Chapter 2 Sections Of A Health Record And Terms

Question 1

The main reason for the patient’s visit

Answer 1

Chief complaint

Question 2

The story of the patient’s problem

Answer 2

History of present illness

Question 3

Description of individual body systems in order to discover any symptoms not directly related to the main problem

Answer 3

Review of systems

Question 4

Other significant past illnesses, like high blood pressure, asthma, or diabetes

Answer 4

Past medical history

Question 5

Any of the patient’s past surgeries

Answer 5

Past surgical history

Question 6

Any significant illnesses that run in the patient’s family

Answer 6

Family history

Question 7

Hey record of habits like smoking, drinking, drug abuse, and sexual practices that can impact help

Answer 7

Social history

Question 8

It just started recently or is a sharp, severe symptom

Answer 8

Acute

Question 9

It has been going on for a while now

Answer 9

Chronic

Question 10

It is getting worse

Answer 10

Exacerbation

Question 11

All of a sudden

Answer 11

Abrupt

Question 12

To have a fever

Answer 12

Febrile

Question 13

To not have a fever

Answer 13

Afebrile

Question 14

More and more each day

Answer 14

Progressive

Question 15

Not feeling well

Answer 15

Malaise

Question 16

Something a patient feels

Answer 16

Symptom

Question 17

Not related to the specific problem

Answer 17

Noncontributory

Question 18

A decrease in level of consciousness’s; in a medical record, this is generally an indication that the patient is really sick

Answer 18

Lethargic

Question 19

It runs in the family

Answer 19

Genetic, hereditary

Question 20

Able to answer questions; responsive; interactive

Answer 20

Alert

Question 21

Being aware of who he or she is, where he or she is, and the current time

Answer 21

Oriented

Question 22

It really stands out

Answer 22

Marked

Question 23

Another way of saying normal

Answer 23

Unremarkable

Question 24

To listen

Answer 24

Auscultation

Question 25

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

Answer 25

Percussion

Question 26

To feel

Answer 26

Palpation

Question 27

Another way of saying assessment

Answer 27

Impression

Question 28

What the healthcare professional thinks the patient has

Answer 28

Diagnosis

Question 29

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

Answer 29

Differential diagnosis

Question 30

Safe

Answer 30

Benign

Question 31

Dangerous; a problem

Answer 31

Malignant

Question 32

To be getting worse

Answer 32

Degeneration

Question 33

The cause

Answer 33

Etiology

Question 34

To get better or improve; most often used when discussing cancer; this does not mean cured

Answer 34

Remission

Question 35

No no specific cause; it just happens

Answer 35

Idiopathic

Question 36

Stays in a certain part of the body

Answer 36

Localized

Question 37

All over the body or most of it

Answer 37

Systemic/generalized

Question 38

The risk of being sick

Answer 38

Morbidity

Question 39

The risk for dying

Answer 39

Mortality

Question 40

The chances for things getting better or worse

Answer 40

Prognosis

Question 41

Hidden

Answer 41

Occult

Question 42

The organism that causes the problem

Answer 42

Pathogen

Question 43

Diseased tissue

Answer 43

Lesion

Question 44

To have again

Answer 44

Recurrent

Question 45

The problem resulting from a disease or injury

Answer 45

Sequela

Question 46

Waiting for

Answer 46

Pending

Question 47

What happened to the patient at the end of the Vison; often use at the end of ED down to reference where the patient went after the visit

Answer 47

Disposition

Question 48

Literally, to unload; it has two meanings: 1. To send home 2. Fluid coming out of a part of the body

Answer 48

Discharge

Question 49

Preventative treatment

Answer 49

Prophylaxis

Question 50

Treating the symptoms, but not actually getting rid of the cause

Answer 50

Palliative

Question 51

Watch, keep an eye on

Answer 51

Observation

Question 52

To tell the patient that the problem is not serious or dangerous

Answer 52

Reassurance

Question 53

To treat the symptoms and make the patient feel better

Answer 53

Supportive care

Question 54

Extremely clean, germ-free condition; especially important during medical procedures in surgery

Answer 54

Sterile