Chapter 2 Flashcards
Introduction to Health Records (140 cards)
1
Q
acute
A
it just started
2
Q
chronic
A
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 consciouness
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/she is
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 or feel something for result
19
Q
palpation
A
to feel
20
Q
impression
A
another way of saying assessment
21
Q
diagnosis
A
what the health care professional things the patient has
22
Q
differential diagnosis
A
a list of conditions the patient may have based on 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
etiology
the cause
27
remission
to get better or improve
28
idiopathic
no known specific cause; it just happens
29
localized
stays in a certain part of the body
30
systemic/generalized
all over the body (most of it)
31
morbidity
the risk of being sick
32
mortality
the risk for dying
33
prognosis
the chances for things getting worse or better
34
occult
hidden
35
pathogen
the organism that causes the problem
36
lesion
diseased tissue
37
recurrent
to have again
38
sequelah
a problem resulting from a disease or injury
39
pending
waiting for
40
disposition
what happened to the patient at the end of the visit
41
discharge
to unload
42
prophylaxis
preventive treatment
43
palliative
treating the symptoms, but not actually gettting rid of the cause
44
observation
watch, keep an eye on
45
reassurance
to tell the patient that the problem is not serious or dangerous
46
supportive care
to treat the symptoms and make the patient feel better
47
sterile
extremely clean, germ-free conditions
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
caudial
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
top of hand or foot
65
plantar
sole of the foot
66
palmar
palm of the hand
67
sagittal
divides body in slices right to left
68
coronal
divies body in slice from front to back
69
transverse
divides the body from top to bottom
70
CCU
coronary care unit
71
ECU
emergency care unit
72
ER
Emergency Room
73
ED
emergency department
74
ICU
intensive care unit
75
PICU
pediatric intensive care unit
76
NICU
neonatal intensive care unit
77
SICU
surgical intensive care unit
78
PACU
post-anesthesia care unit
79
L&D
labor and delivery
80
OR
operating room
81
post-op
after surgery
82
pre-op
before surgery
83
VS
vital signs
84
T
temperature
85
BP
blood pressure
86
HR
heart rate
87
RR
respiratory rate
88
Ht
height
89
Wt
wight
90
BMI
body mass index
91
I/O
intake/output
92
Dx
diagnosis
93
DDx
differential diagnosis
94
Tx
treatment
95
Rx
prescription
96
H&P
history and physical
97
Hx
histroy
98
CC
cheif complaint (main reason for the visit)
99
HPI
history of present illness (the story of the sympstoms)
100
ROS
review of systems (anything else not related to chief complaint)
101
PMHx
past medical history
102
FHx
family history
103
NKDA
no known drug allergies
104
PE
physical exam
105
Pt
patient
106
y/o
years old
107
h/o
history of
108
PCP
primary care provider
109
f/u
follow up
110
SOB
shortness of breath
111
HEENT
head, eyes, ears, nose and throat
112
PERRLA
pupils are equal, round, and reactive to light and accomodation
113
NAD
no acute distress
114
CV
cardiovascular
115
RRR
regular rate and rhythm (heart exam)
116
CTA
clear to auscultation (lungs)
117
WDWN
well developed, well nourished
118
A&O
alert and oriented
119
WNL
within normal limits
120
NOS
not otherwise specified
121
NEC
not elsewhere classified
122
PO
per os (by mouth)
123
NPO
nil per os (nothing by mouth)
124
PR
per rectum
125
IM
intramuscular
126
SC
subcutaneous
127
IV
intravenous
128
CVL
central venous line
129
PICC
peripherally inserted central catheter
130
Sig
label
131
BID
twice daily
132
TID
three times daily
133
Q
every X (Q4hr-4 times daily)
134
QD
each day
135
QID
four times daily
136
QHS
at night
137
AC
before meals
138
PC
after meals
139
prn
as needed
140
ad lib
as desired
