Med Term Ch 2 Health Care Records

Assessment

alive and well

chief complaint

complains of

diagnosis

family history

Head, eyes, ears, nose, and throat

history and physical

history of present illness, present illnes

history

impression

living and well

no acute distress

no known allergies, no known drug allergies

objective information

occupational history

plan (recommendation, disposition)

physical examination

pupils equal, round, and reactive to light and accomodation

past history, past medical history

rule out

review of systems, systems review

subjective information

social history

symptom

usual childhood diseases

within normal limits

sharp; having intense, often severe symptoms and a short course

a condition that develops slowly and persists over a period of time

mild or noncancerous

harmful or cancerous

gradual deterioration of normal cells and body functions

any disease in which deterioration of the structure or function of tissue occurs

determination of the presence of a diseases based on an evaluation of symptoms, signs and test findings

study of the cause of a disease (etio= cause)

increase in the severity of disease, with aggravtion of symptoms (ex=out; acerbo=harsh)

a period in which symptoms and signs stop or abate

relating to a fever (Elevated temperature)

a condition occurring without a clearly identified cause (idio= one's own)

limited to a definite area or part

relating to the whole body rather than one part

a feeling of uneasiness or discomfort; often the first indiciation of illness

significant

sick; a diseased state

the state of being subject to death

foreknowledge; prediction of the likely outcome of a disease based on general health status of patient along with disease knowledge; often one-word (eg: prognosis: good)

pertaining to the advance of the condition as the signs and symptoms increase in severity

a process or measure that prevents disease (pro=before, phylassein = guard)

to occur again; return of symptoms after period of quiescence (rest or inactivity)

a disorder or condition usually resulting from a previous disease or injury

a mark

subjective evidence of disease that is perceived by patient

a running together; combination of symptoms and signs that give a distince clinical picture indicating a particular con./disease

not involved in bringing on the condition or result

common

coronary (cardiac) care unit

Emergency care unit

emergency room

intensive care unit

inpatient (a registered bed patient)

outpatient

operating room

postanesthetic care unit

postanesthetic recovery

after surgery

before surgery

return to clinic

return to office

bilateral

bathroom privileges

chest pain

discharge, discontinue (spell out discharge or discontinue)

ethyl alcohol

left

right

murmur

patient

regular rate and rhythm

shortness of breath

treatment

treatment or traction

vital signs

temperature

pulse

respiration

blood pressure

height

weight

well-developed and well-nourished

year old

number or pound

celsius

fahrenheit

female

male

degree or hour

increased

decreased

none or negative

standing

sitting

lying

cubic centimeter (1 cc= 1 mL)

centimeter

gram

kilogram

liter

milligram (1/1000 of g)

milliliter (1/1000 of L)

millimeter (1/1000 of meter)

cubic millimeter

fluid ounce

grain

drop (gutta = drop)

drops

dram (1/8 ounce)

quart

oral (p.o.), sublingual (SL), buccal

vaginal (PV), rectal (PR)

inhalation: aerosol (spray) or nebulizer (fine spray or mist)

• by injection:
• intradermal (ID) 
• intramuscular (IM)
• intravenous (IV)
• subcutaneous (SC, SQ, or sub-Q)

topical

absorption of drug through unbroken skin

a drug resorvoir imbedded in the body to provide continual infusion of a medication 

before

before meals

before noon

2x a day

day

hour

hour of sleep (bedtime)

night

after

after meal

as needed

after noon

every

every day (spell out every day or daily)

every hour

every 2 hours

4x a day

every other day (spell out)

immediately

3x a day

week

year

right ear (spell out)

as desired

amount

water

left ear (spell out)

both ears (spell out)

with

nothing by mouth

right eye (spell out)

left eye (spell out)

both eyes (spell out)

by or through

by mouth

through rectum

through vagina

recipe, prescription

without

label, instruction to patient

one-half (spell out)

while awake

time or for (ex: x6 means six times or x2d means for two days)

greater than (spell out)

less than (spell out)

modified lower case numerals