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79 terms

Medical Terminology- Medical History and Physical Examination

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abrasion
scraping or rubbing away of skin or mucous membrane
abscess
localized collection of pus in any body part
alopecia
hair loss
analgesic
medication/treatment that relieves pain
anomaly
marked deviation from normal
asymptomatic
without symptoms
arthralgia
joint pain
ataxia
failure of muscular coordination
auscultation
act of listening for sounds within the body
benign
noncancerous; not progressive
blood chemistry profile
analysis of chemical components of the patient's blood
carotid
principle after of the neck
cheilitis
inflammation of the lip
chief complaint
subjective description of the symptoms that caused the patient to seek medical attention
clinical diagnosis
diagnosis made on the basis of knowledge obtained from the medical history and physical examination
consultation
report written by consulting physician on the request of the patient's primary physician
contusion
bruise
decubitus
lying down
dermis
second layer of skin
diagnosis
identification of a disease or condition by a scientific evaluation of physical signs, symptoms, laboratory tests, and procedures
diaphoresis
profuse perspiration
differential diagnosis
distinguishing between two or more diseases with similar symptoms by comparing their signs and symptoms
dysphonia
voice impairment; difficulty in speaking
edema
abnormal accumulation of fluid in intercellular spaces; swelling
emesis
vomiting
eschar
hard crust produced by a thermal burn
erythema
redness on the skin
exanthem
measles like eruption or rash that may be due to a virus or allergic reaction to a drug
extraocular
outside of the eye
femoral (pulse)
pulse of the feral artery felt in the groid
fibrosis
abnormal formation of fibrous tissue (scar tissue)
flaccid
weak, soft, flabby, poor muscle tone
fundi
back portion of the interior of the eyeball
ganglion
a know, group of nerve cell bodies outside the central nervous system
hematoma
blood clot
hematuria
presence of blood in the urine
hemoptysis
spitting up of blood or blood-tinged sputum
hepatosplenomegaly
enlargement of the liver and spleen
Impression/Diagnosis
section of the report in which the physician indicates diagnostic conclusions
incontinent
inability to control urination
keloid
abnormally large, thickened scar
laboratory diagnosis
diagnosis arrived at after the study of laboratory findings
laceration
tear in the skin
lacrimation
secretion and discharge of tears
lumbar puncture
spinal tap
melanin
pigment granules that give color to the skin and protect the body from injurious ultraviolet light rays
malaise
general feeling of bodily discomfort
murmur
auscultatory sound, particularly a periodic, short-duration sound of cardiac or vascular origin
nocturia
excessive urination at night
palpation
feeling with fingers of hands to determine the physical characteristics of organs or tissues
paresis
partial or incomplete paralysis
Past History
information that includes any childhood or adult diseases, surgical procedures, accidents, pregnancies, deliveries, and allergies
percussion
using fingertips to tap the surface of the body in order to produce sound
Physical Examination
physician's objective assessment of the patient, using auscultation, palpation, percussion, and visualization
postmortem
after death
Present Illness
information provided by patient as to when the symptoms were first notice, the extent and intensity, and the patient's opinion about what caused the symptoms
primary symptoms
symptoms directly related to a disease
primigravida
pregnant for the first time
prognosis
prediction of course and end of disease
progress note
brief note from a physician documenting a patient's progress
pruritis
itching
ptosis
dropping of the upper eyelid
purpura
large bruises in the skin
Review of Systems
exchange between doctor and patient to determine presence or absence of signs and symptoms
scleroderma
chronic disease caused by infiltration of fibrous tissue resulting in "hard skin"
sebacceous glands
oild glands located in the dermis
secondary symptoms
symptoms that are the result of a disease process
shunt
to bypass, an example use of a catheter to drain fluid
Social History
information summarizing the patient's lifestyle and environment to determine whether something about these factors are contributing to the problem
sputum
matter ejected from the trachea, bronchi, and lungs via the mouth
syncope
temporary loss of consciousness
tinnitus
a noise (ringing_ in the ear
tympanic membrane
eardrum
uticaria
hives
verruca
wart; type of viral skin infection
vertigo
dizziness
vesicle
small sac containing liquid
vital signs
pulse rate, respiration rate, body temperature, blood pressure
xanthoma
distinct yellow growth caused by deposits of fat in the skin, usually reflects increased fatty materials in the bloodstream