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Medical Terminology for the Vocational Professional By Judith A. Cooney RN, MSN, CCM Objectives 1. Participant will be able to distinguish the difference between appropriate medical terminology and non medical terminology 2. Participant will be able to differentiate between acute vs chronic references to processes 3.The participant will able to verbalize the difference between reliable, reputable resources vs non reputable, non reliable resources. medical terminology and non medical terminology Medical terminology is language that is used to accurately describe the human body and associated components, conditions and processes in a science-based manner. Why is that important? Medical terminology “ The DR opines the IW’s pain comes from before or after the fusion” The DR opines the IW’s pain originates from a site either superior or inferior to the recent fusion site. General Anatomy Superior Inferior Lateral Medial Anterior = front Posterior = back Adduction = add to or move towards medial Abduction = move away from medial Plantar = bottom surface of foot or palmar surface of hand Dorsal= top surface of the foot or hand Proximal = closer to the attachment point Distal = more distant from the attachment point Vocabulary Abbreviations Prefixes & suffixes Root words General – anatomical markers Systems – anatomical & provider Operative terms Context and Drafter In context – what field – medical vs legal Drafter – Pulmonary VS GI Example = c/o BS Medium Written – c/o Spoken – HNP vs H&P Abbreviations ADJ - adjuster A.D. - right ear ( auris dextra) A.S. – left ear ( auris sinistra) BP – blood pressure BS – breath sounds, bowel sounds C1, C2 – cervical disc C – with CA – carcinoma CC – chief complaint, cubic centimeter, carbon copy CNS – central nervous system CVA – cardiovascular accident ( stroke) Dx – diagnosis ER – emergency room OR employer ESI – epidural steroid injection FCE – Functional Capacity Evaluation FH – family history GE – gastroenterology GI – gastrointestinal GU – genitourinary abbreviations IW – injured worker IME – Independent Medical Evaluation L1, L2 – lumbar disc NAD – no appreciable disease NV – nausea, vomitting O- objective OD – right eye ( ocula dextra) OS – left eye ( ocula sinistra) PDL – physical demand level A & P – ausculation & percussion OR anatomy & physiology P - plan PE – physical exam OR pulmonary emboli PH -( PMH) past medical history PT – physical therapy OR patient S – without OR subjective SN – skilled nursing or special needs TPR – temp, pulse, resp VS – vital signs ABBREVIATIONS RESOURCES – Medilexicon.com http://www.abbreviations.com/ Prefixes a, an = without Ab, apo-de = from, out of Ambi = both Ante, pre, pro = before Anti, contra, counter = against Circum, peri = Around Con,com,syn,syn = with, together Dextro = to the right of Dia, per,trans = through Dis = apart, from Dorsi = backwards Dys = painful, bad E,ec, ex = out from, away Ecto, exo,extra = outside Em, en, im, in = in Endo, ento, intra = within Epi = upon Eso = inward •Hemi = half •Hyper, per,ultra = excessive, beyond •Hypo, sub = under •Infero, infra = low •Inter = between •Intra = withiin •Intro = into •Latero = to the side •Mesa = middle •Para = beside •Peri = around •Postero = behind •Retro, re = backward •Sinistro = to the left of •Spondylo = spinal column or vertabra •Sub = below •Super, supra = above, more Suffixes Algia = pain Cele – swelling Cleisis = closure Cyst = sac of fluid Ectasia, ectasis = expansion Emia = relating to blood Esthesia = sensation Iasis = condition of Itis = inflammation Lith = stone Lysis – breakdown Lysthesis = slip or slide Malacia = softening Opia = vision Oma = tumor Osis = condition or abnormal state Paresis = weakness Pathy = disease Phagia = eating, swallowing Phasia = speaking Plasia = growth, formation Plegia = paralysis Pnea – breath Ptosis – failing Rhage, (r)hagia = bursting forth (r) rhea = flow Rhexis = rupture Stasis = stopping, position Staxis = discharge by drops Trophy = nourishment Root words Angi, vaso = vessel Arthr = joint Bronch = of the lung Cardi = heart Cephal = head Cervic = neck Chondro = cartilage Coccy = coccyx ( tailbone) Col = colon ( lg intestine) Cost = rib Coxa = hip Crani = skull Cutis = skin Cysto = bladder Derm = skin Encephalo = brain Gastro = stomach Hepat = liver Ileo = 3rd section of small intestine Ilio = hipbone Myal = bone marrow or spinal cord Myo = muscle Nephro = kidney Neuro = nerve Opthalm, opto = eye Ossa, oste = bone Oto = ear Pes = foot Phleb = vein Pneumo = lung, air Ren = kidney Rhino = nose Teno, tendo = tendon Thorac = thorax Tracheo = of the trachea resources http://en.wikipedia.org/wiki/List_of_medical_r oots,_suffixes_and_prefixes http://www.thefreedictionary.com/application Practice Dyspnea = pain + breathing Dysphasia = difficulty + speaking Dysphagia = difficulty + swallowing Hemiplegia = half + paralyzed Hemiparesis = half + weakness Submaximal = below + maximum Arthritis = joint + inflammation Chondromalacia = cartilage + softening More practice Spondylosis is a term referring to degenerative osteoarthritis of the joints between the centre of the spinal vertebrae and/or neural foraminae Spondylolysis is a defect of a vertebra. More specifically it is defined as a defect in the pars interarticularis of the vertebral arch. When spondylolysis is present in the spine, it means that the pars interarticularis is detached and there is a separation of the joints. Spondylo = vertabrae Spondylolisthesis is the anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. Operative Terms Incision Otomy = cutting Ostomy = cutting to form an opening for drainage Centesis = puncture Excision Ectomy = cutting out Amputation Disarticulation – at the joint Dismemberment – through the bone Introduction Resection = subtotal removal Radical excision = total removal Injection of Transfusion of Implantation of radioactive sustances Insertion of Endoscopy Looking within Operative Terms Repair Destruction Clasis = destroy Tripsy = crush Lysis = free Suture Plasty = Repair, reform Desis = fusion, binding Pexy = fixation, suspension Ostomy = formation of permanent opening between two normally distinct places Graft = transplanting tissue from one site to another Open reduction = restore fracture to normal alignment via surgical incision (r) raphy = sewing Manipulation Ectasia, tsis = stretch Closed reduction = restore fracture to normal alignment without incision Application = the act of bringing something into contact practice Arthroplasty = joint + repair Craniotomy = skull + cutting Colostomy = lrg intestine + cutting to form an opening for drainage acute vs chronic references to processes The NIH defines acute conditions as severe and sudden in onset that is brief in its duration; while a chronic condition, by contrast is a long-developing. Therefore an acute condition not treated appropriately can develop into a chronic condition. While chronic symptoms or even a syndrome can improve over time, a chronic defect does not. Your suffixes are going to help you indentify acute vs chronic processes. Pathy = disease Lysis – breakdown Ortho testing Now that you are more familiar with medical terminology you should be able to decipher the description of any testing referred to in medical documentation. Lets practice!!! – Clonus test = the foot is dorsiflexed by the examiner which elicits repetitive, uncontrolled up and down motion of the ankle. This is a + test indicating pressure on the spinal cord. Ortho testing continued Impingement syndrome = The shoulder is forcefully abducted and internally rotated causing the greater tuberosity to press against the undersurface of the acromion. c/o discomfort = positive finding. Ortho testing continued Hoffmans test = Fingernail of the long finger is pinched and the examiner notes flexion of the distal phalanx of the other digits = indicative of pathology affecting the spinal cord in the cervical region FCE Sample pending reliable, reputable resources vs non reputable, non reliable resources. Obvious resource references Dr. Oz American Medical Association Less Obvious resource references Any definition that uses the same term in the definition is poor Any resource > 10 years old except historic or standards of the associated resource Any resource not supported references and subsequent research resources Tabers Medical Dictionary http://en.wikipedia.org/wiki/List_of_medical_r oots,_suffixes_and_prefixes http://www.thefreedictionary.com/application http://www.abbreviations.com/ http://www.globalrh.com/medterm.htm