Key Medical Terms, Drug Action, and Clinical Documentation

Posted on May 22, 2025 in Medicine & Health

Essential Medical Vocabulary and Concepts

Common Medical Terms and Symptoms

Dosage:

The amount of a medicine, drug, or vitamin that should be taken at one time or regularly over a period of time.

Intravenous:

Administered directly into a vein.

Prescription:

A written order from a doctor for a specific medicine or treatment.

Over-the-Counter (OTC):

Medication that can be bought without a doctor’s prescription.

Capsules, Tablets, and Sprays:

Common forms of medication delivery.

Painkillers (Analgesics):

Medications used to relieve pain.

Antibiotic:

A medicine that inhibits the growth of or destroys microorganisms.

Common Symptoms and Conditions

Itchy (adj) / Comezón:

A sensation that makes you want to scratch your skin.

Drowsy (adj) / Somnoliento:

Feeling tired and wanting to sleep.

Dizzy (adj) / Mareado:

Feeling like everything is spinning, potentially leading to a fall.

Rash (n) / Erupción:

Red spots or patches on your skin.

Constipated (adj) / Estreñido:

Difficulty passing solid waste from your body.

Insomnia (n) / Insomnio:

Difficulty falling asleep or staying asleep.

Nausea (n) / Náusea:

The sensation of wanting to vomit.

Diarrhea (n) / Diarrea:

Frequent discharge of loose, watery stools.

Understanding Conditional Sentences in Medical Context

Conditional sentences describe a condition and its result. They are crucial for explaining cause and effect in medical scenarios.

Types of Conditional Sentences

Zero Conditional: If + Present Tense / Present Tense

Used for things that are generally true or scientific facts. ‘If’ can often be replaced with ‘when’.

Example: If a patient takes this medication with milk, it doesn’t work properly.

Example: If you leave ice in the sun, it melts.

First Conditional: If + Present Tense / Future Tense

Used for real or possible future situations.

Example: If you take these tablets twice a day, you will feel better soon.

Example: If you drink too much coffee, you will have trouble sleeping.

Second Conditional: If + Past Tense / Would + Verb

Used for impossible or unlikely situations in the present or future.

Example: If your mother had blood pressure, I wouldn’t prescribe this medication.

Example: If I were taller, I would play basketball professionally.

Third Conditional: If + Past Perfect Tense / Would have + Past Participle

Used for impossible or unlikely situations in the past (regrets or missed opportunities).

Example: If you had told me of the side effects, I wouldn’t have taken this drug.

Example: If she had studied, she would have passed the test.

Key Medical Terms and Drug Types

Painkillers (Analgesics):

Medications that relieve pain.

Antihistamines:

Medications used to treat allergic reactions.

Bronchodilators:

Medications that widen the airways in the lungs.

Antibiotics:

Medications that fight bacterial infections.

Immunosuppressants:

Medications that reduce the strength of the body’s immune system.

Insulin Shots:

Injections of insulin, used to manage blood sugar levels in diabetes.

Chlorthalidone:

A diuretic medication used to treat high blood pressure and fluid retention.

Antacid Tablets:

Medications that neutralize stomach acid.

Diuretic:

A substance that increases the production of urine.

Increases:

To make or become greater in amount, number, or size.

Urine:

A watery, typically yellowish fluid stored in the bladder and discharged through the urethra.

Reduce:

To make smaller or less in amount, degree, or size.

Amount:

A quantity of something.

Side Effect:

An unintended and usually undesirable effect of a drug or medical treatment.

Heart Beat:

The rhythmic contraction and expansion of the heart.

Blood:

The red liquid that circulates in the arteries and veins of humans and other vertebrate animals, carrying oxygen to and carbon dioxide from the tissues of the body.

Discharge:

To release a patient from a hospital or care facility.

Procedures:

A series of actions conducted in a certain order or manner.

Edoxaban:

An anticoagulant medication used to prevent blood clots.

Anticoagulant:

A substance that prevents blood from clotting.

How Medication Works in Your Body

Understanding Drug Absorption and Action

When you take medication, it is absorbed into the bloodstream and transported to the target area where it can exert its therapeutic effect.

How Painkillers Target Pain

Painkillers do not target a specific area; instead, they work by blocking pain signals in the nervous system or reducing inflammation throughout the body.

Essential Vocabulary for Drug Action

Swallow:

To make food, drink, medicine, etc., go down your throat into your stomach.

Foreign Substance:

Something that comes from outside your body.

Blood Vessel:

A small tube through which blood circulates in your body.

Liver:

An organ that cleans your blood and metabolizes drugs.

Enzyme:

A substance produced by a living organism that acts as a catalyst to bring about a specific biochemical reaction.

Molecule:

A group of two or more atoms held together by chemical bonds.

Kidneys:

Organs that remove waste from the blood and produce urine.

Label:

A piece of paper or material attached to an object, such as a bottle, that gives information about it.

The Medication Process in the Body: An Ibuprofen Example

1. You take an ibuprofen tablet for a sore ankle.
2. The tablet disintegrates in your stomach.
3. The ibuprofen enters your bloodstream through the stomach lining or small intestine.
4. The ibuprofen reaches your liver, where it may be partially metabolized.
5. The ibuprofen travels throughout your body via your veins and arteries.
6. The ibuprofen molecules locate the area where you’re feeling pain.
7. The ibuprofen molecules block the pain signals or reduce inflammation.
8. Your kidneys eliminate the ibuprofen from your body through urine.

Common Medical Abbreviations

PC:

Presenting Complaint (the main reason a patient seeks medical attention)

LMP:

Last Menstrual Period

BMI:

Body Mass Index

Wt:

Weight

Dx:

Diagnosis

FBC:

Full Blood Count

ii:

Two Tablets

BDS:

Twice a Day (from Latin “bis in die sumendus”)

RTA:

Road Traffic Accident

CXR:

Chest X-ray

CMHN:

Community Mental Health Nurse

EUA:

Examination Under Anesthesia

EMU:

Early Morning Urine Sample

OD:

Once a Day (from Latin “omni die”)

PC:

After Food (from Latin “post cibum”)

Electronic Medical Record Example

This section illustrates a typical entry in an Electronic Medical Record (EMR).

• Name of Patient: Gissel Torres
• Appointment Date: Tuesday, April 29, 2025
• Main Complaint: Stomach pain
• Diagnosis: Gastritis
• Medication Prescribed: 2 tablets Omeprazole 20 mg once daily, before breakfast.
• Notes: Advised to avoid spicy food and alcohol.