Chp 2 Flashcards
1
Q
Acute
A
It just started recently or is a sharp, severe symptom
2
Q
Chronic
A
It has been going on for a while now
3
Q
Exacerbation
A
It is getting worse
4
Q
Abrupt
A
All of a sudden
5
Q
Febrile
A
To have a fever
6
Q
Afebrile
A
To not have a fever
7
Q
Malaise
A
Not feeling well
8
Q
Progressive
A
More and more each day
9
Q
Symptom
A
Something a patient feels
10
Q
Noncontributory
A
Not related to this specific problem
11
Q
Lethargic
A
A decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick
12
Q
Genetic/hereditary
A
It runs in the family
13
Q
Alert
A
Able to answer questions; responsive; interactive
14
Q
Oriented
A
Being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three Is “_______ x 3”
15
Q
Marked
A
It really stands out
16
Q
Unremarkable
A
Another way of saying normal
17
Q
Auscultation
A
To listen
18
Q
Percussion
A
To hit something and listen to the resulting sound or feel for the resulting vibration
19
Q
Palpation
A
To feel
20
Q
Impression
A
Another way of saying assessment
21
Q
Diagnosis
A
What the health care professional thinks the patient has
22
Q
Differential Diagnosis
A
A list of conditions the patient may have based on the symptoms exhibited and the results of the exam
23
Q
Benign
A
Safe
24
Q
Malignant
A
Dangerous; a problem
25
Degeneration
To be getting worse
26
Remission
To get better or improve; most often used when discussing cancer; remission does not mean cure
27
Idiopathic
No known specific cause; It just happens
28
Localized
Says in a certain part of the body
29
Systemic/Generalized
All over the body
30
Prognosis
The chances for things getting better or worse
31
Occult
Hidden
32
Lesion
Diseased tissue
33
Recurrent
To have again
34
Sequela
A problem resulting from a disease or injury
35
Pending
Waiting for
36
Pathogen
The organism that causes the problem
37
Morbidity
The risk for being sick
38
Mortality
The risk for dying
39
Etiology
The cause
40
Disposition
What happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit
41
Discharge
Two meanings: to send home OR fluid coming out of a part of the body
42
Palliative
Treating the symptoms, but not getting rid of the cause
43
Observation
watch, keep an eye on
44
Reassurance
to tell the patient that the problem is not serious or dangerous
45
Supportive care
to treat the symptoms and make the patient feel better
46
Sterile
Extremely clean, germ-free conditions; especially important during medical procedures and surgery
47
Prophylaxis
Preventative treatment
48
Proximal
closer in to the center
49
Distal
farther away from the center
50
Lateral
out to the side
51
Medial
toward the middle
52
Ventral/Antral/Anterior
the front
53
Dorsal/Posterior
The back
54
Cranial
Toward the top
55
Caudal
Toward the bottom
56
Superior
above
57
Inferior
Below
58
Prone
Lying down on belly
59
Supine
Lying down on back
60
Contralateral
Opposite side
61
Ipsilateral
Same side
62
Unilateral
one side
63
Bilateral
both sides
64
dorsum
the top of the hand or foot
65
plantar
the sole of the foot
66
palmar
the palm of the hand
67
Sagittal
divides the body into right and left
68
Coronal
divided the body into front and back
69
Transverse
divides the body into top and bottom
70
Physician
a skilled health care provider
71
Pediatrician
a physician with special training in caring for children
72
surgeon
a physician qualified to treat patients surgically
73
Anesthesiologist
a physician with special training in pains sedation and pain control
74
epidemiologist
a specialist in the study of the causes and distribution of diseases in populations
75
physician assistant
a midlevel health care provider who works under th license of a supervising physician
76
nurse practitioner (NP)
a nurse with postgraduate training that serves as a midlevel health care provider
77
Emergency medical technician (EMT)
specially trained in the emergency care of a patient before and/or during transport to medical facility
78
Speech therapist
specially trained in evaluation and treating problems with speech and/or swallowing
79
Occupational therapist
specially trained in evaluating and treating problems with performing daily task
80
Physical Therapist
specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury
81
Respiratory therapist
specially trained in treating patient's respiratory issues under the guidance of a health care provider
82
Dietician
specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan
83
Licensed practical nurse (LPN)/Licensed vocational nurse (LVN)
Trained and certified to provide basic care to a patient
84
Register nurse
an advanced level nurse who has completed an associate's or bachelor's degree; often assists with patient care planning and patient education
85
Medical assistant
Trained to carry out basic administrative and clinical tasks under the guidance of a health care provider
86
Pathologist
a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
87
Medical laboratory technician
trained in performing laboratory testing on bodily fluids
88
Phlebotomist
trained in the removal of blood from the body for diagnostic or therapeutic purposes
89
Radiologist
A physician specially trained in evaluating images of the body to diagnose illness or injury
90
Radiology Technician
trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
91
Ultrasonographer
Trained in performing ultrasound imaging on a patient
92
Pharmacist
trained and licensed in preparing and dispensing medicine
93
Pharmacy technician
trained to assist a pharmacist with pharmacy-related tasks
94
Patient service coordinator
Handles administrative tasks and coordinates patient care
95
Medical transcriiptionist
Trained in converting the voice-recorded dictations of health care providers into text format
96
Chief Complaint
the main reason for the patient's visit
97
History of present illness
the story of the patient's problem
98
Review of Systems
Description of individual body systems in order to discover any symptoms not directly related to the main problem
99
Past Medical History
Other significant past illnesses, like high blood pressure, asthma, or diabetes
100
Past surgical history
Any of the patient's past surgeries
101
Family History
Any significant illnesses that run in the patient's family
102
Social history
A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
103
CCU
Coronary care unit
104
ECU
emergency care unit
105
ER
emergency room
106
ED
emergency department
107
ICU
intensive care unit
108
PICU
pediatric intensive care unit
109
NICU
neonatal intensive care unit
110
SICU
surgical intensive care unit
111
L&D
Labor and delivery
112
OR
Operating Room
113
Post-Op
After surgery
114
Pre-op
Before surgery
115
R
right
116
L
left
117
B
bilateral
118
VS
vital signs
119
T
temperature
120
BP
Blood pressure
121
HR
Heart Rate
122
RR
Respiratory rate
123
Ht
height
124
Wt
Weight
125
BMI
Body Mass Index
126
I/O
Intake/Output
127
Dx
Diagnosis
128
DDx
Differential Diagnosis
129
Tx
Treatment
130
Rx
Prescription
131
H&P
History and physical
132
Hx
History
133
CC
Chief Complaint
134
HPI
History of present illness
135
ROS
Review of systems
136
PMHx
Past medical history
137
FHx
Family history
138
NKDA
no known drug allergies
139
PE
physical exams
140
Pt
Patient
141
y/o
years old
142
h/o
history of
143
PCP
Primary care provider
144
f/u
follow up
145
SOB
shortness of breath
146
SOA
shortness of air
147
HEENT
head, eyes, ears, nose, and throat
148
PERRLA
pupils are equal, round, and reactive to light and accommodation
149
NAD
No acute distress
150
CV
cardiovascular
151
RRR
regulate rate and rhythm
152
CTA
clear to auscultation (normal-sounding lungs)
153
WDWN
well-developed, well nourished
154
A&O
Alert and oriented
155
WNL
within normal limits
156
NOS
Not otherwise specified
157
NEC
not elsewhere classified
158
PO
Per os (by mouth)
159
NPO
nil per os (nothing by mouth)
160
PR
per rectum (anal)
161
IM
intramuscular
162
SC
subcutaneous
163
IV
intravenous
164
CVL
central venous line
165
PICC
peripherally inserted central catheter
166
Sig
"label"
167
BID
twice daily
168
TID
three times daily
169
Q
every x
170
QD*
each day
171
QID
four times daily
172
QHS
at night
173
AC
before meals
174
PC
after meals
175
prn
as needed
176
ad lib
as desired
