1. Patient History
Definition: A comprehensive record of a patient’s past and present health issues.
Example: “Let’s go over your patient history to understand any prior conditions.”
2. Chief Complaint
Definition: The main reason a patient seeks medical help.
Example: “The patient’s chief complaint is severe chest pain.”
3. Vital Signs
Definition: Key indicators of a patient’s health, including heart rate, blood pressure, and temperature.
Example: “Let’s check her vital signs before we proceed.”
4. Assessment
Definition: The process of evaluating a patient’s condition.
Example: “We’ll conduct a thorough assessment before diagnosing.”
5. Triage
Definition: Prioritizing patient treatment based on the severity of their condition.
Example: “We triage patients in the ER based on urgency.”
6. Bedside Manner
Definition: The way healthcare providers interact with patients, showing compassion and professionalism.
Example: “Good bedside manner can make patients feel more comfortable.”
7. Medical Chart
Definition: A record of a patient’s health information and treatment history.
Example: “All notes should be documented in the patient’s medical chart.”
8. Follow-Up
Definition: Continuing care and evaluation after initial treatment.
Example: “Schedule a follow-up visit to monitor your recovery.”
9. Informed Consent
Definition: A patient’s agreement to a procedure after understanding the risks and benefits.
Example: “We need informed consent before the surgery.”
10. Rounds
Definition: Visits by healthcare professionals to patients in the hospital.
Example: “I’ll see you during rounds tomorrow morning.”
Diagnosis
11. Differential Diagnosis
Definition: A list of possible conditions based on symptoms.
Example: “We’re working through a differential diagnosis to rule out other causes.”
12. Prognosis
Definition: The likely course or outcome of a disease.
Example: “The prognosis for recovery is very good.”
13. Lab Results
Definition: Findings from laboratory tests that aid in diagnosis.
Example: “We’re waiting on lab results to confirm the diagnosis.”
14. Screening
Definition: Tests to detect early signs of disease.
Example: “Routine screening can help catch issues early.”
15. Symptom
Definition: A physical or mental feature indicating a condition.
Example: “Coughing is a common symptom of respiratory infection.”
16. Risk Factor
Definition: Elements that increase the likelihood of disease.
Example: “Smoking is a major risk factor for lung disease.”
17. Case Study
Definition: Detailed analysis of a specific case for educational purposes.
Example: “We’ll discuss a case study on heart disease.”
18. Diagnosis
Definition: The identification of a condition based on symptoms and tests.
Example: “The diagnosis is based on the patient’s symptoms and history.”
19. Benign
Definition: Non-cancerous; not harmful in effect.
Example: “The tumor is benign and won’t spread.”
20. Malignant
Definition: Cancerous; can be life-threatening if untreated.
Example: “The biopsy showed the growth is malignant.”
21. Treatment Plan
Definition: The approach to managing a patient’s condition.
Example: “We’ll discuss your treatment plan after the consultation.”
22. Prescription
Definition: A doctor’s written order for medication.
Example: “I’ll write you a prescription for antibiotics.”
23. Dosage
Definition: The amount of medication to be taken.
Example: “Take the prescribed dosage twice a day.”
24. Over-the-Counter (OTC)
Definition: Medications available without a prescription.
Example: “You can get this pain reliever over-the-counter.”
25. Side Effects
Definition: Unintended effects of a medication.
Example: “Drowsiness is a common side effect.”
26. Administer
Definition: To give medication or treatment to a patient.
Example:“I’ll administer the medication as prescribed.”
27. Therapy
Definition: Treatment for a condition, often physical or mental.
Example: “Physical therapy can help with mobility.”
28. Surgery
Definition: A medical procedure involving an incision.
Example: “The patient needs surgery to remove the tumor.”
29. Alternative Medicine
Definition: Non-traditional therapies, like acupuncture or herbal remedies.
Example: “Some patients prefer alternative medicine approaches.”
30. Antibiotic
Definition: A medication to fight bacterial infections.
Example: “Antibiotics are prescribed for bacterial infections, not viral ones.”
31. Biopsy
Definition: A sample of tissue for diagnostic testing.
Example: “We’ll perform a biopsy to check for cancer cells.”
32. Imaging
Definition: Diagnostic scans, such as X-rays or MRIs.
Example: “Imaging shows no fractures.”
33. X-Ray
Definition: A scan to view inside the body, especially bones.
Example: “An X-ray will show if there’s a break.”
34. Ultrasound
Definition: Imaging that uses sound waves to view internal organs.
Example: “We’ll do an ultrasound to examine your heart.”
35. MRI (Magnetic Resonance Imaging)
Definition: A scan that produces detailed images of organs.
Example: “An MRI is scheduled to check for soft tissue damage.”
36. CT Scan (Computed Tomography)
Definition: A scan that provides cross-sectional images of the body.
Example: “A CT scan can give us a detailed view of the organs.”
37. Physical Exam
Definition: A general check-up to assess health.
Example: “I’ll conduct a physical exam to check your vitals.”
38. Blood Test
Definition: A test that analyzes a blood sample for health markers.
Example: “A blood test will help us identify any issues.”
39. IV (Intravenous)
Definition: Administering fluids or medication directly into the vein.
Example: “We’ll start an IV for fluid administration.”
40. Vaccination
Definition: Injection to protect against specific diseases.
Example: “A flu vaccination is recommended each year.”
41. Consultation
Definition: A meeting between patient and healthcare provider to discuss health.
Example: “The patient has a consultation scheduled with the specialist.”
42. Referral
Definition: Sending a patient to a specialist for further care.
Example: “I’m giving you a referral to a cardiologist.”
43. Medical Record
Definition: A comprehensive file containing a patient’s health history.
Example: “All information will be recorded in your medical record.”
44. SOAP Notes (Subjective, Objective, Assessment, Plan)
Definition: A standardized way for healthcare providers to document notes.
Example: “SOAP notes keep our patient assessments organized.”
45. Patient Compliance
Definition: When a patient follows the prescribed treatment.
Example: “Patient compliance is essential for effective treatment.”
46. Discharge Summary
Definition: A summary of care provided and instructions upon discharge.
Example: “I’ll prepare your discharge summary before you leave.”
47. Health Literacy
Definition: A patient’s ability to understand health information.
Example: “Health literacy ensures patients understand treatment instructions.”
48. Second Opinion
Definition: An additional medical opinion for a diagnosis or treatment.
Example: “You can seek a second opinion if you’re unsure.”
49. Inpatient
Definition: A patient who stays in the hospital for treatment.
Example: “You’ll be an inpatient until your surgery.”
50. Outpatient
Definition: A patient who receives treatment without staying in the hospital.
Example: “It’s a simple procedure, so you’ll be an outpatient.”
51. Acute
Definition: A condition that is severe and sudden in onset.
Example: “The patient presented with acute abdominal pain.”
52. Chronic
Definition: A condition that persists over a long time, often with a slow progression.
Example: “Diabetes is a chronic condition that requires ongoing management.”
53. Pathogen
Definition: A microorganism that causes disease, like bacteria, viruses, or fungi.
Example: “The lab identified the pathogen responsible for the infection.”
54. Inflammation
Definition: The body’s response to injury or infection, often causing redness, swelling, and pain.
Example: “The inflammation is likely due to an infection.”
55. Allergic Reaction
Definition: An immune response to a substance that is not typically harmful.
Example: “The patient had an allergic reaction to penicillin.”
56. Hypotension
Definition: Abnormally low blood pressure.
Example: “Her hypotension may explain the dizziness.”
57. Hypertension
Definition: Abnormally high blood pressure.
Example: “We need to monitor his hypertension closely.”
58. Relapse
Definition: The return of a disease or symptoms after improvement.
Example: “The patient experienced a relapse after stopping treatment.”
59. Remission
Definition: A period during which symptoms of a disease are reduced or disappear.
Example: “The patient’s cancer is currently in remission.”
60. Congenital
Definition: A condition present from birth, often due to genetic factors.
Example: “The baby was diagnosed with a congenital heart defect.”
61. Pain Scale
Definition: A tool used to measure a patient’s pain, typically from 0 to 10.
Example: “On a pain scale of 0 to 10, how would you rate your pain?”
62. Bed Rest
Definition: A treatment directive requiring the patient to stay in bed.
Example: “The doctor has prescribed two weeks of bed rest.”
63. Bedpan
Definition: A device used by patients who cannot leave their beds to use the toilet.
Example: “I’ll bring you a bedpan if you need one.”
64. Comfort Measures
Definition: Non-medical actions taken to improve a patient’s comfort, like adjusting their bed or providing extra pillows.
Example: “Comfort measures were provided to ease her pain.”
65. Vitals Check
Definition: Routine measurement of a patient’s vital signs, including temperature, blood pressure, and pulse.
Example: “Let’s do a vitals check before the morning round.”
66. Pain Management
Definition: Methods used to reduce or control pain in patients.
Example: “Effective pain management is essential after surgery.”
67. Respiratory Rate
Definition: The number of breaths a person takes per minute.
Example: “Her respiratory rate was slightly elevated.”
68. Palliative Care
Definition: Supportive medical care that focuses on comfort rather than cure, often for terminal illnesses.
Example: “Palliative care can help manage symptoms in end-stage cancer.”
69. Advance Directive
Definition: A legal document outlining a patient’s preferences for end-of-life care.
Example: “The patient has an advance directive requesting no resuscitation.”
70. Patient Confidentiality
Definition: The ethical practice of protecting a patient’s private health information.
Example: “Maintaining patient confidentiality is essential in all healthcare settings.”
71. Intake Form
Definition: A form used to collect a patient’s personal and health information during the initial visit.
Example: “Please complete the intake form before your appointment.”
72. Discharge Instructions
Definition: Guidelines provided to a patient upon leaving the hospital or clinic.
Example: “Follow the discharge instructions closely to aid your recovery.”
73. Medical Summary
Definition: A document that provides an overview of a patient’s medical history and treatments.
Example: “The medical summary will include all treatment details.”
74. Progress Notes
Definition: Notes documenting a patient’s condition and response to treatment.
Example: “We’ll update progress notes daily.”
75. SOAP Format
Definition: A method for documenting patient notes, standing for Subjective, Objective, Assessment, and Plan.
Example: “All consultations should be recorded using the SOAP format.”
76. Chief Complaint (CC)
Definition: The main reason a patient seeks medical care.
Example: “The chief complaint is shortness of breath.”
77. Sign vs. Symptom
Definition: A ‘sign’ is an objective indicator (e.g., rash), while a ‘symptom’ is subjective (e.g., headache).
Example: “Fever is a sign, while nausea is a symptom.”
78. Chart Review
Definition: Examining a patient’s medical records to understand their history and current condition.
Example: “The nurse did a chart review before the doctor’s rounds.”
79. Electronic Health Record (EHR)
Definition: A digital version of a patient’s medical history.
Example: “All records are now stored in the electronic health record system.”
80. Patient Portal
Definition: A secure online platform for patients to access their health information.
Example: “Patients can view their test results through the patient portal.”
81. CPR (Cardiopulmonary Resuscitation)
Definition: A life-saving technique used in emergencies for patients not breathing or whose heart has stopped.
Example: “CPR was initiated immediately on the unresponsive patient.”
82. Code Blue
Definition: A hospital code indicating a patient in critical need of resuscitation, often cardiac arrest.
Example: “We have a code blue in Room 203.”
83. AED (Automated External Defibrillator)
Definition: A portable device that can help restart a person’s heart in an emergency.
Example: “An AED was used to revive the patient.”
84. ER (Emergency Room)
Definition: The section of a hospital providing immediate treatment for urgent cases.
Example: “The patient was taken to the ER after the accident.”
85. Stabilize
Definition: To make a patient’s condition steady and improve chances for recovery.
Example: “We need to stabilize her before transferring her to surgery.”
86. First Responder
Definition: The first healthcare provider to arrive and provide assistance at an emergency scene.
Example: “The first responder administered basic life support.”
87. Trauma
Definition: Physical or emotional injury, often from an accident.
Example: “The patient suffered major trauma to the chest.”
88. Intubation
Definition: The process of inserting a tube into a patient’s airway to assist with breathing.
Example: “Intubation was required to secure the patient’s airway.”
89. Hemorrhage
Definition: Excessive or uncontrolled bleeding.
Example: “The patient was rushed to surgery to control the hemorrhage.”
90. Shock
Definition: A life-threatening condition with insufficient blood flow, often following severe injury or trauma.
Example: “The patient is in shock and needs immediate intervention.”
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