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Chapter 4 - The Medical Record

Common Medical Record Terms Related to Disease

AB
acutesharp; having severe symptoms and a short course
chronica condition developing slowly and persisting over time
benignmild or noncancerous
malignantharmful or cancerous
degenerationgradual deterioration of normal cells and body functions
degenerative diseaseany disease in which there is deterioration of structure or function of tissue
diagnosis (dia=through; gnosis=knowing)determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results)
etiology (etio=cause)cause of a disease
exacerbation (ex=out; acerbo=harsh)increase in severity of a disease with aggravation of symptoms
remissiona period in which symptoms and signs stop or abate
febrilerelating to a fever (temperature)
grosslarge; visible to naked eye
idiopathic (idio=one's own)a condition occurring without a clearly identified cause
localizedlimited to a definite area or part
systemicrelating to the whole body rather than only a part
malaisea feeling of unwellness, often the first indication of illness
markedsignificant
equivocalvague, questionable
morbiditya diseased state; sick
morbidity ratethe number of cases of a disease in a given year; the ratio of sick to well persons in a given population
mortalitythe state of being subject to death
mortality ratedeath rate; ratio of total number of deaths to total number in a given population
prognosisforeknowledge; prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease
progressivethe advance of a condition as signs and symptoms increase in severity
prophylaxix (pro=before; phylassein=to guard)a process or measure that prevents disease
recurrentto occur again; describes a return of symptoms and signs after a period of quiescence (rest or inactivity)
sequelaa disorder or condition after, and usually resulting from, a previous disease or injury
signa mark; objective evidence of disease that can be seen or verified by an examiner
symptomoccurrence; subjective evidence of disease that is perceived by the patient and often noted in his or her own words
syndromea running together; combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease (e.g., menopausal syndrome)
noncontributorynot involved in bringing on the condition or result
unremarkablenon significant or worthy of noting


Anne

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