Health Record Terms Flashcards
abrupt
all of the sudden
acute
it just started recently or is a sharp, severe symptoms
afebrile
to not have a fever
chronic
it has been going on for a while now
genetic/hereditary
runs in the family
exacerbation
it is getting worse
febrile
to have a fever
lethargic
a decrease in the level of consciousness; in a medical record, this is generally an indication that the patient is really sick
noncontributory
not related to this specific problem
malaise
not feeling well
progressive
more and more each day
symptom
something a patient feels
alert
able to answer questions; responsive; interactive
auscultation
to listen
marked
it really stands out
oriented
being aware of who they are, where they are, and the current time; patient who is aware of all 3 is “oriented x 3”
palpation
to feel
percussion
to hit something and listen to the resulting sound or feel for the resulting vibration
unremarkable
normal
impression
another way of saying assessment
diagnosis
what the health care professional thinks the patient has
differential diagnosis
a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
benign
safe
malignant
dangerous; a problem
degeneration
to be getting worse
etiology
the cause
remission
to get better or improve; most often used when discussing cancer; remission does NOT mean cure
idiopathic
no known specific cause; it just happens
localized
stays in a certain part of the body
systematic
generalized
all over the body (or most of it)
morbidity
the risk of being sick
mortality
the risk of dying
prognosis
the chances for things getting better or worse
occult
hidden
pathogen
the organism that causes the problem
lesion
diseased tissue
recurrent
to have again
sequelae
a problem resulting from a disease or injury
pending
waiting for
discharge
- to send home
- fluid coming out of a part of the body
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
observation
watch; keep an eye on
pallative
treating the symptom but not actually getting rid of the cause
prophylaxis
preventative treatment
reassurance
to tell the patient that the problem is not serious or dangerous
sterile
extremely clean, germ-free conditions; especially important during medical procedures and surgery
supportive care
to treat the symptoms and make the patient feel better
distal
farther away from the center
proximal
closer in the center
lateral
out to the side
medial
toward the middle
dorsal/posterior
the back
ventral/antral/anterior
the front
caudal
toward the bottom
cranial
toward the top
inferior
below
superior
above
prone
lying down on belly
supine
lying down on back
contralateral
opposite side
ipsilateral
same side
bilateral
both sides
unilateral
one side
dorsum
top of hand or foot
palmar
palm of the hand
plantar
sole of the foot
coronal
divides body into slices front to back
sagittal
divides body into slices right to left
transverse
divides body into slices top to bottom
