Med terms Ch 2

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 illness

History

impression

living and well

no acute distress

no know allergies, no known drug allergies

objective information

occupational history

plan (recommendation, disposition)

physical examination

pupils equal, round, and reactive to light and accommodation

past history, past medical history

rule out

review of systems, systems review

subjective information

• are used to document the pts continued care
• SOAP
• Subjective
• Objective
• Assessment
• Plan

social history

symptom

unusual childhood diseases

within normal limits

the first document entered into the patient's hospital recored and is commonly required before elective admission for surgery

list the directives for care prescribed by the doctor who is attending to the patient

chronicle the the care throughout the patients stay

a process that changes the electrical charge of atoms and has a possible effect on body cells

• ionizing modalities :
• radiography (x ray) 
• computed tomography ( CT)
• nuclear medicine 
• non ionizing modalities: 
• magnetic resonance imaging (MRI)
• sonography (US)

• X-RAY
• imaging modality that uses x-rays (ionizing radiation) to produce body images of thebody's anatomy   for the diagnosis of a condition or impairement 
• an image is created when a small amount of radiation is passed through the body to expose a sensitive film 
• image called a radiograph

CAT- a radiologic procedure that uses a machine (scanner) to examine a body site by taking a series of cross-sectional (tomographic) x-ray films in a full-circle rotation. A computer then calculates and converts the rates of absorption and density of the x-rays into a 3-D picture on the screen

• uses an injected or ingested radioactive isotope (radionuclide) or a chemical that has been tagged with radioactive compounds that emit gamma rays 
• a gamma camera detects and produces an image of the distributed gamma rays in the body
• a technique is useful in determining the size, shape, location, and function of body organs, such as the brain, lungs, bones, and heart

• MRI
• a non-ionizing imaging technique using magnetic fields and radiofrequency waves to visualize anatomic structures with the body
• a large magnet surrounds the pt as a scanner subjects the body to a radio signal that temporarily alters the alignment of the H atoms in the pts tissue
• as the radio signal is turned off, the atoms realign, and the energy produced is absorbed by detectors and then interpreted using computers to provide detailed anatomic images of the body part
• this modality is particulary useful in examining soft tissues, joints, and the brain and spinal cord

• MRA
• applies magnetic resonance technology is the study of blood flow

• diagnostic ultra sound
• U/S or US
• the use of high-frequency sound waves (ultrasound) to visualize body tissues 
• ultrasound waves are sent trough a scanning device (transducer) are reflected off structures within the body and then analyzed by a computer to produce moving images on the monitor 
• used to examine abdomen, male and female reproduction organs, thyroid and parathyroid glands, and the cardiovascular system

• used to enhance anatomic structures 
• barium, iodinated compounds, gases 
• maybe injected, swallowed, or introduced through an enema or catheter

• 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 disease based on an evaluation of symptoms, signs, and test findings (results)
• dia= through
• gnosis= knowing

• study of the cause of the disease
• etio = cause

• increase in the severity of a disease, with aggravation of symptoms
• ex= out
• acerbo= harsh

a period in which symptoms and signs stop or abate

relating to a fever (elevated temperature)

• a condition occuring without a clearly identified cause
• idio = one's own

limited to a definite area or part

relating to the whole body rather than to only a part

• feeling of uneasiness or discomfort
• often the first indication 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 the general health status of the pt along with knowledge of the usual course of the disease
• often noted in one word (prognosis = good)

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

• a process or measure that prevents disease
• pro= before
• phylassein = guard

• to occur again
• describes a return of symptoms and signs after a period of quiescence (rest or inactivity)

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

• a mark
• objective evidence of disease that can be seen or verified by an examiner

subjective evidence of disease that is perceived by the pt and often noted in his or her owns words

• a running together
• combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease (menopausal syndrome)

not involved in bringing on the condition or result

• common
• not out of the ordinary or significant

coronary (cardiac) care unit

emergency care unit

emergency room

intensive care unit

• inpatient
• a registered bed pt

out patient

operating room

postanesthetic care unit

postanesthetic recovery

postoperative (after surgery)

preoperative (before surgery)

return to clinic

return to office

bilateral

bathroom privileges

chest pain

discharge, 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
• before a number: number
• after the number: pound

celsius, centigrade

fahrenheit

standing

sitting

lying

• cubic centimeter
• 1cc = 1 mL

• centimeter
• 2.5 cm = 1 inch

gram

nothing by mouth

through rectum

through vagina

without

one half

assessment

as desired

amount

water

alive and well

complete blood count

coronary (cardiac) care unit

complains of

intradermal

impression

joint commission on accreditation of healthcare organizations

no acute distress

night

occupational history

before noon

afternoon

within normal levels