Chapter 2 - Common Health Record Terms

Question 1

Acute

Answer 1

it just started recently or is a sharp, severe symptom

Question 2

Chronic

Answer 2

it has been going on for a while now

Question 3

Exacerbation

Answer 3

it is getting worse

Question 4

Abrupt

Answer 4

all of a sudden

Question 5

Febrile

Answer 5

to have a fever

Question 6

Afebrile

Answer 6

to not have a fever

Question 7

Malaise

Answer 7

not feeling well

Question 8

Progressive

Answer 8

more and more each day

Question 9

Symptom

Answer 9

something the patient feels

Question 10

Noncontributory

Answer 10

not related to this specific problem

Question 11

Lethargic

Answer 11

a decrease in level of consciousness; in a medical record this is generally an indication that the patient is really sick

Question 12

Genetic/Hereditary

Answer 12

it runs in the family

Question 13

Alert

Answer 13

able to answer questions; responsive; interactive

Question 14

Oriented

Answer 14

being aware of who he/she is, where he/she is, and the current time; a patient who is aware of all three is “oriented x 3”

Question 15

Marked

Answer 15

it stands out

Question 16

Unremarkable

Answer 16

another way of saying normal

Question 17

Auscultation

Answer 17

to listen

Question 18

Percussion

Answer 18

to hit something and listen to the resulting sound or feel for the resulting vibration

Question 19

Palpation

Answer 19

to feel

Question 20

Impression

Answer 20

another way of saying assessment

Question 21

Diagnosis

Answer 21

what the health care professional thinks the patient has

Question 22

Differential diagnosis

Answer 22

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

Question 23

Benign

Answer 23

safe

Question 24

Malignant

Answer 24

dangerous; a problem

Question 25

Degeneration

Answer 25

to be getting worse

Question 26

Etiology

Answer 26

the cause

Question 27

Remission

Answer 27

to get better or improve; most often used when discussing cancer; remission does not mean cure

Question 28

Idiopathic

Answer 28

no known specific cause; it just happens

Question 29

Localized

Answer 29

stays in a certain part of the body

Question 30

Systemic/Generalized

Answer 30

all over the body (or most of it)

Question 31

Morbidity

Answer 31

the risk for being sick

Question 32

Mortality

Answer 32

the risk for dying

Question 33

Prognosis

Answer 33

the chances for things getting better or worse

Question 34

Occult

Answer 34

hidden

Question 35

Pathogen

Answer 35

the organism that causes the problem

Question 36

Lesion

Answer 36

diseased tissue

Question 37

Recurrent

Answer 37

to have again

Question 38

Sequelae

Answer 38

a problem resulting from a disease or injury

Question 39

Pending

Answer 39

waiting for

Question 40

Disposition

Answer 40

what happened to the patient at the end of the visit; often used a t the end of ED notes to reference where the patient went after the visit (home, the ICU, normal hospital bed)

Question 41

Discharge

Answer 41

literally, to unload; it has two meanings:

1. to send home (to unload the patient form the health care setting to home)
2. fluid coming out of the part of the body (your body unloading a fluid)

Question 42

Prophylaxis

Answer 42

preventive treatment

Question 43

Palliative

Answer 43

treating the symptom, but not actually getting rid of the cause

Question 44

Observation

Answer 44

watch, keep an eye on

Question 45

Reassurance

Answer 45

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

Question 46

Supportive Care

Answer 46

to treat the symptoms and make the patient feel better

Question 47

Sterile

Answer 47

extremely clean, germ-free conditions; especially important during medical procedures and surgery