Inglês para trabalhadores de saúde: vocabulário essencial

"informed consent"

A patient's voluntary agreement to a treatment or procedure after receiving and understanding all relevant information about it.

"The surgeon obtained informed consent before proceeding with the operation, explaining all risks and alternatives."

"chief complaint"

The primary reason a patient is seeking medical care, stated in their own words.

"The nurse documented the chief complaint as 'sharp chest pain radiating to the left arm' before the doctor's assessment."

"pain scale"

A standardised numerical or visual tool (usually 0–10) used to measure and communicate a patient's level of pain.

"The patient rated their pain as 7 on the pain scale, prompting the team to adjust the analgesic dose."

"bedside manner"

The way a healthcare professional interacts with patients — including tone, empathy, and communication style — during clinical encounters.

"His calm bedside manner helped reduce the anxiety of a frightened child awaiting surgery."

"next of kin"

The closest living relative of a patient, who may be contacted in an emergency or involved in care decisions.

"The ward sister called the patient's next of kin to notify them about the change in condition overnight."

"advance directive"

A legal document expressing a patient's wishes about medical treatment in case they become unable to make decisions themselves.

"The advance directive clearly stated that the patient did not wish to be resuscitated if their heart stopped."

"therapeutic communication"

A purposeful, patient-centred style of communication used by health professionals to support emotional and physical wellbeing.

"Using therapeutic communication, the counsellor reflected the patient's feelings back to them without judgment."

"discharge instructions"

Written or verbal guidance given to a patient explaining how to care for themselves after leaving a healthcare facility.

"The nurse reviewed the discharge instructions carefully, emphasising which symptoms should prompt an immediate return to the emergency department."

"vital signs"

The four key indicators of basic body function: temperature, pulse, respiration rate, and blood pressure.

"The healthcare assistant recorded vital signs every four hours and flagged any values outside the normal range."

"auscultation"

Listening to internal sounds of the body — usually with a stethoscope — to assess the heart, lungs, or bowels.

"On auscultation, the physician heard reduced breath sounds at the right lung base, suggesting a pleural effusion."

"differential diagnosis"

A list of possible conditions that could explain a patient's symptoms, ranked from most to least likely.

"The registrar presented a differential diagnosis of appendicitis, ovarian cyst, and mesenteric adenitis for the teenage girl with right iliac fossa pain."

"presenting symptoms"

The signs and symptoms that cause a patient to seek medical attention at a given time.

"The presenting symptoms — fever, neck stiffness, and photophobia — were highly suggestive of bacterial meningitis."

"Glasgow Coma Scale"

A neurological assessment tool that scores eye, verbal, and motor responses to evaluate a patient's level of consciousness.

"The paramedic recorded a Glasgow Coma Scale score of 10 at the scene and alerted the trauma team on arrival."

"palpation"

A physical examination technique in which the clinician uses their hands to feel for abnormalities in the body.

"Deep palpation of the abdomen revealed tenderness in the right upper quadrant, consistent with gallbladder inflammation."

"acute onset"

A sudden and rapid development of symptoms, as opposed to a gradual or chronic presentation.

"The acute onset of severe headache was described by the patient as 'the worst of my life', raising suspicion of a subarachnoid haemorrhage."

"baseline observations"

Initial measurements of a patient's vital signs and condition taken on admission, used as a reference point for monitoring changes.

"Baseline observations were taken immediately on admission so that any deterioration could be detected quickly."

"contraindication"

A specific situation or condition in which a drug or procedure should not be used because it may be harmful to the patient.

"Aspirin is a contraindication in children under 16 with viral illness due to the risk of Reye's syndrome."

"titrate"

To gradually adjust the dose of a medication to achieve the desired effect while minimising side effects.

"The anaesthetist titrated the propofol infusion until the patient reached an appropriate depth of sedation."

"adverse drug reaction"

An unintended and harmful response to a medication given at a normal therapeutic dose.

"The patient developed a severe rash — a classic adverse drug reaction — within hours of starting the new antibiotic."

"loading dose"

An initial higher dose of medication given to rapidly achieve a therapeutic concentration in the body.

"A loading dose of amiodarone was administered intravenously before switching the patient to oral maintenance therapy."

"PRN medication"

Medicine prescribed to be given 'as needed' (from the Latin pro re nata) rather than on a fixed schedule.

"The patient was prescribed PRN paracetamol for breakthrough pain, to be given every four to six hours if required."

"therapeutic window"

The range of a drug concentration in the blood that produces the desired effect without causing toxicity.

"Digoxin has a narrow therapeutic window, so blood levels must be monitored closely to avoid toxicity."

"polypharmacy"

The concurrent use of multiple medications by a patient, increasing the risk of interactions and adverse effects.

"The elderly patient's polypharmacy — eleven different drugs — made medication reconciliation a priority on admission."

"evidence-based practice"

A clinical approach that integrates the best available research evidence with clinical expertise and patient preferences.

"The ward adopted an evidence-based practice protocol for preventing pressure ulcers in immobile patients."

"SOAP note"

A structured format for clinical documentation comprising four sections: Subjective, Objective, Assessment, and Plan.

"The intern was taught to write every patient encounter as a SOAP note to ensure comprehensive and consistent documentation."

"medical history"

A comprehensive record of a patient's past illnesses, surgeries, medications, allergies, and family health background.

"A detailed medical history revealed that the patient had previously experienced an anaphylactic reaction to penicillin."

"handover"

The formal process of transferring patient care and relevant information from one healthcare professional to another at shift change.

"The night shift nurse gave a structured handover using the SBAR tool to ensure nothing was missed."

"care plan"

A documented, individualised plan outlining the nursing or clinical goals for a patient and the actions needed to meet them.

"The multidisciplinary team reviewed the care plan weekly and updated goals as the patient's condition improved."

"referral letter"

A written communication from one clinician to another requesting a specialist opinion or transfer of care.

"The GP wrote a referral letter to the cardiologist after the patient failed to respond to first-line hypertension treatment."

"discharge summary"

A clinical document summarising a patient's hospital stay, diagnoses, treatment, and follow-up instructions sent to their community physician.

"The discharge summary was faxed to the patient's GP within 24 hours, as per hospital protocol."

"audit trail"

A chronological record of all actions taken in relation to a patient's care, used to ensure accountability and traceability.

"The audit trail showed exactly when each medication was administered and by which member of staff."

"abbreviation policy"

A set of approved shortened terms that may be used in clinical documentation, reducing the risk of misinterpretation.

"The hospital's abbreviation policy prohibited the use of 'u' for 'units' after several near-miss insulin errors."

"triage"

The process of sorting patients based on the urgency of their condition to prioritise treatment when resources are limited.

"The triage nurse assessed five patients simultaneously and immediately escalated the man with a suspected stroke."

"code blue"

A hospital emergency code indicating that a patient is in cardiac or respiratory arrest and requires immediate resuscitation.

"The announcement of a code blue sent the crash team rushing to the coronary care unit within seconds."

"sepsis protocol"

A standardised set of interventions — including blood cultures, antibiotics, and IV fluids — to be implemented rapidly when sepsis is suspected.

"The emergency team activated the sepsis protocol within one hour of the patient presenting with fever, confusion, and low blood pressure."

"intubation"

The insertion of a tube into the trachea to maintain an open airway and support mechanical ventilation.

"After multiple failed attempts at non-invasive ventilation, the intensivist proceeded with intubation and connected the patient to a ventilator."

"SBAR"

A communication framework — Situation, Background, Assessment, Recommendation — used to convey critical patient information concisely.

"The junior doctor used SBAR to escalate the deteriorating patient to the registrar over the phone."

"fluid resuscitation"

The rapid administration of intravenous fluids to restore circulating blood volume in a patient who is haemodynamically unstable.

"Two litres of normal saline were given for fluid resuscitation before reassessing the patient's blood pressure and urine output."

"deteriorating patient"

A patient whose clinical condition is worsening, requiring timely escalation and intervention to prevent serious harm.

"The early warning score identified the deteriorating patient before the situation became life-threatening."

"trauma activation"

A hospital protocol triggered when a patient with major trauma is incoming, mobilising a multidisciplinary team to receive them.

"Trauma activation was called when the paramedics radioed ahead about a motorcyclist with multiple suspected fractures and declining consciousness."

"standard precautions"

A set of minimum infection prevention practices applied to all patients regardless of suspected or confirmed infection status.

"Standard precautions require all staff to wear gloves and perform hand hygiene before and after every patient contact."

"aseptic technique"

A method of working that prevents contamination of wounds, instruments, or body cavities during clinical procedures.

"The nurse used strict aseptic technique when changing the central venous catheter dressing to prevent bloodstream infection."

"nosocomial infection"

An infection acquired in a hospital or healthcare setting, not present when the patient was admitted.

"The investigation identified a cluster of nosocomial infections on the surgical ward linked to inadequate hand hygiene compliance."

"PPE"

Personal Protective Equipment — protective items such as gloves, masks, gowns, and goggles worn to reduce exposure to infectious agents.

"Staff were required to don full PPE before entering the isolation room of the patient with confirmed tuberculosis."

"isolation precautions"

Specific infection control measures — including contact, droplet, or airborne precautions — used to contain contagious pathogens.

"Airborne isolation precautions were implemented for the patient with suspected measles, requiring negative-pressure room placement."

"antimicrobial stewardship"

A coordinated programme to optimise the use of antimicrobials, improving patient outcomes and reducing antibiotic resistance.

"The hospital's antimicrobial stewardship programme reduced inappropriate antibiotic prescribing by 30% within six months."

"sharps disposal"

The safe discarding of needles, scalpels, and other sharp instruments into approved puncture-resistant containers to prevent injury.

"The clinical governance team reminded all staff that sharps disposal directly into the yellow bin — never recapping needles — is non-negotiable."

"near miss"

An unplanned event that did not cause patient harm but had the potential to do so, reported to improve safety systems.

"The nurse reported a near miss after catching a ten-fold medication dosing error before it reached the patient."