Chapter 2 Flashcards

(180 cards)

1
Q

General subjective terms

Acute

A

Sudden onset problem

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2
Q

General subjective terms

chronic

A

long time problem

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3
Q

General subjective terms

abrupt

A

all of a sudden

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4
Q

General subjective terms

febrile

A

to have a fever

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5
Q

General subjective terms

afebrile

A

to not have a fever

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6
Q

General subjective terms

malaise

A

not feeling well

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7
Q

General subjective terms

progressive

A

worsens with time

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8
Q

General subjective terms

exacerbation

A

it is getting worse

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9
Q

General subjective terms

symptom

A

physical or mental feature indicating disease

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10
Q

General subjective terms

noncontributory

A

doesn’t have an effect on disease

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11
Q

General subjective terms

lethargic

A

no energy, loss of interest

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12
Q

General subjective terms

genetic/hereditary

A

it runs in the family

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13
Q

General objective terms

alert

A

responsive, interactive

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14
Q

General objective terms

oriented

A

aware of their surroundings, themselves, and the time

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15
Q

General objective terms

marked

A

it really stands out

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16
Q

General objective terms

unremarkable

A

another way of saying normal

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17
Q

General objective terms

auscultation

A

to listen

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18
Q

General objective terms

percussion

A

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

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19
Q

General objective terms

palpation

A

to feel

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20
Q

General assessment terms

impression

A

another way of saying assessment

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21
Q

General assessment terms

diagnosis

A

what the health care professional thinks the patient has

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22
Q

General assessment terms

differential diagnosis

A

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

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23
Q

General assessment terms

benign

A

safe

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24
Q

General assessment terms

malignant

A

dangerous, a problem

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25
# General assessment terms degeneration
to be getting worse
26
# General assessment terms remission
to get better or improve | most often used when discussing cancer
27
# General assessment terms idiopathic
no known specific cause
28
# General assessment terms localized
stays in a certain part of the body
29
# General assessment terms systemic/generalized
all over the body (or most of it)
30
# General assessment terms prognosis
the chances for things getting better or worse
31
# General assessment terms occult
hidden
32
# General assessment terms lesion
diseased tissue
33
# General assessment terms recurrent
to have again
34
# General assessment terms sequela
a problem resulting from a disease or injury
35
# General assessment terms pending
waiting for
36
# Public health pathogen
the organism that causes the problem
37
# Public health morbidity
the risk of being sick
38
# Public health mortality
the risk for dying
39
# Public health etiology
the cause
40
# General plan terms disposition
what happened to the patient at the end of the visit
41
# General plan terms discharge
"to unload" | used to send home, fluid coming out of a part of the body
42
# General plan terms palliative
treating the symptoms, but not actually getting rid of the cause
43
# General plan terms observation
watch, keep an eye on
44
# General plan terms reassurance
to tell the patient that the problem is not serious or dangerous
45
# General plan terms supportive care
to treat the symptoms and make the patient feel better
46
# General plan terms sterile
extremely clean, germ-free conditions
47
# Public health prophylaxis
preventive treatment
48
# Opposites proximal
closer in the center
49
# Opposites distal
farther away from the center
50
# Opposites lateral
out to the side
51
# Opposites medial
toward the middle
52
# Opposites ventral/antral/anterior
the front
53
# Opposites dorsal/posterior
the back
54
# Opposites cranial
toward the top
55
# Opposites caudal
toward the bottom
56
# Opposites superior
above
57
# Opposites inferior
lying down on belly
58
# Opposites prone
lying down on belly
59
# Opposites supine
lying down on back
60
# Opposites contralateral
opposite side
61
# Opposites ipisilateral
same side
62
# Opposites unilateral
one side
63
# Opposites bilateral
both sides
64
# Opposites dorsum
the top of the hand or foot
65
# Opposites plantar
the sole of the foot
66
# Opposites palmar
the palm of the hand
67
# Body planes sagittal
divides the body into right and left
68
# Body planes coronal
divides the body into front and back
69
# Body planes transverse
divides the body into top and bottom
70
# Health professionals physician
a skilled health care provider who attended and graduated medical school
71
# Health professionals pediatrician
a physician with special training in caring for children
72
# Health professionals surgeon
a physician qualified to treat patients surgically
73
# Health professionals anesthesiologist
a physician with special training in pain sedation and pain control
74
# Health professionals epidemiologist
a specialist in the study the causes and distribution of disease
75
# Health professionals physician assistant (PA)
a midlevel health care provider who works under the license of a supervising physician
76
# Health professionals nurse practitioner (NP)
a nurse with postgraduate training that serves as a midlevel health care provider
77
# Health professionals emergency medical technician (EMT)
specially trained in the emergency care of a patient before and/or during transport to medical facility
78
# Health professionals speech therapist
specially trained in evaluating and treating problems with speech and/or swallowing
79
# Health professionals occupational therapist
specially trained in evaluating and treating problems with performing daily activities at home, school, or work
80
# Health professionals physical therapist
specially trained in evaluating and treating physical impairments including disabilities or recovering from an injury
81
# Health professionals respiratory therapist
specially trained in treating patient's respiratory issues under the guidance of a health care provider
82
# Health professionals dietician
specially trained in evaluating the nutritional status of a patient and developing an appropiate diet plan
83
# Health professionals licensed practical nurse (LPN) + licensed vocational nurse (LVN)
trained and certified to provide basic care to a patient
84
# Health professionals registered nurse (RN)
an advanced level nurse who has completed an associate's or bachelor's degree, often assists with patient care planning and patient education
85
# Health professionals medical assistant
trained to carry out basic administrative and clinical tasks under the guidance of a health provider
86
# Laboratory and pathology pathologist
a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
87
# Laboratory and pathology medical laboratory technician
trained in performing laboratory testing on bodily fluids
88
# Laboratory and pathology phlebotomist
trained in the removal of blood from the body for diagnostic or therapeutic purposes
89
# Radiology radiologist
a physician specially trained in evaluating images of the body to diagnose illness or injury
90
# Laboratory and pathology radiology technician
trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
91
# Laboratory and pathology ultrasonographer
trained in performing ultrasound imaging on a patient
92
# Pharmacy pharmacist
trained and licensed in preparing and dispensing medicine
93
# Pharmacy pharmacy technician
trained to assist a pharmacist with pharmacy-related tasks
94
# Clinical support patient service coordinator
handles administrative tasks and coordinates patient care
95
# Clinical support medical transcriptionist
trained in converting the voice-recorded dictations of health care providers into text format
96
# Sections of a health record chief complaint
the main reason for the patient's visit
97
# Sections of a health record history of present illness
the story of the patient's problem
98
# Sections of a health record review of systems
description of individual body systems in order to discover any symptoms not directly related to the main problem
99
# Sections of a health record past medical history
other significant past illnesses, like high blood pressure, asthma, or diabetes
100
# Sections of a health record past surgical history
any of the patient's past surgeries
101
# Sections of a health record Family history
any significant illnesses that run in the patient's family
102
# Sections of a health record social history
a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
103
# Health care facility abbreviations CCU
coronary care unit
104
# Health care facility abbreviations ECU
emergency care unit
105
# Health care facility abbreviations ER
emergency room
106
# Health care facility abbreviations ED
emergency department
107
# Health care facility abbreviations ICU
intensive care unit
108
# Health care facility abbreviations PICU
pediatric intensive care unit
109
# Health care facility abbreviations NICU
neonatal intensive care unit
110
# Health care facility abbreviations SICU
surgical intensive care unit
111
# Health care facility abbreviations PACU
post-anesthesia care unit
112
# Health care facility abbreviations L&D
labor and delivery
113
# Health care facility abbreviations OR
operating room
114
# Health care facility abbreviations post-op
after surgery
115
# Health care facility abbreviations pre-op
before surgery
116
# Symbols ♂
male
117
# Symbols ♀
female
118
# Symbols (R)
right
119
# Symbols (L)
left
120
# Symbols (B)
bilateral (both sides)
121
# Symbols ↑
increased
122
# Symbols ↓
decreased
123
# Abbreviations common on health records VS
vital signs
124
# Abbreviations common on health records T
temperature
125
# Abbreviations common on health records BP
blood pressure
126
# Abbreviations common on health records HR
heart rate
127
# Abbreviations common on health records RR
respiratory rate
128
# Abbreviations common on health records Ht
height
129
# Abbreviations common on health records Wt
weight
130
# Abbreviations common on health records BMI
body mass index
131
# Abbreviations common on health records I/O
intake/output of fluid
132
# Abbreviations common on health records Dx
diagnosis
133
# Abbreviations common on health records DDx
differential diagnosis
134
# Abbreviations common on health records Tx
treatment
135
# Abbreviations common on health records Rx
prescription
136
# Abbreviations common on health records H&P
history and physical
137
# Abbreviations common on health records Hx
history
138
# Abbreviations common on health records CC
chief complaint
139
# Abbreviations common on health records HPI
history of present illness
140
# Abbreviations common on health records ROS
review of systems
141
# Abbreviations common on health records PMHx
past medical history
142
# Abbreviations common on health records FHx
family history
143
# Abbreviations common on health records NKDA
no known drug allergies
144
# Abbreviations common on health records PE
physical exam
145
# Abbreviations common on health records Pt
patient
146
# Abbreviations common on health records y/o
years old
147
# Abbreviations common on health records h/o
history of
148
# Abbreviations common on health records PCP
primary care provider
149
# Abbreviations common on health records f/u
follow up
150
# Abbreviations used for symptoms or exam findings SOB
shortness of breath
151
# Abbreviations used for symptoms or exam findings HEENT
heads, eyes, ears, nose, and throat
152
# Abbreviations used for symptoms or exam findings PERRLA
pupils are equal, round, and reactive to light and accomodation
153
# Abbreviations used for symptoms or exam findings NAD
no acute distress
154
# Abbreviations used for symptoms or exam findings CV
cardiovascular
155
# Abbreviations used for symptoms or exam findings RRR
regular rate and rhythm
156
# Abbreviations used for symptoms or exam findings CTA
clear to auscultation
157
# Abbreviations used for symptoms or exam findings WDWN
well developed, well nourished
158
# Abbreviations used for symptoms or exam findings A&O
alert and oriented
159
# Abbreviations used for symptoms or exam findings WNL
within normal limits
160
# Abbreviations used for symptoms or exam findings NOS
not otherwise specified
161
# Abbreviations used for symptoms or exam findings NEC
not elsewhere classified
162
# Abbreviations associated with orders and administering medicine PO
per os (by mouth)
163
# Abbreviations associated with orders and administering medicine NPO
nil per os (nothing by mouth)
164
# Abbreviations associated with orders and administering medicine PR
per rectum (anal)
165
# Abbreviations associated with orders and administering medicine IM
intramuscular
166
# Abbreviations associated with orders and administering medicine SC
subcutaneous (under the skin)
167
# Abbreviations associated with orders and administering medicine IV
intravenous
168
# Abbreviations associated with orders and administering medicine CVL
central venous line
169
# Abbreviations associated with orders and administering medicine PICC
peripherally inserted central catheter
170
# Abbreviations associated with orders and administering medicine Sig
short for signa, "for label"
171
# Timing abbreviations BID
twice daily, bis in die
172
# Timing abbreviations TID
three times daily, ter in die
173
# Timing abbreviations Q
every x | e.g., Q4hr = every 4 hours
174
# Timing abbreviations QD
daily
175
# Timing abbreviations QID
four times daily, quater in die
176
# Timing abbreviations QHS
at night, quaque hora somni
177
# Timing abbreviations AC
before meals, ante cibum
178
# Timing abbreviations PC
after meals, post cibum
179
# Timing abbreviations prn
as needed, per re nata
180
# Timing abbreviations ad lib
as desired