Medical Terminology: Introduction to Medical Terminology PDF

Medical Terminology: A Living Language Seventh Edition Chapter 1 Introduction to Medical Terminology Copyright © 2019, 2016, 2013 Pearson Education,...

Medical Terminology: A Living Language Seventh Edition Chapter 1 Introduction to Medical Terminology Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Learning Objectives (1 of 3) 1.1 Discuss the four parts of medical terms. 1.2 Recognize word roots and combining forms. 1.3 Identify the most common prefixes and suffixes. 1.4 Define word building and describe a strategy for translating medical terms. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Learning Objectives (2 of 3) 1.5 State the importance of correct spelling of medical terms. 1.6 State the rules for determining singular and plural endings. 1.7 Discuss the importance of using caution with abbreviations. 1.8 Recognize the documents found in a medical record. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Learning Objectives (3 of 3) 1.9 Recognize the different healthcare settings. 1.10 Understand the importance of confidentiality. 1.11 Describe how drugs are named and classified. 1.12 Read and understand all abbreviations and notations in a written prescription. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Medical Terminology at a Glance (1 of 2) Studying medical terminology is like learning a new language. Basic rules for building terms will help you both build and translate many different words. You must be able to put words together or build words from their parts. – This is like piecing together a puzzle. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Medical Terminology at a Glance (2 of 2) It is impossible to memorize every medical term. You can determine the meaning of many terms from their word parts. – Word roots – Combining vowels – Prefixes – Suffixes https://globalrph.com/medical-terms-introduction/ Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Building Medical Terms From Word Parts (1 of 2) Word roots are the foundation of words. Prefixes are at the beginning of words and modify the word root. Suffixes are at the end of words and modify the word root. Combining vowels connect word parts. – There are always exceptions to these rules! Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved  https://www.google.com/imgres?imgurl=https%3A%2F%2Fimages.squarespace-cdn.com%2Fcontent%2Fv1%2F5e48489da899cd09424943db%2F1630007076798- EDCDTP88KIE2QWSE0JFI%2Fmedical%2Bterminology%2Bcourse%2Bbook%2Bquiz%2Bprefix%2Bword%2Broot%2Bsuffix%2Bnursing&imgrefurl=https%3A%2F%2Fwww.ezmedlearning.com%2Fblog%2Fmedical-terminology-word- root-list&tbnid=FR_WlPnjG-sggM&vet=12ahUKEwjC4ci18d3zAhWDD-wKHcfEB-8QMygOegUIARDMAQ..i&docid=lI700Hh6rg-3KM&w=1500&h=841&q=medical%20term%20example&ved=2ahUKEwjC4ci18d3zAhWDD-wKHcfEB- 8QMygOegUIARDMAQ Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Building Medical Terms From Word Parts (2 of 2) Word Part Example (Meaning) Word root cardiogram (record of the heart) Prefix Pericardium (around the heart) Suffix carditis (inflammation of the heart) Combining vowel cardiomyopathy (heart muscle disease) Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Word Roots (1 of 2) The word root is the foundation of the term. It gives a general sense of the word’s meaning. It often refers to a body system or part. – cardi = heart It may also describe an action. – cis = to cut Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Word Roots (2 of 2) Medical terms may have more than one root. – Osteoarthritis contains two roots, one combining vowel, and one suffix. Not all medical terms have a root. – Hypertrophy contains one prefix and one suffix. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Combining Vowel/Form (1 of 3) The combining vowel makes it easier to pronounce long terms. It is usually an "o." It is used in specific situations: – Between two word roots – Between a word root and a suffix that starts with a consonant Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Combining Vowel/Form (2 of 3) The combining vowel is not used if the suffix begins with a vowel: – Arthritis, not arthroitis It is used if the suffix begins with a consonant: – Arthroscope, not arthrscope Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Combining Vowel/Form (3 of 3) The combining vowel is typically used between two word roots, even if the second word root begins with a vowel: – Gastroenteritis, not gastrenteritis Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Combining Forms (1 of 4) When writing a word root by itself, the combining form is typically used. It is written in the form word root/combining vowel. – cardi/o – arthr/o – gastr/o Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Combining Forms (2 of 4) Combining Form Definition bi/o life carcin/o cancer cardi/o heart chem/o Chemical cis/o to cut dermat/o Skin enter/o small intestine gastr/o stomach Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Combining Forms (3 of 4) Combining Form Definition gynec/o female hemat/o blood immun/o immunity laryng/o voice box nephr/o kidney neur/o nerve ophthalm/o eye Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Combining Forms (4 of 4) Combining Form Definition ot/o ear path/o disease pulmon/o lung rhin/o nose Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Prefixes (1 of 2) Prefixes are added to the beginning of a term. They add meaning to terms: – Location of organ  sub- = below – Number of parts  mono- = one – Time (frequency)  post- = after Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Prefixes (2 of 2) Not all medical terms have a prefix. When written by itself, a prefix is followed by a hyphen. – intra- – hyper- – multi- Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Prefixes (1 of 6) Prefix Definition a- without an- without anti- against auto- Self brady- Slow de- without Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Prefixes (2 of 6) Prefix Definition dys- painful, difficult, abnormal endo- within, inner epi- above eu- normal ex- outward extra- outside of Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Prefixes (3 of 6) Prefix Definition hetero- different homo- same hyper- excessive hypo- below, insufficient in- not, inward inter- between intra- within Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Prefixes (4 of 6) Prefix Definition macro- large micro- small neo- new para- beside, abnormal, two like parts of a pair per- through Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Prefixes (5 of 6) Prefix Definition peri- around post- after pre- before pro- before pseudo- false re- again retro- backward, behind sub- under Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Prefixes (6 of 6) Prefix Definition tachy- fast trans- across ultra- beyond un- not Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Number Prefixes (1 of 2) Prefix Definition bi- two hemi- half mono- one multi- many nulli- none pan- all Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Number Prefixes (2 of 2) Prefix Definition poly- many quadri- four semi- partial, half tetra- four tri- three Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Suffixes (1 of 2) Suffixes are attached to the end of a term. They add meaning to terms: – Condition  -algia = pain – Disease  -itis = inflammation – Procedure  -ectomy = surgical removal Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Suffixes (2 of 2) All medical terms must have a suffix! – It is the only mandatory word part. When written by itself, a suffix is preceded by a hyphen. – -logy – -sclerosis – -cyte Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Suffixes (1 of 5) Suffix Definition -algia pain -cele protrusion -cyte cell -dynia pain -ectasis dilation -gen that which produces -genic producing Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Suffixes (2 of 5) Suffix Definition -ia condition -iasis abnormal condition -ism state of -it is inflammation -logist one who studies -logy study of Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Suffixes (3 of 5) Suffix Definition -lytic destruction -malacia abnormal softening -megaly enlarged -oma tumor, mass -opsy view of -osis abnormal condition -pathy disease Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Suffixes (4 of 5) Suffix Definition -plasm formation -plegia paralysis -ptosis drooping -rrhage abnormal flow -rrhagia abnormal flow condition -rrhea discharge -rrhexis rupture -sclerosis hardening Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Common Suffixes (5 of 5) Suffix Definition -stenosis narrowing -therapy treatment -trophy development Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Adjective Suffixes A suffix may be used to change a root into a complete word. These are known as adjective suffixes, and they translate as pertaining to. The new word created by adding the suffix can be used to modify another word. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Adjective Suffix Example To state that a patient has an ulcer in his or her stomach: – gastr/o = stomach – -ic = pertaining to – gastric = pertaining to the stomach – gastric ulcer = ulcer found in the stomach Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Adjective Suffixes (1 of 3) -ac -al -an -ar -ary -atic Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Adjective Suffixes (2 of 3) -eal -iac -ic -ical -ile -ine Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Adjective Suffixes (3 of 3) -ior -nic -ory -ose -ous -tic Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Surgical Suffixes Suffix Definition -centesis puncture to withdraw fluid -ectomy surgical removal -ostomy surgically create an opening -otomy cutting into -pexy surgical fixation -plasty surgical repair -rrhaphy suture -tome instrument to cut Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Procedural Suffixes Suffix Definition -gram record -graphy process of recording -meter instrument for measuring -metry process of measuring -scope instrument for viewing -scopic pertaining to visually examining -scopy process of visually examining Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Word Building (1 of 2) Word building involves putting word parts together to form new terms. It begins with knowing the meaning of the word parts and selecting the correct ones. While doing so, you must remember the rules regarding the location of each word part. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Word Building (2 of 2) For example: – hypo- = below or under – derm/o = the skin – -ic = pertaining to Combine these parts to form a term: – Hypodermic – This term means pertaining to under the skin. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Interpreting Medical Terms (1 of 2) Term to be translated: – gastroenterology Divide the term into its word parts: – gastr / o / enter / o / logy Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Interpreting Medical Terms (2 of 2) Define each word part: – gastr = stomach – o = combining vowel – enter = small intestine – o = combining vowel – -logy = study of Together these parts mean “the study of the stomach and small intestine.” Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Pronunciation Pronunciation differs according to place of birth and education. When in doubt, ask for the spelling! New terms in the book are introduced in bold type followed by a phonetic spelling in parentheses. Stressed syllables are in capital letters: – pericarditis (per ih car DYE tis) Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Spelling (1 of 2) There is only one correct way to spell a term. Changing one letter can change the meaning of a word. – abduction (moving away) versus adduction (moving toward) – ileum (small intestine) versus ilium (hip bone) Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Spelling (2 of 2) Sounds like si: – psy psychiatry (sigh-KIGH-ah-tree) – cy cytology (sigh-TALL-oh-gee) Sounds like dis: – dys dyspepsia (dis-PEP-see-ah) – dis dislocation (dis-low-KAY-shun) Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Singular and Plural Endings Many medical terms come from Greek or Latin words. Rules for forming plurals in these languages are different from English: – Plural of atrium is atria, not atriums Other words follow English rules: – Plural of ventricle is ventricles Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved General Rules for Plurals Word Ends In Singular Plural -a vertebra vertebrae -ax thorax thoraces -ex or -ix appendix appendices -is metastasis metastases -ma sarcoma sarcomata -nx phalanx phalanges -on ganglion ganglia -us nucleus nuclei -um ovum ova -y biopsy biopsies Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Abbreviations Abbreviations are commonly used in medical fields to save time. They can be confusing! If you are concerned about confusion, spell out the term. Do not use your own personal abbreviations! Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (1 of 13) The medical record details: – The patient's day-to-day condition – The type and time of services provided – The patient’s response to treatment All personnel with patient contact complete appropriate reports. The medical records department ensures all documents are present, complete, signed, and in order. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (2 of 13) The electronic medical record (EMR) is a software program. It allows entry of patient information into a computer. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (3 of 13) Once digitally stored, EMR information can be: – Analyzed and monitored to detect and prevent potential errors. – Easily accessed and shared between healthcare providers.  Reduces repeating tests unnecessarily.  Reduces inadvertent medication errors. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (4 of 13) History and Physical – Written by the admitting physician. – Details the patient's:  History  Exam results  Initial diagnosis  Plan of treatment Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (5 of 13) Physician's Orders – Ordered by the doctor. – Provides a complete list of:  Care  Medications  Tests  Treatments Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (6 of 13) Nurse's Notes – Completed by the nursing staff to record the patient's care throughout the day. – Includes:  Vital signs  Treatment specifics  Patient's response to treatment  Patient's condition Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (7 of 13) Physician's Progress Notes – The physician’s daily record of the patient's condition. – Generally include:  Results of the physical exam  Summary of test results  Updated assessment and diagnoses  Further plans for treatment Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (8 of 13) Consultation Reports – Given by a specialist when the physician asks for patient evaluation. Ancillary Reports – From various treatments and therapies. – May include rehabilitation, social services, respiratory therapy, or dietetics. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (9 of 13) Diagnostic Reports – Include the results of all diagnostic tests performed on the patient. – They are often written by the lab or the medical imaging department. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (10 of 13) Informed Consent – A document voluntarily signed by the patient or responsible party. – It clearly describes the purpose, methods, procedures, benefits, and risks of procedures. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (11 of 13) Operative Report – From a surgeon detailing an operation. – Includes:  Pre- and post-operative diagnoses  Specific details of the procedure  How the patient tolerated the procedure Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (12 of 13) Anesthesiologist's Report – Provides details of any drugs given to patient during surgery. – Includes patient response to anesthesia and vital signs during surgery. Pathologist's Report – A report given by a pathologist who studies tissue removed from the patient Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved The Medical Record (13 of 13) Discharge Summary – Outlines the patient's entire hospital stay. – Includes:  Condition at admission  Admitting diagnosis  Test results or treatments  Patient's response  Final diagnosis and follow-up plans Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Healthcare Settings (1 of 7) Acute Care or General Hospitals – Provide services to diagnose and treat diseases for a short period of time. Specialty Care Hospitals – Provide care for a specific type of disease. – Examples: psychiatric hospital or children’s hospital Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Healthcare Settings (2 of 7) Nursing Homes or Long-Term Care Facilities – Provide long-term care for patients who need extra time to recover before going home. – They also provide care for persons who cannot care for themselves. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Healthcare Settings (3 of 7) Ambulatory Care Centers, Surgical Centers, or Outpatient Clinics – Provide services to patients who do not need overnight care. – They offer simple surgeries, therapies, or diagnostic testing. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Healthcare Settings (4 of 7) Physician's Offices – An individual or group of doctors providing diagnostic and treatment services in an office setting. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Healthcare Settings (5 of 7) Health Maintenance Organization (HMO) – A group of primary care physicians, specialists, and other healthcare professionals. – The HMO provides wide range of services in a pre-paid system. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Healthcare Settings (6 of 7) Home Health Care – Agencies that provide nursing, therapy, personal care, or housekeeping services in the patient's home. Rehabilitation Centers – Provide physical and occupational therapy in inpatient and outpatient settings. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Healthcare Settings (7 of 7) Hospices – Organized groups of health workers that provide supportive treatment to terminally ill patients and their families. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Confidentiality (1 of 2) Any information or record relating to a patient is considered privileged. Healthcare workers have a moral and legal responsibility to keep all information private. Proper authorization must be signed by the patient before any information can be released. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Confidentiality (2 of 2) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) set federal standards for protecting records and medical information. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Pharmacology Pharmacology is the study of the origin, characteristics and effects of drugs. Drugs come from many sources and may be: – Natural  From food, animals, plants, or fungi – Synthetic  Artificially developed in a laboratory Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Drug Names (1 of 2) Drugs have three names: – Chemical name  The description of the chemical formula – Generic name  The official name of the drug – Brand name  The manufacturer’s unique trademark name for the drug Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Drug Names (2 of 2) A drug name example with ibuprofen: – Chemical name  2-p-isobutyl phenyl propionic acid – Generic name  ibuprofen – Brand name  Motrin™  Advil™  Nuprin™ Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Legal Classification of Drugs (1 of 4) A prescription drug can only be ordered by a licensed healthcare practitioner. – It requires a written prescription. – The prescription serves as instructions to the pharmacist. An over-the-counter (OTC) drug does not require a prescription. – Should be used under advisement of a physician or pharmacist. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Legal Classification of Drugs (2 of 4) Drugs that are addictive or have the potential to be abused are controlled substances. The Drug Enforcement Agency (DEA) classifies these drugs as Schedule I through Schedule V. Codeine, oxycontin, and morphine are all examples of controlled substances. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Legal Classification of Drugs (3 of 4) Schedule I drugs have the highest potential for addiction. – Examples: heroin, LSD Schedule II drugs have a high potential for addiction. – Examples: codeine, morphine Schedule III drugs have a moderate potential for addiction. – Example: butabarbital Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Legal Classification of Drugs (4 of 4) Schedule IV drugs have a lower potential for addiction. – Examples: phenobarbital, diazepam Schedule V drugs have a low potential for addiction. – Example: codeine cough suppressant Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved How to Read a Prescription (1 of 2) Prescriptions use many abbreviations based on Latin and Greek words. – The abbreviation po means to be taken by mouth. To be legal, a prescription must have: – Date – Physician name, address, and DEA number, and signature – Patient’s name and birth date Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved How to Read a Prescription (2 of 2) Some abbreviations are common to prescriptions. – Rx: The drug prescribed – mg: Milligram, a unit of measure – Sig: Instructions for the label – Disp: Amount to dispense, number of refills Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Figure 1-4 A sample prescription written by a physician. Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved Copyright Copyright © 2019, 2016, 2013 Pearson Education, Inc. All Rights Reserved