Med Hx/Terminology Flashcards
Ambi
Both sides
Con-
Together
Dys-
Bad pain difficult
Homeo-
Likeness same
Idio-
Individual
Nulli-
None, nulliparous
Andr/o-
Male, men
Anis/o-
Unequal
Arthr/o-
Joint
Ather/o-
Fatty
Blephar/o-
Palpebr/o
eyelid
Arche-
beginning
Dipsia-
thirst
Cholecyst-
gallbladder
Cheil-
lips (cheilitis, inflamed lips)
Melan/o-
black (melanoma, black tumor)
Oma-
tumor
Lysis-
destruction/paralysis
Lithiasis-
presence/formation of stones
Lexia-
reading
Polysomnography-
sleep study
Thoracentesis-
surgical drainage of pleural cavity
Hydronephrosis-
abnormal dilation of renal pelvis from accumulated urine
Arthroscopy-
visual exam of interior joint
Diagnosis of colon cancer and will need surgical removal of the colon with a permanent hole in the abdomen for drainage into a bag
Colostomy
Inflammation of the kidneys is called?
Nephritis
Enlarged heart, but that this can be a normal finding in well-conditioned athletes
Cardiomegaly
Surgical removal of uterus along with ovaries
Oophorectomy
Chronic inflammation of her uterine tubes
Salpingitis
Recording of the electrical activity of the heart
Electrocardiogram
Cells gives the red color to the blood
Erythrocytes
Inflammation of veins is termed?
Phlebitis
A tumor of blood vessels
Hemangioma
Neuropathy
a noninflammatory disease of nerves
meningomyelocele
herniation of both protective membranes and spinal cord
procedures involves injecting a radioactive element into a patient’s vein that may mark the presence of a tumor
A brain scan with MRI having the highest resolution
Baby is born without a brain
Anencephalic
Tumor of the protective membranes surrounding the brain and spinal cord
Meningioma
PT suddenly has difficulty speaking and her right arm feels stiff and weak. After four hours, she has complete return of normal speech and movement. What has occurred?
Transient ischemic attack
Abnormal or lack of development of part of the spinal cord is termed?
Myelodysplasia
Introduction of a fiberoptic instrument through the abdominal wall for diagnostic purposes
Laparoscopy
Surgical removal of an inflamed gallbladder containing stones
Cholecystectomy
Procedure to crush stones but retain the organ
Cholelithotripsy
Degeneration of the liver
Cirrhosis
Guaiac test is used to determine presence of?
Blood in the stool
Proctoscopic exams the ?
Rectum
PT from a car accident has a swollen belly and the surgeon suspects bleeding into the abdomen. He/she will puncture the belly and drain any fluid looking for blood. This procedure is termed?
Abdominocentesis
If I have GERD, I have?
Severe ‘heartburn’
Surgically creates a passageway between the gallbladder duct to the intestine.
Cholangioenterostomy
Coughing up blood from the lungs
Hemoptysis
A patient with a foreign body trapped in a lung passageway would be a candidate for which of the following procedures
Bronchoscopy
Difficult or painful to take deep breaths
Dyspnea
A special procedure to examine the blood vessels of the lungs by X-ray is called?
Pulmonary angiography
Temporary opening cut into the trachea
Tracheostomy
PT may not void urine for a period of time, because the kidneys have stopped producing urine
Anuria
Kidney “stone” is termed ?
Nephrolithiasis
Removing a kidney stone
Nephrolithotomy
Scanty or less than normal urine formation
Oliguria
Surgical fixation or return and attachment of a kidney dislodged during an auto accident would be termed?
Nephropexy
Azot/o-
nitrogenous compounds (azotemia)
Ankyl/o-
stiffness, bent, crooked
Spondy/o-
vertebrae
Chrom/o
color
Menorrhagia
abnormal heavy/long period
Metrorrhagia
irregular bleeding between menses
Oligomenorrhea
abnormal light/infrequent periods
Dysmenorrhea
cramps/painful period
Amenorrhea
absence of period in woman of reproductive age
Surgical repair of hypospadias using the foreskin of the head of the penis would be termed?
Balanoplasty
Cancer of the testicle usually requires its surgical removal. This procedure is termed
Orchidectomy
A hydrocele defines
Clear fluid filled sac partially surrounding the testis
The surgical procedure performed to relieve partial obstruction of the male urethra due to an enlarged gland at the base of the bladder is called a?
TURP
Cryptorchidism refers to
Undescended testicle (not in scrotum)
A male with testosterone deficiency may most likely be treated with which of the following agents to restore and maintain normal sexual function
Androgenic
Surgical implantation of an undescended testicle into the scrotum and anchoring it in its correct anatomical position is termed
Orchidopexy
Inflammation of the head of the penis is termed?
Balanitis
Hematosalpinx is a term describing?
Blood in a uterine tube
Surgical reconstruction of the vagina would be termed?
Colpoplasty
What is the term for painful, difficult or abnormal intercourse?
Dyspareunia
What is the term for surgical removal of the uterus, uterine tubes and ovaries?
Hysterosalpingo-oophorectomy
A woman who has two children, but had four pregnancies would be noted on her chart as?
Gravida 4, Para 2
Mammoplasty refers to?
Surgical reconstruction of a breast
Oligomenorrhea refers to?
Scanty, less than normal menstrual flow
Difficult, complicated, labor and delivery is termed?
Dystocia
A patient requires surgery to restore and reattach the uterus back in its normal anatomical position because of uterine prolapse into the vagina. This procedure is termed?
Hysteropexy
A herniation or prolapse of the urinary bladder into the vagina would be termed?
Colpocystocele
Medical terminology is based off of what language?
Latin, some Greek
Dead language that is universally understood
What are the three parts to a medical term?
Prefix
Root- base or stem
Suffix
Define Suffix
End of a root word to dictate a terms role in grammar.
Characteristics of Suffix
Dictate term’s role in grammar (noune, adjective)
Changes meaning of entire term but is translated first when defining a term without changing root’s meaning
Define Prefix
Attached to beginning of root word and changes meaning of entire term
Characteristics of Prefixes
Not required by every term and is never altered by the suffix
Typically added to indicated number, measurement, position, direction, negative and color
Named second after suffix
Define Word Root
Basic foundation of any medical term
Characteristics of Word Roots
Almost every term has one EXCEPTION- stand alone root words (lymph, cyan)
Typically joined by combining vowel- O, I E or Y
What part of a medical term never changes meaning?
Root
When combining roots to make more complex terms, they are usually joined by what vowels?
O or I
How are compound roots listed when describing anatomic organs?
Order of study or anatomic relationship
Greek Plurals of -on, -ma, -sis and -nx
- on = -a
- ma = -mata
- sis = -ses
- nx = -ges
Latin plurals of a, us, um, is, ex, ix, yx and ax?
- a = -ae
- us = -i
- um = -a
- is = -es
- ex = -ices
- ix = -ices
- yx = -ices
- ax = -aces
What happens for the provider before walking into a PTs room?
Start w/ DDx:
What can kill
Zebra
Most likely cause
What is the sequence of events during a PT encounter?
CC/HPI Meds/Allergies PMHx / SocHx / FamHx ROS PE Labs/Rads Consults Plan Prevention
3 characteristics of medicine as science?
Prolonged study of theoretical science
Observation
Reliability and reproducibility of tests
3 characteristics of medicine as art?
Interpretation of perception
Communication of ideas
Reliance on instinct
What is key to the delivery of good healthcare and achieving desireable outcomes?
Clinician-PT communication
What skill lies at the core of the art of medicine?
Interview skills
What are the four objectives of the medical interview?
Gather info about illness
Establish rapport- facilitates Dx/Tx, respnd to PT emotions
Instruct/educate- provide PT understanding of illness
Support/direct PT in treatment- motivate/inc compliance
What are the five clinician traits?
Objective Precise Sensitive Specific Reliable
Define and Characterize Objectivity
Objectivity- AKA accuracy/validity to remain unbiased and non-judgmental
Failure= poor relationship and misdiagnosis
Define and characterize Precision
AKA real value Distribution of observations around mean Precise is around mean Accuracy is around goal Imprecise is scattered
What’s the acronym/way to remember differences between accuracy and precision?
aCcurate is Correct
pRecise is Repeating
Define and characterize sensitivity
Accurately ID or pick up real cases of disease
Reflection of how many PTs with a Dz test positive
The higher a test’s sensitivity mean there will be ??? result
The higher a test’s specificity is means there will be ?? result?
More true positives
Fewer false negatives
Define and characterize reliability
Reproducibility
Characteristic of a test/finding/ procedure that allow others to obtain same result
Reliability/reproducibility is variable to what factors?
Altering version Story teller Predetermined beliefs PT recall Provider skill
Symptoms, just like tests, are subject to the rules of ? and ?
Sensitivity
Specificity
A single Sx holds low ?
Reliability
Define Empathetic response
Capacity to identify with PT and feel PTs pain as own then respond in a supportive manner to deepen emotional trust
Define Pity
Feeling of discomfort at distress of another but has condescending overtones.
Recognizes another doesn’t deserve but can’t prevent the circumstance
Define Sympathy
Feeling of concern accompanied by wish to see them better off w/out a shared perspective (sympathize w/ wounded animal but can’t empathize with it)
What are techniques of guided questioning?
Open ended to focused questions ?s to elicit graded response Series of ? one at a time Multiple choice answers Clarifying PT statements Encouraging w/ continuers Echoing
What is the first step to effective reassurance?
Identify and acknowledge PTs feelings
What are the three key characteristics to therapeutic core qualities?
Respect
Genuineness
Empathy
What do the therapeutic core values offer in PT care?
Aid in PT connection
Improves Hx taking skills
Links art/science of medicine
Better therapeutic relationships
Define Respect/Nonjudgmental
Ability to accept the PT as they are despite personal preferences
How does a skilled clinician demonstrate respect?
By attending to PTs words and providing comfort
How can clinicians show respect to PTs?
Introduction Explain PA role Ask permission to use first name Respond to concerns Inquire about PTs comfort Warn PT before touching
Define Genuineness
Ability to be yourself in relationship despite professional role
How do providers demonstrate understanding to PTs?
Listen cognitively and affectively
Convey understanding by summary/re-evaluate
Think of empathy as feedback loop even if inaccurate
What are the levels of responding?
Ignoring- lack of response
Minimizing- response w/ lesser regard than expressed
Interchangeable- respond w/ same level of intensity
Additive- recognizing expressed and not expressed feelings
Interview skills that maximize __ and ___ produce accurate data and reduces ___ and ___
Objectivity / precision
False-pos and false-negs
When was the Controlled Substance Act enacted?
1970- regulating the manufacture, importation, possession and use of certain substances
What office created the Substance abuse Act of 1970?
DEA and FDA in 1973
Schedule 2 Drugs include ?
Hydromorphone
Methadone
Meperidine
Schedule 3 drugs include?
Codeine <90mg/dose unit
Anabolic steroids
Ketamine
Schedule 4 drugs include ?
Alprazolam Carisaprodol Diazepam Lorazepam Zolpidem Tramadol
Schedule 5 drugs include?
Cough syrups with no more than 200mg of codiene per 100mL/ or 100g
When were tamper resistance prescription regulations put into place?
2008- all written Rxs required to be on tamper-resistant prescription blanks
Tamper resistant prescription paper must have a minimum of one of what three qualities?
Prevention of photocopying
Prevent modification of writing
Prevention of counterfeiting
What are the parts of a prescriber’s ID?
Pre-printed on Rx Name NPI# Institution name, address, phone # DEA # area
What info is placed into the PT ID block of an Rx?
Legal name Age/DOB Address/phone # Weight- req'd on all ped PTs in Kgs Sponsor's SSN
What are the parts of the inscription?
What goes in the Superscription?
Drug name and strength
Generic/trade name
Strength- amount per dosing unit
Rx
What info is in the Subscription section?
Info for pharmacist on dose form and number of units to dispense
Amount dispensed should be amount to complete treatment (tabs or ml)
What info is placed in the Signa section of an Rx?
Instructions to PT
Route, frequency, number of units per dosing schedule, indication for use and special instructions
What is a key note for number of Rx refills?
When do Rx refills expire?
PT will receive one more than the printed number of refills
After 12mon
All chronic meds needs to be re-evaluated how often?
Minimally- annually
It may be cost-effective to write refills for ___ supply per refill
3mon
What info is in the dispense as written?
Whether generic substitute is allowed
Usually not harmful
Cost effective for PT
PT allergy to component of generic/trade brand
Warning are typically performed automatically by pharmacist but is still who’s responsibility?
What other safety step can be indicated here?
Yours
Child proof container
What info goes in the signature block of an Rx?
Name
Title
What is a prescription calling for specific medical devices called?
What info is required to be included?
Durable Medical Equipment
Device/supplies, diagnosis and length of need
Function of a consult
Requested when management is beyond scope of referring provider and recommended for testing, diagnosis, treatment of management
During a consult, the role is dictated by whom and who maintains overall control of the PT?
Referring provider x 2
What info is included in a consult?
Summary of HPI Progress notes Problem/med list Test results Failed treatment modalities
When are normal results typically omitted from charting?
Admission HandP
What part of an admission are procedures and consults mentioned?
Admission H&P Plan
Function of the Admission Orders
Direct team in PT care and must be unambiguous due to enactment until another order/meets limit of order
What is the mnemonic for Admission Orders?
AD CAVA DIMPLS Admit Diagnosis/surgery procedure Condition Activity Vitals- how often, is weight needed? Allergies Diet- dictated by PT condition, must have something here Interventions- PT, IV, nebulizer Medications- where 2/3 of errors occur, always name drug, dose, route and frequency Procedures- bandage changes, catheters Labs- frequency/justification Special instructions
What does Ad Lib on admission notes mean?
What does BR with BRP mean?
What does OOB mean?
No restriction
Bed rest w/ bathroom
Out of bed
During an admission note, medications are listed in what specific order?
Pertaining to admit Dx
Initiated prior to admit and need to be continued
Symptomatic/PRN
What does the abbreviations hs and h.s. mean?
hs- half strength
h.s.- at bedtime
What doe QID and QOD mean?
4 x / day
Every other day
What abbreviations are not preferred?
ug- mcg H.S.- write half-strength or bedtime T.I.W.- 3 times weekly S.C./S.Q. - SubQ D/C- discharge c.c- ml AS/AD/AU- l/r/both ears
Max presentation to preceptor should last how long?
5min
What is the “headline” of the presentation?
1-2 sentences on who PT is and why they’re being seen
Social profile
Major medical issues
Chief complaint
What is “the illness” part of the preceptor report?
Major focus
Includes essential info for diagnosis and management organized into: chronologic, symptom or problem solving/hypothesis testing
Describe Symptom Characterization method of reporting?
Key Sx and description of it’s dimensions
Started, what’s it like, progression, better/worse
Describe Problem Solving method of reporting?
In conjunction with another form
Start w/ presumptive Dx and present facts to confirm/refute theory
Most difficult for students
What PMH is included in preceptor reporting?
Relevant to PTs health
How is The Exam documented?
General assessment
VS
Head to Toe only mentioning findings to establish Dx or deserve attention
What is one of the most important aspects of the entire clinical encounter?
Opening the interview
How far apart should PT, Provider and interpreter be?
3ft apart w/ interpreter sitting next to PT
How is the chief complaint documented?
PTs own words in quotations or,
Medical terminology
The chief complaint must answer what two things?
Mandatory- primary complaint and duration
Optional- age and sex
This fills S of H&P
Purpose of the HPI
Thorough elaboration of the chief complaint beginning whe PT last felt well or first experienced Sx
Describe Non-Directive questions
Open ended
Allow PT freedom to talk and offer Sx while affirming importance of Dz effect on PT
Provides “Sketch” of problem
What types of questions can fill in gaps of a “sketch” from Non-Directive questions?
Directive questions from open ended to specific questions
5Ws and How
Laundry List
Close ended
When are Close-Ended questions usefule?
Emergency
Confirmation of hypothesis
Elicit structured data
What are the downsides of close-ended questions?
Less likely to achieve correct diagnosis
Loss of PT trust
What are the mnemonics for HPI gathering
OPQRST
LOCATES
Sacred 7 + 1
What are the seven characteristics of a major Sx
Onset Location Duration Character- quality/severity Alleviating/aggravating factors Radiation Timing- triggers/frequency
When is OPQRST most often used?
Assessing Pain Onset Provocation/palliation Quality/quantity Radiation/region Severity Timing/triggers
What is the LOCATES mnemonic?
Location Onset Characteristics/quality of Sx Associated S/Sx Time Exacerbating/relieving factors Severity
What is the Sacred + 1 used for?
Ortho Type Severity Pain radiation Makes it worse/better Previous injuries/treatments Point with one finger to point of max intensity
What is a major pitfall of new providers when PTs are describing Sx?
Interpreting PT word into familiar medical conditions
What are the two techniques to clarify complaints?
Summarization- clinician feeds main info back
Confrontation- addressing discrepancies in seen/perceived
What is the “A HISSTORY” acronym for PMHx
Allergies Hospitalizations Immunizations Surgeries Screening procedures Trauma/major illness Oral meds Reproductive Hx in females Youth/childhood illnesses
Where are allergies listed in a history note?
Why are food allergies important?
PMHx
Impact on meds/vaccines or during inpatient diet
If a PT has had an allergic reaction, what is the f/u question?
What kind of reaction?
What info is gathered for Hospitalizations of a PMHx?
ANY admission
Dates/reason
Facility/Dr
Reverse chronological order, most recent working back
What info needs to be documented for surgeries in a PMHx?
Procedure, year and Dx at minimum
What info needs to be noted for medications of a PMHx?
Dose
Route
Reason
What info is needed for medications during a PMHx?
Name Dose Frequency Route Reason
A SocHx should include what info?
FLAMES Family/food Lifestyle Abuse of substances Marital/relationship Employment Support systems
What are the 6 S’s of abuse?
Substance ETOH Smoking/nicotine Security of guns at home Sexual contact Seatbelts Safety seats
What are the CAGE questions of alcohol?
Cut down
Annoyance
Guilt
Eye opener in the AM
What is the goal of asking about PTs marital status?
Detect personal relationships that are abusive to the PT
What is the SAFE acronym for the physical abuse questions?
Sage in relationship
Afraid in relationship
Friends/family aware?
Emergency safe place
What is the final part of the medical Hx?
ROS- the laundry list/screening tool
Demonstrates responsibility for total PT
What is the goal of ROS?
Reveal additional active/ongoing medical problems
Potentially serious findings during the SOR need to have what info included?
Duration
Frequency
Severity
Previously evaluated?
If a medical issue is discovered during the ROS that needs medical attention, where is the info placed?
Assessment
How to transition from interview to exam
Allow PT last word
Explain to PT
Specify where/how PT needs to be
Let PT know focus is on them
What is the single factor that is most indicative of whether a Sx goes in the Subjective or ROS?
Diagnosis
What is typically the basis for all medical management for a given PT?
Complete H&P
When is a comprehensive H&P usually obtained?
When provider sees PT for first time or,
Upon admission to hospital
Exception- ER
PT identification usually includes what info?
DOB Race Name Age Gender
Family Hx doesn’t include Spouse info except for ?
Communicability
Reproductive disorder
For H&P, ROS commonly goes back how far?
12mon, including labs
May be extended for specialties
Within each subsection of the PE documentation, what order are findings given in?
Inspection Auscultation Percussion Palpation Other- ROM, special tests Abnormal findings given first from most to least severe
Define USPSTF
US Preventive Services Task Force in 1984, independent volunteer panel of experts for evidence base recommendations about clinical services and meds
What are the USPSTF Grades meanings?
A-I
Of most recommended to least recommended
What info goes in the Subjective paragraph?
CC HPI PMH/FM/S/Hx, ROS
What info goes in the Objective paragraph?
PE Labs
What info goes in the Assessment paragraph?
Problem list
What info goes in the Plan paragraph?
Treatment plan
What is subjective data
What PT tells
Sx and Hx from CC through ROS
What is Objective data
What is detected
PE findings
Pertinent info is written in the body of a note and never in the ?
Margins
What is the most challenging aspect of documentation?
What is pertinent- if it helps rule a Dx in/out, it’s pertinent
How is the objective paragraph documented?
Head to toe in bullet format
Interventions performed during the visit are documented where?
Objective
How should the Assessment/Plan paragraph be bulleted?
Separately for one Dx, together for two or more Dx
Define arthroplast
Surgical reconstruction of joint
Define Tenorrhaphy
Surgically suturing a torn tendon
Define Myalgia
Painful aching muscles
Where are chondrocytes found?
Cartilage
Define myloma
Bone marrow tumor
Define achondroplasia
Lack of normal cartilage development
Define Encephalocele
Herniation of brain tissue out of skull
Define Pyelonephritis
Inflammation of collecting system of kidneys
Define myometritis
Inflammation of muscular layer of the uterus
Define laparohysteropexy
Surgical attachment of uterus to abdominal wall
Define salpingorrhaphy
Surgical suturing of uterine tube
Define Orchiditis
Inflammed testis
Define lipoma
Tumor of fat tissue
Define myeloma
Bone marrow tumor
Define Arthralgia
Painful joints
Define Myositis
Inflammation of muscles
Eclampsia is characterized by what 3 things?
HTN
Seizure
Coma
Prefix bio-
Prefix cata-
LIfe
Down, lower
Prefix cine-
Prefix epi-
Movement
Upon, over
Prefix de-
Prefix dia
Down, from
Through, between
Prefix eu-
Prefix im-
Well, easily
Not
Prefix juxta-
Prefix meso
Near, beside
Middle
Prefix meta
Prefix oxy
Beyond, after
Rapid, sharp
Prefix pachy
Prefix par
Thick
Apart from
Prefix per
Prefix primi
Through, intense
First
Prefix psuedo
Prefix sym/syn
False
Joined together
Prefix ultra
Beyond, excess
Acid/o
Acr/o
Aden/o
Sour, bitter
Extremity
Gland
Agglutin/o
Alges/o
Ambly/o
To clump
Pain
Dull, dim
Amylo/o
An/o
Angio/o
Starch
Anus
Vessel
Anthrac/o
Cali/o
Celi/o
Coal
Calyx
Pertaining to abdomen
Chlor/o
Cirrh/o
Cor/o
Green
Yellow, tawny
Pupil
Corpor/o
Crin/o
Crur/o
Body
Secrete
Leg, thigh
Cry/o
Crypt/o
Dendr/o
Cold
Hidden
Tree, branches
Drom/o
Eosin/o
Episi/o
Running
Red, rosy
Vulvula
Es/o
Glauc/o
Gnos/o
Within
Gray/silver
To know
Hidr/o
Iatr/o
Ichthy/o
Sweat
Pertaining to physician/treatment
Fish-like, scaly
Kary/o
Kel/o
Kerat/o
Nucleus
Fibrous growth
Hard, horny, cornea of eye
Lei/o
Leiomy/o
Mi/o
Smooth
Smooth muscle
Smaller
Mydr/o
Myring/o
Myx/o
Widen
Ear drum
Relating to mucus
Nat/i
Nat/o
Nom/o
Pertaining to birth
Birth
Relating to usage
Omphal/o
Onych/o
Orth/o
Naval
Nail
Straight correct normal
Papill/o
Phac/o
Phe/o
Resembling a nipple
Lens of eye
Dusky
Phor/o
Phren/o
Pil/o
Bearing
Diaphragm/mind
Hair
Pleg/o
Pne/o
Poikil/o
Paralysis/stroke
Breathing
Varied, irriegular
Poli/o
Presby/o
Py/o
Gray matter of NS
Old age
Pus
Pyel/o
Rach/i
Radicul/o
Renal pelvis
Spine
Root
Rhiz/o
Sarc/o
Schiz/o
Root
Flesh
Split, division
Scot/o
Sial/o
Sider/o
Darkness
Saliva
Iron, steel
Somat/o
Steat/o
Tax/o
Body
Fat
Order
Tel/e
Thec/o
Toc/o
Distance, end
Sheath, case
Child birth
Tom/o
Trich/o
Ungu/o
Cut, section
Hair
Nail
Vesic/o
Vitre/o
Xanth/o
Urinary bladder
Glassy
Yellow
