Family Medical Records Glossary of Terms

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Abdominal: Relating to the abdomen, the belly, that part of the body that contains all of the structures between the chest and the pelvis. The abdomen is separated anatomically from the chest by the diaphragm, the powerful muscle spanning the body cavity below the lungs.
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Abdominal pain: Pain in the belly (the abdomen). Abdominal pain can come from conditions affecting a variety of organs. The abdomen is an anatomical area that is bounded by the lower margin of the ribs above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (the skin and abdominal wall muscles), the term abdominal pain generally is used to describe pain originating from organs within the abdominal cavity (from beneath the skin and muscles). These organs include the stomach, small intestine, colon, liver, gallbladder, and pancreas.
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Abnormal: Not normal. Deviating from the usual structure, position, condition, or behavior. In referring to a growth, abnormal may mean that it is cancerous or premalignant (likely to become cancer).

Allergic reaction: The hypersensitive response of the immune system of an allergic individual to a substance.
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Allergy: A misguided reaction to foreign substances by the immune system, the body system of defense against foreign invaders, particularly pathogens (the agents of infection). The allergic reaction is misguided in that these foreign substances are usually harmless. The substances that trigger allergy are called allergen. Examples include pollens, dust mite, molds, danders, and certain foods. People prone to allergies are said to be allergic or atopic.
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Anxiety: A feeling of apprehension and fear characterized by physical symptoms such as palpitations, sweating, and feelings of stress. Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults. These disorders fill people's lives with overwhelming anxiety and fear. Unlike the relatively mild, brief anxiety caused by a stressful event such as a business presentation or a first date, anxiety disorders are chronic, relentless, and can grow progressively worse if not treated.
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Asthma: A common disorder in which chronic inflammation of the bronchial tubes (bronchi) makes them swell, narrowing the airways. Asthma involves only the bronchial tubes and does not affect the air sacs (alveoli) or the lung tissue (the parenchyma of the lung) itself.
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Baseline: 1. Information gathered at the beginning of a study from which variations found in the study are measured.
2. A known value or quantity with which an unknown is compared when measured or assessed.
3. The initial time point in a clinical trial, just before a participant starts to receive the experimental treatment which is being tested. At this reference point, measurable values such as CD4 count are recorded. Safety and efficacy of a drug are often determined by monitoring changes from the baseline values.

Blood clots: Blood that has been converted from a liquid to a solid state. Also called a thrombus.
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Blood pressure: The blood pressure is the pressure of the blood within the arteries. It is produced primarily by the contraction of the heart muscle. It's measurement is recorded by two numbers. The first (systolic pressure) is measured after the heart contracts and is highest. The second (diastolic pressure) is measured before the heart contracts and lowest. A blood pressure cuff is used to measure the pressure. Elevation of blood pressure is called "hypertension".

Breathing: The process of respiration, during which air is inhaled into the lungs through the mouth or nose due to muscle contraction, and then exhaled due to muscle relaxation.

Cancer: An abnormal growth of cells which tend to proliferate in an uncontrolled way and, in some cases, to metastasize (spread).
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Chest: The area of the body located between the neck and the abdomen. The chest contains the lungs, the heart and part of the aorta. The walls of the chest are supported by the dorsal vertebrae, the ribs, and the sternum.
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Cholesterol: The most common type of steroid in the body, cholesterol has gotten something of a bad name. However, cholesterol is a critically important molecule.
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Chronic: This important term in medicine comes from the Greek chronos, time and means lasting a long time.
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CPR: Cardiopulmonary resuscitation. Also cardiac and pulmonary rehabilitation and computer-based patient records.

Diabetes: Refers to diabetes mellitus or, less often, to diabetes insipidus. Diabetes mellitus and diabetes insipidus share the name "diabetes" because they are both conditions characterized by excessive urination (polyuria).
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Diagnosis: 1 The nature of a disease; the identification of an illness. 2 A conclusion or decision reached by diagnosis. The diagnosis is rabies. 3 The identification of any problem. The diagnosis was a plugged IV.
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Durable power of attorney: This is a type of advance medical directive in which legal documents provide the power of attorney to another person in the case of an incapacitating medical condition.
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Emergency department: The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care. Emergency department personnel may also respond to certain situations within the hospital such cardiac arrests.
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Emphysema: 1) A lung condition featuring an abnormal accumulation of air in the lung's many tiny air sacs, a tissue called alveoli. As air continues to collect in these sacs, they become enlarged, and may break, or be damaged and form scar tissue. Emphysema is strongly associated with smoking cigarettes, a practice that causes lung irritation. It can also be associated with or worsened by repeated infection of the lungs, such as is seen in chronic bronchitis. The best response to the early warning signs of emphysema is prevention: stop smoking and get immediate treatment for incipient lung infections. Curing established emphysema is not yet possible. Because patients don't have an adequate amount of space in the lungs to breathe, they gasp for breath, and may not be able to obtain enough oxygen. Those with severe emphysema usually end up using an oxygen machine to breathe. In some cases, medication may be helpful to ease symptoms or to treat infection in already-damaged lungs.
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Essential: 1. Something that cannot be done without.
2. Required in the diet, because the body cannot make it. As in an essential amino acid or an essential fatty acid.
3. Idiopathic. As in essential hypertension. "Essential" is a hallowed term meaning "We don't know the cause."

Family physician: A physician who is educated and trained in family practice.
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Headache: A pain in the head with the pain being above the eyes or the ears, behind the head (occipital), or in the back of the upper neck. Headache, like chest pain or back ache, has many causes.
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Health Insurance Portability & Accountability Act: See: HIPAA.

Heart: The muscle that pumps blood received from veins into arteries throughout the body. It is positioned in the chest behind the sternum (breastbone; in front of the trachea, esophagus, and aorta; and above the diaphragm muscle that separates the chest and abdominal cavities. The normal heart is about the size of a closed fist, and weighs about 10.5 ounces. It is cone-shaped, with the point of the cone pointing down to the left. Two-thirds of the heart lies in the left side of the chest with the balance in the right chest.
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Herbal: 1. An adjective, referring to herbs, as in an herbal tea.
2. A noun, usually reflecting the botanical or medicinal aspects of herbs; also a book which catalogs and illustrates herbs.
The word "herbal" was pronounced with a silent "h" on both sides of the Atlantic until the 19th century but this usage persists only on the American side.

High blood pressure: Also known as hypertension, high blood pressure is, by definition, a repeatedly elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above 140 with a diastolic pressure above 90.
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HIPAA: Acronym that stands for the Health Insurance Portability and Accountability Act, a US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers. Developed by the Department of Health and Human Services, these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers across the country. State laws providing additional protections to consumers are not affected by this new rule. HIPAA took effect on April 14, 2003.

Hives: A raised, itchy area of skin that is usually a sign of an allergic reaction. It can be rounded or flat-topped but is always elevated above the surrounding skin. It reflects circumscribed dermal edema (local swelling of the skin). The hives are usually well circumscribed but may be coalescent and will blanch with pressure. They typically last less than 4 hours but they may stay for days or weeks. Approximately 20% of the population has experienced a bout of hives.
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Immunization: Vaccination. Immunizations work by stimulating the immune system, the natural disease-fighting system of the body. The healthy immune system is able to recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to ward off a disease. To immunize against viral diseases, the virus used in the vaccine has been weakened or killed. To immunize against bacterial diseases, it is generally possible to use only a small portion of the dead bacteria to stimulate the formation of antibodies against the whole bacteria. In addition to the initial immunization process, it has been found that the effectiveness of immunizations can be improved by periodic repeat injections or "boosters." Also see Immunizations (in the plural) and Immunization of a specific type (such Immunization, Polio).

Internal medicine: A medical specialty dedicated to the diagnosis and medical treatment of adults. A physician who specializes in internal medicine is referred to as an internist. A minimum of seven years of medical school and postgraduate training are focused on learning the prevention, diagnosis, and treatment of diseases of adults. Subspecialties of internal medicine include allergy and immunology, cardiology (heart), endocrinology (hormone disorders), hematology (blood disorders), infectious diseases, gastroenterology (diseases of the gut), nephrology (kidney diseases), oncology (cancer), pulmonology (lung disorders), and rheumatology (arthritis and musculoskeletal disorders).

Kidney: One of a pair of organs located in the right and left side of the abdomen which clear "poisons" from the blood, regulate acid concentration and maintain water balance in the body by excreting urine. The kidneys are part of the urinary tract. The urine then passes through connecting tubes called "ureters" into the bladder. The bladder stores the urine until it is released during urination.

Laboratory: A place for doing tests and research procedures and preparing chemicals, etc. Although "laboratory" looks very like the Latin "laboratorium" (a place to labor, a work place), the word "laboratory" came from the Latin "elaborare" (to work out, as a problem, and with great pains), as evidenced by the Old English spelling "elaboratory" designating "a place where learned effort was applied to the solution of scientific problems."

Liver: An organ in the upper abdomen that aids in digestion and removes waste products and worn-out cells from the blood. The liver is the largest solid organ in the body. The liver weighs about three and a half pounds (1.6 kilograms). It measures about 8 inches (20 cm) horizontally (across) and 6.5 inches (17 cm) vertically (down) and is 4.5 inches (12 cm) thick.

Medical history: 1. In clinical medicine, the patient's past and present which may contain clues bearing on their health past, present, and future. The medical history, being an account of all medical events and problems a person has experienced, including psychiatric illness, is especially helpful when a differential diagnosis is needed.
2. The history of medicine.

MedicAlert: A nonprofit emergency medical information service, known for its MedicAlert jewelry, particularly the bracelet, and its 24-hour emergency response center.
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Memory: 1. The ability to recover information about past events or knowledge. 2. The process of recovering information about past events or knowledge. 3. Cognitive reconstruction. The brain engages in a remarkable reshuffling process in an attempt to extract what is general and what is particular about each passing moment.
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MPH: Master of Public Health (a master's degree in this field of medicine).

Nausea: Nausea, is the urge to vomit. It can be brought by many causes including, systemic illnesses, such as influenza, medications, pain, and inner ear disease. When nausea and/or vomiting are persistent, or when they are accompanied by other severe symptoms such as abdominal pain, jaundice, fever, or bleeding, a physician should be consulted.

Nursing: 1) Profession concerned with the provision of services essential to the maintenance and restoration of health by attending the needs of sick persons. 2) Feeding a infant at the breast.

Pacemaker: A system that sends electrical impulses to the heart in order to set the heart rhythm. The pacemaker can be the normal "natural" pacemaker of the heart or it can be an electronic device.
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Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia. Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors.
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Pharmacist: A professional who fills prescriptions, and in the case of a compounding pharmacist, makes them. Pharmacists are familiar with medication ingredients, interactions, cautions, and hints.
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Pharmacy: A location where prescription drugs are sold. A pharmacy is, by law, constantly supervised by a licensed pharmacist.

Poison: Any substance that can cause severe distress or death if ingested, breathed in, or absorbed through the skin. Many substances that normally cause no problems, including water and most vitamins, can be poisonous if taken in too large of a quantity. Poison treatment depends on the substance: if there are treatment instructions on the substance's container and you are sure it contained no other item, follow those directions immediately. Always contact your nearest Poison Control Center if you are concerned about possible poison ingestion.

Poison Control Center: Special information centers set up to inform Americans about how to respond to potential poisoning. These centers maintain a database of poisons and appropriate emergency treatment. The Poison Control Center in your area should be listed with other community service numbers in the front of your telephone book, and can also be reached immediately through any telephone operator.
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Rash: Breaking out (eruption) of the skin. Medically, a rash is referred to as an exanthem.

Stress: Forces from the outside world impinging on the individual. Stress is a normal part of life that can help us learn and grow. Conversely, stress can cause us significant problems.
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Surgery: The word "surgery" has multiple meanings. It is the branch of medicine concerned with diseases and conditions which require or are amenable to operative procedures. Surgery is the work done by a surgeon. By analogy, the work of an editor wielding his pen as a scalpel is s form of surgery. A surgery in England (and some other countries) is a physician's or dentist's office.
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Symptom: Any subjective evidence of disease. Anxiety, lower back pain, and fatigue are all symptoms. They are sensations only the patient can perceive. In contrast, a sign is objective evidence of disease. A bloody nose is a sign. It is evident to the patient, doctor, nurse and other observers.

Temple: An area just behind and to the side of the forehead and the eye, above the side of the check bone (the zygomatic arch) and in front of the ear.
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Tetanus: An often fatal infectious disease caused by the bacteria Clostridium tetani (C. tetani) which usually enters the body through a puncture, cut, or open wound. Tetanus is characterized by profoundly painful spasms of muscles, including "locking" of the jaw so that the mouth cannot open (lockjaw). C. tetani releases a toxin that affects the motor nerves, (the nerves which stimulate the muscles).
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Toxicology: The study of the nature, effects and detection of poisons and the treatment of poisoning.

Unconscious: 1. Interruption of awareness of oneself and one's surroundings, lack of the ability to notice or respond to stimuli in the environment. A person may become unconscious due to oxygen deprivation, shock, central nervous system depressants such as alcohol and drugs, or injury.
2. In psychology, that part of thought and emotion that happens outside everyday awareness.

X-ray: 1. High-energy radiation with waves shorter than those of visible light. X-rays possess the properties of penetrating most substances (to varying extents), of acting on a photographic film or plate (permitting radiography), and of causing a fluorescent screen to give off light (permitting fluoroscopy). In low doses X-rays are used for making images that help to diagnose disease, and in high doses to treat cancer. Formerly called a Roentgen ray. 2. An image obtained by means of X-rays.