound or feel for the resulting vibration
General objective terms
palpation
to feel
General assessment terms
impression
another way of saying assessment
General assessment terms
diagnosis
what the health care professional thinks the patient has
General assessment terms
differential diagnosis
list of conditions the patient may have based on the symptoms exhibited and the results of the exam
General assessment terms
benign
safe
General assessment terms
malignant
dangerous, a problem
General assessment terms
degeneration
to be getting worse
General assessment terms
remission
to get better or improve
most often used when discussing cancer
General assessment terms
idiopathic
no known specific cause
General assessment terms
localized
stays in a certain part of the body
General assessment terms
systemic/generalized
all over the body (or most of it)
General assessment terms
prognosis
the chances for things getting better or worse
General assessment terms
occult
hidden
General assessment terms
lesion
diseased tissue
General assessment terms
recurrent
to have again
General assessment terms
sequela
a problem resulting from a disease or injury
General assessment terms
pending
waiting for
Public health
pathogen
the organism that causes the problem
Public health
morbidity
the risk of being sick
Public health
mortality
the risk for dying
Public health
etiology
the cause
General plan terms
disposition
what happened to the patient at the end of the visit
General plan terms
discharge
“to unload”
used to send home, fluid coming out of a part of the body
General plan terms
palliative
treating the symptoms, but not actually getting rid of the cause
General plan terms
observation
watch, keep an eye on
General plan terms
reassurance
to tell the patient that the problem is not serious or dangerous
General plan terms
supportive care
to treat the symptoms and make the patient feel better
General plan terms
sterile
extremely clean, germ-free conditions
Public health
prophylaxis
preventive treatment
Opposites
proximal
closer in the center
Opposites
distal
farther away from the center
Opposites
lateral
out to the side
Opposites
medial
toward the middle
Opposites
ventral/antral/anterior
the front
Opposites
dorsal/posterior
the back
Opposites
cranial
toward the top
Opposites
caudal
toward the bottom
Opposites
superior
above
Opposites
inferior
lying down on belly
Opposites
prone
lying down on belly
Opposites
supine
lying down on back
Opposites
contralateral
opposite side
Opposites
ipisilateral
same side
Opposites
unilateral
one side
Opposites
bilateral
both sides
Opposites
dorsum
the top of the hand or foot
Opposites
plantar
the sole of the foot
Opposites
palmar
the palm of the hand
Body planes
sagittal
divides the body into right and left
Body planes
coronal
divides the body into front and back
Body planes
transverse
divides the body into top and bottom
Health professionals
physician
a skilled health care provider who attended and graduated medical school
Health professionals
pediatrician
a physician with special training in caring for children
Health professionals
surgeon
a physician qualified to treat patients surgically
Health professionals
anesthesiologist
a physician with special training in pain sedation and pain control
Health professionals
epidemiologist
a specialist in the study the causes and distribution of disease
Health professionals
physician assistant (PA)
a midlevel health care provider who works under the license of a supervising physician
Health professionals
nurse practitioner (NP)
a nurse with postgraduate training that serves as a midlevel health care provider
Health professionals
emergency medical technician (EMT)
specially trained in the emergency care of a patient before and/or during transport to medical facility
Health professionals
speech therapist
specially trained in evaluating and treating problems with speech and/or swallowing
Health professionals
occupational therapist
specially trained in evaluating and treating problems with performing daily activities at home, school, or work
Health professionals
physical therapist
specially trained in evaluating and treating physical impairments including disabilities or recovering from an injury
Health professionals
respiratory therapist
specially trained in treating patient’s respiratory issues under the guidance of a health care provider
Health professionals
dietician
specially trained in evaluating the nutritional status of a patient and developing an appropiate diet plan
Health professionals
licensed practical nurse (LPN) + licensed vocational nurse (LVN)
trained and certified to provide basic care to a patient
Health professionals
registered nurse (RN)
an advanced level nurse who has completed an associate’s or bachelor’s degree, often assists with patient care planning and patient education
Health professionals
medical assistant
trained to carry out basic administrative and clinical tasks under the guidance of a health provider
Laboratory and pathology
pathologist
a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
Laboratory and pathology
medical laboratory technician
trained in performing laboratory testing on bodily fluids
Laboratory and pathology
phlebotomist
trained in the removal of blood from the body for diagnostic or therapeutic purposes
Radiology
radiologist
a physician specially trained in evaluating images of the body to diagnose illness or injury
Laboratory and pathology
radiology technician
trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
Laboratory and pathology
ultrasonographer
trained in performing ultrasound imaging on a patient
Pharmacy
pharmacist
trained and licensed in preparing and dispensing medicine
Pharmacy
pharmacy technician
trained to assist a pharmacist with pharmacy-related tasks
Clinical support
patient service coordinator
handles administrative tasks and coordinates patient care
Clinical support
medical transcriptionist
trained in converting the voice-recorded dictations of health care providers into text format
Sections of a health record
chief complaint
the main reason for the patient’s visit
Sections of a health record
history of present illness
the story of the patient’s problem
Sections of a health record
review of systems
description of individual body systems in order to discover any symptoms not directly related to the main problem
Sections of a health record
past medical history
other significant past illnesses, like high blood pressure, asthma, or diabetes
Sections of a health record
past surgical history
any of the patient’s past surgeries
Sections of a health record
Family history
any significant illnesses that run in the patient’s family
Sections of a health record
social history
a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
Health care facility abbreviations
CCU
coronary care unit
Health care facility abbreviations
ECU
emergency care unit
Health care facility abbreviations
ER
emergency room
Health care facility abbreviations
ED
emergency department
Health care facility abbreviations
ICU
intensive care unit
Health care facility abbreviations
PICU
pediatric intensive care unit
Health care facility abbreviations
NICU
neonatal intensive care unit
Health care facility abbreviations
SICU
surgical intensive care unit
Health care facility abbreviations
PACU
post-anesthesia care unit
Health care facility abbreviations
L&D
labor and delivery
Health care facility abbreviations
OR
operating room
Health care facility abbreviations
post-op
after surgery
Health care facility abbreviations
pre-op
before surgery
Symbols
♂
male
Symbols
♀
female
Symbols
(R)
right
Symbols
(L)
left
Symbols
(B)
bilateral (both sides)
Symbols
↑
increased
Symbols
↓
decreased
Abbreviations common on health records
VS
vital signs
Abbreviations common on health records
T
temperature
Abbreviations common on health records
BP
blood pressure
Abbreviations common on health records
HR
heart rate
Abbreviations common on health records
RR
respiratory rate
Abbreviations common on health records
Ht
height
Abbreviations common on health records
Wt
weight
Abbreviations common on health records
BMI
body mass index
Abbreviations common on health records
I/O
intake/output of fluid
Abbreviations common on health records
Dx
diagnosis
Abbreviations common on health records
DDx
differential diagnosis
Abbreviations common on health records
Tx
treatment
Abbreviations common on health records
Rx
prescription
Abbreviations common on health records
H&P
history and physical
Abbreviations common on health records
Hx
history
Abbreviations common on health records
CC
chief complaint
Abbreviations common on health records
HPI
history of present illness
Abbreviations common on health records
ROS
review of systems
Abbreviations common on health records
PMHx
past medical history
Abbreviations common on health records
FHx
family history
Abbreviations common on health records
NKDA
no known drug allergies
Abbreviations common on health records
PE
physical exam
Abbreviations common on health records
Pt
patient
Abbreviations common on health records
y/o
years old
Abbreviations common on health records
h/o
history of
Abbreviations common on health records
PCP
primary care provider
Abbreviations common on health records
f/u
follow up
Abbreviations used for symptoms or exam findings
SOB
shortness of breath
Abbreviations used for symptoms or exam findings
HEENT
heads, eyes, ears, nose, and throat
Abbreviations used for symptoms or exam findings
PERRLA
pupils are equal, round, and reactive to light and accomodation
Abbreviations used for symptoms or exam findings
NAD
no acute distress
Abbreviations used for symptoms or exam findings
CV
cardiovascular
Abbreviations used for symptoms or exam findings
RRR
regular rate and rhythm
Abbreviations used for symptoms or exam findings
CTA
clear to auscultation
Abbreviations used for symptoms or exam findings
WDWN
well developed, well nourished
Abbreviations used for symptoms or exam findings
A&O
alert and oriented
Abbreviations used for symptoms or exam findings
WNL
within normal limits
Abbreviations used for symptoms or exam findings
NOS
not otherwise specified
Abbreviations used for symptoms or exam findings
NEC
not elsewhere classified
Abbreviations associated with orders and administering medicine
PO
per os (by mouth)
Abbreviations associated with orders and administering medicine
NPO
nil per os (nothing by mouth)
Abbreviations associated with orders and administering medicine
PR
per rectum (anal)
Abbreviations associated with orders and administering medicine
IM
intramuscular
Abbreviations associated with orders and administering medicine
SC
subcutaneous (under the skin)
Abbreviations associated with orders and administering medicine
IV
intravenous
Abbreviations associated with orders and administering medicine
CVL
central venous line
Abbreviations associated with orders and administering medicine
PICC
peripherally inserted central catheter
Abbreviations associated with orders and administering medicine
Sig
short for signa, “for label”
Timing abbreviations
BID
twice daily, bis in die
Timing abbreviations
TID
three times daily, ter in die
Timing abbreviations
Q
every x
e.g., Q4hr = every 4 hours
Timing abbreviations
QD
daily
Timing abbreviations
QID
four times daily, quater in die
Timing abbreviations
QHS
at night, quaque hora somni
Timing abbreviations
AC
before meals, ante cibum
Timing abbreviations
PC
after meals, post cibum
Timing abbreviations
prn
as needed, per re nata
