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Medical Terminology chapters 1-3 > Chapter 2 Sections Of A Health Record And Terms > Flashcards

Chapter 2 Sections Of A Health Record And Terms Flashcards

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USMLE® Step 1 flashcards
1
Q

The main reason for the patient’s visit

A

Chief complaint

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2
Q

The story of the patient’s problem

A

History of present illness

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3
Q

Description of individual body systems in order to discover any symptoms not directly related to the main problem

A

Review of systems

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4
Q

Other significant past illnesses, like high blood pressure, asthma, or diabetes

A

Past medical history

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5
Q

Any of the patient’s past surgeries

A

Past surgical history

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6
Q

Any significant illnesses that run in the patient’s family

A

Family history

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7
Q

Hey record of habits like smoking, drinking, drug abuse, and sexual practices that can impact help

A

Social history

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8
Q

It just started recently or is a sharp, severe symptom

A

Acute

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9
Q

It has been going on for a while now

A

Chronic

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10
Q

It is getting worse

A

Exacerbation

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11
Q

All of a sudden

A

Abrupt

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12
Q

To have a fever

A

Febrile

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13
Q

To not have a fever

A

Afebrile

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14
Q

More and more each day

A

Progressive

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15
Q

Not feeling well

A

Malaise

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16
Q

Something a patient feels

A

Symptom

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17
Q

Not related to the specific problem

A

Noncontributory

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18
Q

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

A

Lethargic

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19
Q

It runs in the family

A

Genetic, hereditary

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20
Q

Able to answer questions; responsive; interactive

A

Alert

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21
Q

Being aware of who he or she is, where he or she is, and the current time

A

Oriented

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22
Q

It really stands out

A

Marked

23
Q

Another way of saying normal

A

Unremarkable

24
Q

To listen

A

Auscultation

25
Q

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

A

Percussion

26
Q

To feel

A

Palpation

27
Q

Another way of saying assessment

A

Impression

28
Q

What the healthcare professional thinks the patient has

A

Diagnosis

29
Q

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

A

Differential diagnosis

30
Q

Safe

A

Benign

31
Q

Dangerous; a problem

A

Malignant

32
Q

To be getting worse

A

Degeneration

33
Q

The cause

A

Etiology

34
Q

To get better or improve; most often used when discussing cancer; this does not mean cured

A

Remission

35
Q

No no specific cause; it just happens

A

Idiopathic

36
Q

Stays in a certain part of the body

A

Localized

37
Q

All over the body or most of it

A

Systemic/generalized

38
Q

The risk of being sick

A

Morbidity

39
Q

The risk for dying

A

Mortality

40
Q

The chances for things getting better or worse

A

Prognosis

41
Q

Hidden

A

Occult

42
Q

The organism that causes the problem

A

Pathogen

43
Q

Diseased tissue

A

Lesion

44
Q

To have again

A

Recurrent

45
Q

The problem resulting from a disease or injury

A

Sequela

46
Q

Waiting for

A

Pending

47
Q

What happened to the patient at the end of the Vison; often use at the end of ED down to reference where the patient went after the visit

A

Disposition

48
Q

Literally, to unload; it has two meanings:

  1. To send home
  2. Fluid coming out of a part of the body
A

Discharge

49
Q

Preventative treatment

A

Prophylaxis

50
Q

Treating the symptoms, but not actually getting rid of the cause

A

Palliative

51
Q

Watch, keep an eye on

A

Observation

52
Q

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

A

Reassurance

53
Q

To treat the symptoms and make the patient feel better

A

Supportive care

54
Q

Extremely clean, germ-free condition; especially important during medical procedures in surgery

A

Sterile

Medical Terminology chapters 1-3 (15 decks)

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