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Acquiring Medical Language > Chapter 2 > Flashcards

Chapter 2 Flashcards

Introduction to Health Records

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USMLE® Step 1 flashcards
1
Q

acute

A

it just started

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2
Q

chronic

A

going on for a while now

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3
Q

exacerbation

A

it is getting worse

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4
Q

abrupt

A

all of a sudden

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5
Q

febrile

A

to have a fever

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6
Q

afebrile

A

to not have a fever

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7
Q

malaise

A

not feeling well

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8
Q

progressive

A

more and more each day

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9
Q

symptom

A

something a patient feels

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10
Q

noncontributory

A

not related to this specific problem

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11
Q

lethargic

A

a decrease in level of consciouness

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12
Q

genetic/hereditary

A

it runs in the family

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13
Q

alert

A

able to answer questions; responsive; interactive

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14
Q

oriented

A

being aware of who he/she is

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15
Q

marked

A

it really stands out

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16
Q

unremarkable

A

another way of saying normal

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17
Q

auscultation

A

to listen

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18
Q

percussion

A

to hit or feel something for result

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19
Q

palpation

A

to feel

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20
Q

impression

A

another way of saying assessment

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21
Q

diagnosis

A

what the health care professional things the patient has

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22
Q

differential diagnosis

A

a list of conditions the patient may have based on symptoms exhibited and the results of the exam

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23
Q

benign

A

safe

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24
Q

malignant

A

dangerous; a problem

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25
Q

degeneration

A

to be getting worse

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26
Q

etiology

A

the cause

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27
Q

remission

A

to get better or improve

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28
Q

idiopathic

A

no known specific cause; it just happens

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29
Q

localized

A

stays in a certain part of the body

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30
Q

systemic/generalized

A

all over the body (most of it)

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31
Q

morbidity

A

the risk of being sick

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32
Q

mortality

A

the risk for dying

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33
Q

prognosis

A

the chances for things getting worse or better

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34
Q

occult

A

hidden

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35
Q

pathogen

A

the organism that causes the problem

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36
Q

lesion

A

diseased tissue

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37
Q

recurrent

A

to have again

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38
Q

sequelah

A

a problem resulting from a disease or injury

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39
Q

pending

A

waiting for

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40
Q

disposition

A

what happened to the patient at the end of the visit

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41
Q

discharge

A

to unload

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42
Q

prophylaxis

A

preventive treatment

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43
Q

palliative

A

treating the symptoms, but not actually gettting rid of the cause

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44
Q

observation

A

watch, keep an eye on

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45
Q

reassurance

A

to tell the patient that the problem is not serious or dangerous

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46
Q

supportive care

A

to treat the symptoms and make the patient feel better

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47
Q

sterile

A

extremely clean, germ-free conditions

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48
Q

proximal

A

closer in to the center

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49
Q

distal

A

farther away from the center

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50
Q

lateral

A

out to the side

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51
Q

medial

A

toward the middle

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52
Q

ventral/antral/anterior

A

the front

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53
Q

dorsal/posterior

A

the back

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54
Q

cranial

A

toward the top

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55
Q

caudial

A

toward the bottom

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56
Q

superior

A

above

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57
Q

inferior

A

below

58
Q

prone

A

lying down on belly

59
Q

supine

A

lying down on back

60
Q

contralateral

A

opposite side

61
Q

ipsilateral

A

same side

62
Q

unilateral

A

one side

63
Q

bilateral

A

both sides

64
Q

dorsum

A

top of hand or foot

65
Q

plantar

A

sole of the foot

66
Q

palmar

A

palm of the hand

67
Q

sagittal

A

divides body in slices right to left

68
Q

coronal

A

divies body in slice from front to back

69
Q

transverse

A

divides the body from top to bottom

70
Q

CCU

A

coronary care unit

71
Q

ECU

A

emergency care unit

72
Q

ER

A

Emergency Room

73
Q

ED

A

emergency department

74
Q

ICU

A

intensive care unit

75
Q

PICU

A

pediatric intensive care unit

76
Q

NICU

A

neonatal intensive care unit

77
Q

SICU

A

surgical intensive care unit

78
Q

PACU

A

post-anesthesia care unit

79
Q

L&D

A

labor and delivery

80
Q

OR

A

operating room

81
Q

post-op

A

after surgery

82
Q

pre-op

A

before surgery

83
Q

VS

A

vital signs

84
Q

T

A

temperature

85
Q

BP

A

blood pressure

86
Q

HR

A

heart rate

87
Q

RR

A

respiratory rate

88
Q

Ht

A

height

89
Q

Wt

A

wight

90
Q

BMI

A

body mass index

91
Q

I/O

A

intake/output

92
Q

Dx

A

diagnosis

93
Q

DDx

A

differential diagnosis

94
Q

Tx

A

treatment

95
Q

Rx

A

prescription

96
Q

H&P

A

history and physical

97
Q

Hx

A

histroy

98
Q

CC

A

cheif complaint (main reason for the visit)

99
Q

HPI

A

history of present illness (the story of the sympstoms)

100
Q

ROS

A

review of systems (anything else not related to chief complaint)

101
Q

PMHx

A

past medical history

102
Q

FHx

A

family history

103
Q

NKDA

A

no known drug allergies

104
Q

PE

A

physical exam

105
Q

Pt

A

patient

106
Q

y/o

A

years old

107
Q

h/o

A

history of

108
Q

PCP

A

primary care provider

109
Q

f/u

A

follow up

110
Q

SOB

A

shortness of breath

111
Q

HEENT

A

head, eyes, ears, nose and throat

112
Q

PERRLA

A

pupils are equal, round, and reactive to light and accomodation

113
Q

NAD

A

no acute distress

114
Q

CV

A

cardiovascular

115
Q

RRR

A

regular rate and rhythm (heart exam)

116
Q

CTA

A

clear to auscultation (lungs)

117
Q

WDWN

A

well developed, well nourished

118
Q

A&O

A

alert and oriented

119
Q

WNL

A

within normal limits

120
Q

NOS

A

not otherwise specified

121
Q

NEC

A

not elsewhere classified

122
Q

PO

A

per os (by mouth)

123
Q

NPO

A

nil per os (nothing by mouth)

124
Q

PR

A

per rectum

125
Q

IM

A

intramuscular

126
Q

SC

A

subcutaneous

127
Q

IV

A

intravenous

128
Q

CVL

A

central venous line

129
Q

PICC

A

peripherally inserted central catheter

130
Q

Sig

A

label

131
Q

BID

A

twice daily

132
Q

TID

A

three times daily

133
Q

Q

A

every X (Q4hr-4 times daily)

134
Q

QD

A

each day

135
Q

QID

A

four times daily

136
Q

QHS

A

at night

137
Q

AC

A

before meals

138
Q

PC

A

after meals

139
Q

prn

A

as needed

140
Q

ad lib

A

as desired

Acquiring Medical Language (14 decks)

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