Health Record Terms

Question 1

abrupt

Answer 1

all of the sudden

Question 2

acute

Answer 2

it just started recently or is a sharp, severe symptoms

Question 3

afebrile

Answer 3

to not have a fever

Question 4

chronic

Answer 4

it has been going on for a while now

Question 5

genetic/hereditary

Answer 5

runs in the family

Question 6

exacerbation

Answer 6

it is getting worse

Question 7

febrile

Answer 7

to have a fever

Question 8

lethargic

Answer 8

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

Question 9

noncontributory

Answer 9

not related to this specific problem

Question 9

malaise

Answer 9

not feeling well

Question 10

progressive

Answer 10

more and more each day

Question 11

symptom

Answer 11

something a patient feels

Question 12

alert

Answer 12

able to answer questions; responsive; interactive

Question 13

auscultation

Answer 13

to listen

Question 14

marked

Answer 14

it really stands out

Question 15

oriented

Answer 15

being aware of who they are, where they are, and the current time; patient who is aware of all 3 is “oriented x 3”

Question 16

palpation

Answer 16

to feel

Question 17

percussion

Answer 17

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

Question 18

unremarkable

Answer 18

normal

Question 19

impression

Answer 19

another way of saying assessment

Question 20

diagnosis

Answer 20

what the health care professional thinks the patient has

Question 21

differential diagnosis

Answer 21

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

Question 22

benign

Answer 22

safe

Question 23

malignant

Answer 23

dangerous; a problem

Question 24

degeneration

Answer 24

to be getting worse

Question 25

etiology

Answer 25

the cause

Question 26

remission

Answer 26

to get better or improve; most often used when discussing cancer; remission does NOT mean cure

Question 27

idiopathic

Answer 27

no known specific cause; it just happens

Question 28

localized

Answer 28

stays in a certain part of the body

Question 29

systematic generalized

Answer 29

all over the body (or most of it)

Question 30

morbidity

Answer 30

the risk of being sick

Question 31

mortality

Answer 31

the risk of dying

Question 32

prognosis

Answer 32

the chances for things getting better or worse

Question 33

occult

Answer 33

hidden

Question 34

pathogen

Answer 34

the organism that causes the problem

Question 35

lesion

Answer 35

diseased tissue

Question 36

recurrent

Answer 36

to have again

Question 37

sequelae

Answer 37

a problem resulting from a disease or injury

Question 38

pending

Answer 38

waiting for

Question 39

discharge

Answer 39

1. to send home 2. fluid coming out of a part of the body

Question 40

disposition

Answer 40

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

Question 41

observation

Answer 41

watch; keep an eye on

Question 42

pallative

Answer 42

treating the symptom but not actually getting rid of the cause

Question 43

prophylaxis

Answer 43

preventative treatment

Question 44

reassurance

Answer 44

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

Question 45

sterile

Answer 45

extremely clean, germ-free conditions; especially important during medical procedures and surgery

Question 46

supportive care

Answer 46

to treat the symptoms and make the patient feel better

Question 47

distal

Answer 47

farther away from the center

Question 48

proximal

Answer 48

closer in the center

Question 49

lateral

Answer 49

out to the side

Question 50

medial

Answer 50

toward the middle

Question 51

dorsal/posterior

Answer 51

the back

Question 52

ventral/antral/anterior

Answer 52

the front

Question 53

caudal

Answer 53

toward the bottom

Question 54

cranial

Answer 54

toward the top

Question 55

inferior

Answer 55

below

Question 56

superior

Answer 56

above

Question 57

prone

Answer 57

lying down on belly

Question 58

supine

Answer 58

lying down on back

Question 59

contralateral

Answer 59

opposite side

Question 60

ipsilateral

Answer 60

same side

Question 61

bilateral

Answer 61

both sides

Question 62

unilateral

Answer 62

one side

Question 63

dorsum

Answer 63

top of hand or foot

Question 64

palmar

Answer 64

palm of the hand

Question 65

plantar

Answer 65

sole of the foot

Question 66

coronal

Answer 66

divides body into slices front to back

Question 67

sagittal

Answer 67

divides body into slices right to left

Question 68

transverse

Answer 68

divides body into slices top to bottom