Inglés para la salud: 48 términos clínicos esenciales

"take a medical history"

gather information about a patient's past and current health conditions through structured questioning

"The nurse will take a medical history before the doctor sees you, covering past illnesses, medications, and allergies."

"informed consent"

a patient's voluntary agreement to a procedure or treatment after fully understanding its risks, benefits, and alternatives

"The surgeon obtained informed consent before performing the operation, ensuring the patient had asked all her questions."

"presenting complaint"

the main symptom or problem that brings a patient to seek medical care, stated in their own words

"The presenting complaint was severe chest pain radiating to the left arm, which had started two hours earlier."

"pain scale"

a standardised numbered system, typically 0–10, used to help patients quantify their pain intensity

"On a pain scale of zero to ten, how would you rate your discomfort right now compared with when it started?"

"teach-back method"

a health education technique where the clinician asks the patient to repeat instructions in their own words to confirm understanding

"Using the teach-back method, the pharmacist asked the patient to explain when and how she would take each of her new medications."

"discharge instructions"

written or verbal guidance given to a patient leaving hospital covering wound care, medications, activity restrictions, and when to seek help

"The discharge instructions explained how to change the dressing at home and listed symptoms that should prompt a return to the emergency department."

"next of kin"

a patient's closest living relative or designated emergency contact who may be involved in care decisions

"We need to contact your next of kin before proceeding with surgery, as you will require a general anaesthetic."

"advance directive"

a legal document in which a patient specifies their treatment preferences and end-of-life wishes in case they become unable to communicate them

"The patient had an advance directive requesting no resuscitation, which the team reviewed before the palliative care meeting."

"vital signs"

key measurements of basic body functions: temperature, pulse, blood pressure, and respiration

"The nurse checked the patient's vital signs every four hours."

"auscultation"

listening to internal body sounds using a stethoscope

"Auscultation revealed reduced breath sounds in the left lung base."

"palpation"

examining the body by touch to assess pain, size, or organ position

"Palpation of the abdomen revealed tenderness in the right iliac fossa."

"differential diagnosis"

a list of possible conditions that could explain a patient's symptoms

"The differential diagnosis included appendicitis, ovarian cyst, and mesenteric adenitis."

"Glasgow Coma Scale"

a neurological scoring tool assessing eye, verbal, and motor responses

"The patient scored 12 on the Glasgow Coma Scale, indicating moderate impairment."

"fundoscopy"

examination of the back of the eye using an ophthalmoscope

"Fundoscopy revealed papilloedema consistent with raised intracranial pressure."

"percussion"

tapping the body surface to assess underlying tissue density

"Percussion of the chest showed dullness at the right base, suggesting a pleural effusion."

"range of motion"

the extent to which a joint can move through its full arc

"The physiotherapist assessed the patient's range of motion in the injured shoulder."

"loading dose"

a higher initial dose given to rapidly achieve therapeutic drug levels

"A loading dose of amiodarone was given intravenously to correct the arrhythmia."

"maintenance dose"

the regular dose needed to keep a drug at a stable therapeutic level

"After the loading dose, the patient was switched to a daily maintenance dose."

"contraindication"

a condition or factor that makes a particular treatment inadvisable

"Aspirin is a contraindication in children with viral infections due to the risk of Reye's syndrome."

"titrate"

to gradually adjust a drug dose to achieve the desired effect

"We will titrate the morphine dose until the patient's pain is adequately controlled."

"nil by mouth"

instruction to give a patient nothing to eat or drink

"The patient is nil by mouth from midnight ahead of tomorrow's procedure."

"PRN (pro re nata)"

medication given as needed, not on a fixed schedule

"Paracetamol 1 g PRN was prescribed for breakthrough pain."

"adverse drug reaction"

a harmful or unintended response to a medication

"The patient developed a rash, which was classified as an adverse drug reaction to penicillin."

"polypharmacy"

the concurrent use of multiple medications by a single patient

"Polypharmacy in elderly patients significantly increases the risk of harmful drug interactions."

"triage"

sorting patients by urgency of need to prioritise care

"On arrival, the paramedic performed triage and categorised the patient as immediate."

"code blue"

a hospital emergency code indicating a cardiac or respiratory arrest

"A code blue was called when the patient went into ventricular fibrillation."

"intubation"

inserting a tube into the trachea to maintain an airway and support breathing

"Rapid sequence intubation was performed to secure the patient's airway."

"SBAR"

Situation, Background, Assessment, Recommendation — a structured communication framework

"The nurse used the SBAR format to hand over the deteriorating patient to the doctor."

"septic shock"

life-threatening organ failure caused by the body's response to infection

"The patient was transferred to the ICU in septic shock requiring vasopressor support."

"Glasgow Outcome Scale"

a scale measuring recovery and disability after brain injury

"At three months post-injury, the patient scored 3 on the Glasgow Outcome Scale."

"defibrillation"

delivering an electric shock to restore normal heart rhythm

"Defibrillation was performed twice before sinus rhythm was restored."

"haemodynamic instability"

abnormal or unstable blood flow that cannot maintain adequate organ perfusion

"The patient showed signs of haemodynamic instability with a rapidly falling blood pressure."

"magnetic resonance imaging (MRI)"

a scan using magnetic fields and radio waves to produce detailed images of organs

"The MRI showed a herniated disc at the L4–L5 level pressing on the nerve root."

"echocardiogram"

an ultrasound scan of the heart assessing structure and function

"The echocardiogram revealed a reduced ejection fraction of 35%."

"full blood count"

a blood test measuring red cells, white cells, platelets, and haemoglobin

"The full blood count confirmed severe anaemia with a haemoglobin of 6.2 g/dL."

"biopsy"

removal of a tissue sample for microscopic examination

"A core needle biopsy of the breast lump was sent to histopathology."

"spirometry"

a lung function test measuring airflow and lung volumes

"Spirometry results showed an obstructive pattern consistent with COPD."

"serology"

blood tests detecting antibodies or antigens related to infection or disease

"Serology confirmed a recent Epstein–Barr virus infection causing glandular fever."

"radiograph"

an X-ray image used to visualise bones and certain soft tissues

"The chest radiograph showed consolidation in the right lower lobe."

"lumbar puncture"

a procedure drawing cerebrospinal fluid from the lower spine for analysis

"Lumbar puncture was performed to rule out bacterial meningitis."

"SOAP note"

a structured clinical note format: Subjective, Objective, Assessment, Plan

"The intern wrote a SOAP note after reviewing the patient on the ward round."

"discharge summary"

a document summarising a patient's hospital admission for the receiving clinician

"The discharge summary was faxed to the patient's GP before they left the ward."

"care pathway"

a pre-planned, evidence-based sequence of care for a specific condition

"The patient was placed on the hip fracture care pathway from the time of admission."

"escalation protocol"

a procedure for raising concerns about a deteriorating patient to senior staff

"The nurse used the escalation protocol when the patient's early warning score reached 7."

"clinical handover"

the transfer of professional responsibility for a patient from one clinician to another

"A structured clinical handover at shift change reduced medication errors on the ward."

"countersignature"

a second clinician's signature confirming or validating an entry in the medical record

"The student's clinical notes required a countersignature from the supervising doctor."

"incident report"

a formal document recording an unexpected event that may affect patient safety

"The nurse filed an incident report after a patient fell getting out of bed unassisted."

"problem list"

a running list of a patient's active and past medical diagnoses

"The problem list was updated to include newly diagnosed type 2 diabetes."