Chapter 2 Sections Of A Health Record And Terms Flashcards
The main reason for the patient’s visit
Chief complaint
The story of the patient’s problem
History of present illness
Description of individual body systems in order to discover any symptoms not directly related to the main problem
Review of systems
Other significant past illnesses, like high blood pressure, asthma, or diabetes
Past medical history
Any of the patient’s past surgeries
Past surgical history
Any significant illnesses that run in the patient’s family
Family history
Hey record of habits like smoking, drinking, drug abuse, and sexual practices that can impact help
Social history
It just started recently or is a sharp, severe symptom
Acute
It has been going on for a while now
Chronic
It is getting worse
Exacerbation
All of a sudden
Abrupt
To have a fever
Febrile
To not have a fever
Afebrile
More and more each day
Progressive
Not feeling well
Malaise
Something a patient feels
Symptom
Not related to the specific problem
Noncontributory
A decrease in level of consciousness’s; in a medical record, this is generally an indication that the patient is really sick
Lethargic
It runs in the family
Genetic, hereditary
Able to answer questions; responsive; interactive
Alert
Being aware of who he or she is, where he or she is, and the current time
Oriented
It really stands out
Marked
Another way of saying normal
Unremarkable
To listen
Auscultation
To hit something and listen to the resulting sound or feel for the resulting vibration
Percussion
To feel
Palpation
Another way of saying assessment
Impression
What the healthcare professional thinks the patient has
Diagnosis
A list of conditions the patient may have based on the symptoms exhibited and the results of the exam
Differential diagnosis
Safe
Benign
Dangerous; a problem
Malignant
To be getting worse
Degeneration
The cause
Etiology
To get better or improve; most often used when discussing cancer; this does not mean cured
Remission
No no specific cause; it just happens
Idiopathic
Stays in a certain part of the body
Localized
All over the body or most of it
Systemic/generalized
The risk of being sick
Morbidity
The risk for dying
Mortality
The chances for things getting better or worse
Prognosis
Hidden
Occult
The organism that causes the problem
Pathogen
Diseased tissue
Lesion
To have again
Recurrent
The problem resulting from a disease or injury
Sequela
Waiting for
Pending
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
Disposition
Literally, to unload; it has two meanings:
- To send home
- Fluid coming out of a part of the body
Discharge
Preventative treatment
Prophylaxis
Treating the symptoms, but not actually getting rid of the cause
Palliative
Watch, keep an eye on
Observation
To tell the patient that the problem is not serious or dangerous
Reassurance
To treat the symptoms and make the patient feel better
Supportive care
Extremely clean, germ-free condition; especially important during medical procedures in surgery
Sterile
