Cma- Chapter 1

Front 1

Cyte/ cyt

Back 1

Cell (of or relating to a cell)

Front 2

-ectomy

Back 2

To cut out; removal of a structure

Front 3

-emia/ hemo-

Back 3

Blood (of relating to blood)

Front 4

Mastia

Back 4

Breast (of or relating to breasts)

Front 5

Metric

Back 5

Measurement

Front 6

-osis

Back 6

State, usually referring to a disease state

Front 7

-pexy

Back 7

Fixation of an anatomical structure

Front 8

-plasty

Back 8

Molding or shaping, reconstruction

Front 9

Pnea

Back 9

Breath or respiration (of relating to the breath)

Front 10

-rrhea

Back 10

Flow; flowing

Front 11

-scopy

Back 11

Using an instrument to view

Front 12

Turia/ uria

Back 12

Of or relating to the urine

Front 13

A-/ an-

Back 13

Without

Front 14

Ana-

Back 14

Up (or against)

Front 15

Andro-

Back 15

Masculine

Front 16

Angina

Back 16

Pain or pressure (in the chest)

Front 17

Anthropo-

Back 17

Humankind (both men and women)

Front 18

Cephal

Back 18

Head (of or related to the head)

Front 19

Corpus

Back 19

Body

Front 20

Cutaneous

Back 20

Of or relating to the skin

Front 21

Dia-

Back 21

Through

Front 22

Dys-

Back 22

Bad (or difficult)

Front 23

Epi-

Back 23

Upon; on top of

Front 24

Exo (-ec-)

Back 24

Outside of; exterior; out

Front 25

Gyn/ gyno

Back 25

Feminine; female

Front 26

Hyper-

Back 26

Higher than normal: elevated/ excessive

Front 27

Hypo-

Back 27

Lower than normal; decreased/ deficient

Front 28

Leuk/ leuko

Back 28

White

Front 29

Litho-

Back 29

Stone

Front 30

Ortho-

Back 30

Straight or ordered; aligned

Front 31

Peri-

Back 31

Near; around

Front 32

Rhin/ rhino

Back 32

Nose (of or related to the nose)

Front 33

Thorax

Back 33

Chest

Front 34

Oligo

Back 34

Few; very little

Front 35

-lytic

Back 35

Burst open

Front 36

Entero

Back 36

Intestines

Front 37

C (with over score)

Back 37

With

Front 38

B/o

Back 38

Because of

Front 39

CA

Back 39

Cancer

Front 40

etOH

Back 40

Ethyl alcohol

Front 41

H/O or h/o

Back 41

History of

Front 42

hs

Back 42

Bedtime, at bedtime (hour of sleep)

Front 43

I and O

Back 43

Intake and output

Front 44

LMP

Back 44

Last menstrual period

Front 45

N/A

Back 45

Not available or not applicable

Front 46

NKDA

Back 46

No known drug allergies

Front 47

N and V

Back 47

Nausea and vomiting

Front 48

NVD

Back 48

Nausea, vomiting, and diarrhea

Front 49

OB

Back 49

Obsterics

Front 50

P (with over score)

Back 50

Post

Front 51

P

Back 51

Pulse

Front 52

p.c.

Back 52

After meals (post cebum)

Front 53

Pt

Back 53

Patient

Front 54

PTA

Back 54

Prior to admission/ prior to arrival at site

Front 55

Post-op

Back 55

Post-operative

Front 56

PP

Back 56

Postpartum or post-prandial (after eating)

Front 57

PRN or prn

Back 57

As needed (pro re nata)

Front 58

PY or P/Y

Back 58

Pack years (packs smoked per day multiplied by number of years of smoking)

Front 59

q

Back 59

Every

Front 60

qd

Back 60

Every day

Front 61

qh

Back 61

Every hour

Front 62

q2h or q2

Back 62

Every 2 hours

Front 63

qod

Back 63

Every other day

Front 64

R/O

Back 64

rule out

Front 65

S (with over score)

Back 65

Without

Front 66

S/P or s/p

Back 66

Status post

Front 67

Si/ Sx

Back 67

Signs and symptoms

Front 68

tid

Back 68

3 times per day

Front 69

V/D

Back 69

Vomiting and diarrhea

Front 70

CC

Back 70

Chief complaint

Front 71

HPI

Back 71

History if present illness

Front 72

PMHx

Back 72

Past medical history

Front 73

FHx

Back 73

Family medical history

Front 74

SHx

Back 74

Social history

Front 75

ROS

Back 75

Review of systems

Front 76

Alg

Back 76

Allergies

Front 77

Immuno

Back 77

Immunizations

Front 78

PE

Back 78

Physical exam

Front 79

Labs

Back 79

Labs

Front 80

Meds

Back 80

Medications

Front 81

A/P

Back 81

Assessment and plan

Front 82

Medical terminology

Back 82

Usually shortened or abbreviated terms used in the medical world

Front 83

Prefix

Back 83

Unit that occurs at the beginning of a word to qualify the meaning of the root term

Front 84

Suffix

Back 84

Unit that occurs at the end of a word to qualify the meaning of the root word

Front 85

Combining Form

Back 85

How root words come- meaning they have been modified to be combined

Front 86

Reliability

Back 86

Depends on the patients memory, mood, or trust... but if you can count on what they are saying

Front 87

Poor historian

Back 87

If you believe a patient is unreliable you write this down

Front 88

Nonmaleficence

Back 88

Or primum non nocere, first do not harm.. a fundamental maximum

Front 89

Beneficence

Back 89

Do good, a fundamental maximum

Front 90

Autonomy

Back 90

Patients have the right to determine what's in their best interest, a fundamental maximum

Front 91

Confidentiality

Back 91

Obligated to not tell others what we learn from our patients, a fundamental maximum

Front 92

Intake Forms

Back 92

Forms that the patient fills out when they arrive for their first visit

Hint 92

Includes demographic and contact info. Generally more relevant for administrative purposes.

Front 93

SOMR

Back 93

Method of charting; Source- oriented medical record, organized by the source of the information

Hint 93

All patients lab tests are kept together, docs orders kept together, follow-ups kept together... kept together in chronological order

Front 94

POMR

Back 94

Method of charting; Problem- oriented medical record, more common organization of the medical chart based on relevance of the documents to a specific problem or treatment.

Hint 94

All documents, lab results, and x-rays related to surgical procedure will be kept together; and all orders, follow -up visit notes about pts viral infection will be kept together.

Front 95

SOAP or SOAPER

Back 95

Form of summarizing a clinical visit, progress note.

Subjective information, pt own words

Objective information, measurable values

Assessment and/or diagnosis of the pt, based on both subjective and objective info Plan for treatment, including all orders from the physician and followup care Educating the patientResponse of the pt to the education and care provided

Plan for treatment, including all orders from the physician and followup care Educating the patientResponse of the pt to the education and care provided

Educating the patient

Response of the pt to the education and care provided

Front 96

CHEDDAR

Back 96

Progress notes, less common, but newer

Chief complaint

History of all relevant info

Examination of relevant systems

Details of complaint and observed problems

Drugs, with dosages, currently being taken

Assessment based on diagnostics, plan for further tests or medications

Returning visit for follow up, if needed

Front 97

Diagnostic examination

Back 97

Looking for clinical findings related to CC

Front 98

General examination

Back 98

Looking for findings that the pt may not even be aware of and is designed to assess general health as a modality for finding disease early with information intervention

Front 99

Auscultation

Back 99

Listening with stethoscope for wheezing, rubs, bowel sounds, bruits, rales, rhonchi, and adventitious sounds

Front 100

Percussion

Back 100

Tapping with intent of differentiating solid from hollow structures organs, tissue, and masses

Front 101

Visual inspection

Back 101

Identifying symmetry, erythema, or other visual signs

Front 102

Palpation

Back 102

Touching and feeling

Front 103

EHR

Back 103

Electronic health records, detailed digital account of a pt paper chart that is accessible to all authorized medical users