Medical Terminology Penn Foster

PERRLA

Pupils are Equal, round, reactive to light and accommodation

Ventral vs Dorsal

Ventral - towards the front Dorsal - towards the back

Reproductive System

includes the male and female sex organs

Frontal Plane

"crown" Back and front sides A vertical plane that divides the body into front and back sections

Release of Information Requirements

(What Info) Specifically what information is to be released (who) To whom the information is to be disclosed (Why) Reason for the disclosure (Sign it) Request signed and dated by the phone (keep it) Request kept in the patient's file

centesis

- puncture to withdraw fluid - surgical puncture of a cavity - the surgical puncturing of a part of the body with a hollow needle in order to extract fluid - (surgery) the act of puncturing a body cavity or organ with a hollow needle in order to draw out fluid example:amniocentesis -(pregnancy) extraction by centesis of amniotic fluid from a pregnant woman (after the 15th week of pregnancy) to aid in the diagnosis of fetal abnormalities

Abbreviations

A & P = Auscultation and Percussion BP = Blood Pressure CBC = Complete Blood Count CC = Chief Complaint H & P = History and Physical

Suffix

A word part attached to the end of a word. Usually indicates a condition, disease, disorder or procedure. Almost ALL medical terms have a suffix.

Word Root

A word root is the foundation of a medical term. It provides us with the general meaning of the word.

Rules about Eponyms

ALWAYS be capitalized ALWAYS going to end with "S" at end

Confidentiality

All information provided by the patient to a physician and the physician and the physician's observations is considered privileged communication.

Anterior vs Posterior

Anterior (front) toward the ventral Posterior (back) toward the dorsal

Confidentiality

Any other heathcare providers and support personnel using this information are also bound by confidentiality rules.

Using a stethoscope to listen to sounds within the body is called?

Auscultation

Muscular Tissue

Cardiac - involuntary Skeletal (only voluntary out of the three) Smooth - digestive organs

Central vs PEripheral

Central - near or toward the midline of the body Peripheral - away from the midline or center of the body

The 6 Levels of Organizations from smallest to largest?

Chemical (atoms - oxygen, carbon, hydrogen, etc) Cells - group of atoms, molecules or organelles Tissues - a group of similar cells working together Organs - two or more tissues working together Organ Systems - DIFFERENT tissues working together Organism (human body)

Progress Notes (Pt change from day to day so keep accurate notes for the doctor to check progress)

Collection of notes made after actions taken following the initial physical exam Provides updated information on the patient's condition and progress Can be used to change the course of treatment

Common Diagnostic Testing

Complete Blood Count CBC Urinalysis UA - composition of urine Chest X-ray - CXR overall condition of lungs Electrocardiogram - EKG/ECC heart rhythm Stool Specimen - blood, parasites, infectious process Blood chemistry profile - electrolytes imbalance Lipid profile - cholesterol levels

Examples of Eponyms

Crohn's disease Parkinson's disease Hodgkin's disease Alzheimer's disease

When a medical disease, a body part, an instrument, or a procedure includes the name of the person who discovered or created it, the term is called a/an?

Eponym

Consultations

Evaluation or second opinion concerning a patient's specific problem requested by the primary physician Report in letter form or hospital provided form

Connective Tissue (4 types)

FM/AM (connect) Fibroblasts Masts Adipocytes Macrophages

Abbreviations for exam section for doctor

HEENT Head Eyes Ears Nose Throat

HEENT

Head, Eyes, Ears, Nose and Throat

Hct

Hematocrit

The basic components of medical terminology?

Knowledge of root, prefix, suffix body structures and human anatomy diagnostic procedures

exam section for doctor Abbreviations

LDL = Low Density Lipoprotein PERRLA = Pupils are Equal, Round, React to Light and accommodations Pt = Patient

Tissues (4 types)

MEN C Muscular Epithelial Nervous Connective

Physical examination (PX or PE)

Objective assessments are made based on: Auscultation (listening) lungs, heart, bowel sounds Palpation (feeling) lumps, masses, painful spots Percussion (tapping) listen to sounds (lungs) Visualization or inspection (use their eyes) general overall appearance, is the wound healing, what size is the wound, red color?

Respiratory system

Obtains oxygen and removes carbon dioxide from the body

Feeling with fingers or hands to determine the physical characteristics of organs or tissues is?

Palpation

Using the fingertips to tap the body is referred to as?

Percussion

Body position terms for patient when laying down

Prone - face down Spine - face up Lateral - on their side with pillows - usually for sleeping

Prefix

Provide information about the root word. Is added to the front (before) of the root word. Could give location of the organ. Number or frequency NOT all medical terms have prefixes!!!!

tachy

Rapid Fast example: tachycardia Rapid heart beat (over 120 beats per min)

The part of a medical word that usually tells what part of the body is involved is the?

Root word

The plane of the body that passes through the center of the body and divides it into a left and a right is called?

Sagittal Median

Body planes

Sagittal Plane aka median plane Frontal Plane aka coronal plane Transverse Plane aka horizontal plane

body position for laying down

Sim's Dorsal Recumbent Lithotomy position

brady

Slow *think brady brunch slowwww

Plan Accrediting and Regulatory agencies require a treatment plan which may include?

Specific Laboratory and Diagnostic Tests Referrals to Specialist Specific instructions to the patient Follow up appointments as needed

Medical history and physical exam content

Subjective information Objective information

Superficial vs Deep

Superficial - closer to the body surface Epidermis is superficial to subdermis Deep - farther away from body surface

ectomy

Surgical removal: tonsillectomy - removal of tonsils appendectomy - surgical removal of the vermiform appendix. vasectomy -surgical procedure that removes all or part of the vas deferens (usually as a means of sterilization); is sometimes reversible

TPR

Temperature, Pulse, Respiration

Body Regions

The body is divided into large regions that can be easily identified.

hepat/o + splen/ o + megaly = hepatosplenomegaly

The combing vowel is typically kept between two word roots When reading a book - you read from left to right Medical terms - you read from left to right (start with the suffix) *remember "S" start with suffix

Legal Health Record (AHIMA definition)

The documentation of the healthcare services provided to an individual, in any aspect of healthcare delivery by a healthcare provider organization.

Cells

The fundamental unit of all living things Cytology - the study of cells all cells in the human body have a nucleus, cytoplasm, and cell membrane.

Eponyms

The name given a medical disease, body part, or procedure derived from the name of the person who discovered, defined or perfected it.

Directional and positional Terms

These are terms that assist in discussing and identifying the position or location on a patient's body. When using location or directional terms - it is assumed that the patient is in the anatomical position.

Transverse plane

Top and bottom A horizontal plane that divides the body inot upper and lower sections. This plane is parallel to the ground. commonly used in x-ray

The plane that divides the body into two parts horizontally is called?

Transverse plane

body positions for laying down

Trendelenburg - not routinely used stabilize BP drainage from lungs

Combing words Forms

Why combine forms are used? The vowel O is the most often used. I. Used between a word root and suffix or 2. between two root words When do we use a combing vowel? 1st take a look at the suffix If the suffix BEGINS with a vowel then do NOT use a combining vowel.

aden/o + carcin + oma = adenocarcinoma

a malignant tumor originating in glandular epithelium

Confidentiality

be aware on where you discuss the patient's condition you would not want to talk in elevators, stairwell, nurse's station - a person might walk past and over hear you talking - remember that is privilege information

pre

before

Anatomical position

body erect feet slightly apart palms facing forward thumbs point away from the body

Epithelial Tissue

closely impacted cells lines, secretes glands, covers

lysis

destruction example: hemolysis = destruction of RBC (red blood cells bacteriolysis = destruction of bacteria

Dys

difficulty bad painful example:Dysmenorrhea is the occurrence of painful cramps during menstruation.

rrhage

excessive, abnormal flow ex: menorrhagia = abnormal bleeding at menstruation hemorrhage = excessive blood flow

Urinary system

filtering of waste products out of the blood and removes them from the body

Select the word root from the following? a) gastr b) gastro c) hemi d) ectomy

gastr = word root gastrO = the o was added on (combine word)

HGB

hemoglobin

Spelling is so important! One wrong letter can be a critical difference.

ileum (enter = small intestines) VS ilium (hip bone/pelvis) Prostate (male reproductive gland) VS ProstRate (means to collapse) lying flat or to be overcome with exhaustion

Digestive system

includes ingestion, digeston, absorption on nutients

Surgical and procedural suffixes

indicate surgical procedures examples: ectomy = surgical removal ("e" exit) plasty = surgical repair/correction (plastic - to correct) centesis = puncture to withdraw fluid/surgical puncture of a cavity gram = record or take picture (written record) scope = instrument used for viewing

scope

instrument used for viewing example: microscope

Anatomical postion

is used when describing the positions and relationships of structures in the human body.

Multi

many

Objective information

medical team can observe and measure it Measurable has numbers (BP, HR, Respirations, temp) Vomiting, bleeding, swelling

neur

nerve

Mono

one

Organs/Organ Systems

organs are made up of tissues A system is composed of several organs working together to perform a complex functions.

algia

pain/painful condition example: myalgia - my = muslce, algia = pain neur = nerve, algia = pain

Nervous Tissue

part of the CNS spinal cord, brain, eyes neurons = nerve cells

Muscular

produces movement

Integumentary system

protective barrier/aids in temp regulation largest organ

Lymphatic system

protects the body from disease and pathogens

Skeletal System

provides support for the body

cardiovascular system

pumps blood through body to transport nutrients, oxygen and waste

Nervous system

receives sensory informaton and responds to stimuli

Endocrine System

regulates the metabolic activities of the body

Fowler's body position

sitting up in bed respiratory conditions

enter

small intestines

gastr

stomach

logy

study of example: biology = study of life

plasty

surgical repair/correction Surgery - A procedure in which the shape of a tissue is altered or enhanced. examples: Mammoplasty -plastic surgery of the breast vaginoplasty - surgery of the vagina.

hematic system

the blood that circulates through our bodies. Made up of plasma, erythrocytes, leukocytes and platelets.

gram

written record such as picture example:electrocardiogram -A graphic record of heart muscle activity recorded by an electrocardiograph sonogram

3 Rules for Building Medical Words Rule #2

◦ A combining form (word root + combining vowel) links a suffix that begins with a consonant.◦ (keep the combining vowel when the suffix begins with a consonant) Hepat/o -cyte = hepatocyte

3 Rules for Building Medical Words Rule #3

◦ A combining form links one root to another root to form a compound word. Even if the second root begins with a vowel. ◦ Oste/o arthr -itis = osteoarthritis

3 Rules for Building Medical Words Rule #1

◦ A word root links a suffix that begins with a vowel. Hepat -itis = Hepatitis ◦ drop the combining vowel when the suffix begins with a vowel)

Sagittal plane

"sides" right and left sides a vertical plane that divides the body into L and R

BUN

Blood, Urea, Nitrogen (increased number may indicate kidney troubles)

CBC

Complete Blood Count

Subjective information

Is reported by patient Symptoms (thumb hurts, headache, bellyache) feelings - dizzy *what the patient feels, says Subjective = symptoms