15 terms you might see when looking at your medical records and what they mean
Guava Health compiled a list defining 15 medical terms that patients may see in their newly available medical records, with info from Mayo Clinic and others.
Past medical history
Your doctor, especially a new doctor, will compile a medical history showing your allergies, past illnesses and surgeries, and any medications you have taken or are still taking. Additionally, this will often include your family history of major illnesses, as there are genetic factors that can be passed down generationally. The purpose of the medical history is to help your doctor understand how any other factors may influence the reason for your visit.
Social history
Your social history is usually a subset of the general medical history that also includes past illnesses and conditions. Questions will likely cover issues like legal and illegal drug use, sexual history and behaviors, and even as specific as what your career is—all factors that could have implications for any treatments you need. A lifelong smoker with a hacking cough has a different patient profile than someone who has never touched a cigarette—both should receive the best individual care.
Allergies
During your medical history, your doctor will ask about your allergies. This should include any medications, of course, but may also include “regular stuff” like lactose or eggs. Both of these food-related substances are commonly used in medicines and can cause reactions for those with serious allergies. Ultimately, the goal of the allergy write-up is to make sure you don’t take medications you’re allergic to.
Immunizations
Immunizations, or vaccines, are an important part of your medical history. For young children, this information is vital to make sure kids are up to date on their necessary childhood vaccines. For adults, it’s still important to find out case-by-case vaccines like for tetanus infections, as well as the availability of ones like the HPV vaccine where eligibility changes by age.
Recently completed tests
Any medical facility should have a list of the tests you’ve recently had done as a form of recordkeeping as well as part of your medical history. This helps your doctors ensure they’re not ordering duplicate tests and also makes them aware of results that should be available to them as part of your record. Test results can also explain why particular medications or procedures were prescribed.
Root terms
Root terms often refer to an organ, tissue, or condition. Many medical words are put together from pieces that date back to ancient Greek or Latin. The term “tension,” like hypertension and hypotension, refers to blood pressure. You may see -algia, meaning pain, in terms like neuralgia and fibromyalgia. The root -ema, meaning blood, is found in terms like edema or anemia.
Prefixes or suffixes describe the root
Hyper- and hypo- are commonly used prefixes in the medical world. Hyper- means above or high, while hypo- means below or low. Hypoglycemia, for instance, refers to low blood sugar, compared with hypertension, which means high blood pressure. Hypo- also shows up in terms like “hypodermic,” which refer to needles that go under the skin, whereas “hypothesis” means under consideration.
Procedure notes
Procedure notes document a series of facts and observations related to procedures you’ve had, like getting stitches or having an endoscopy. The doctor will likely note what led to the procedure, any tests or other indications that are relevant, and how the procedure itself actually went. The notes will also include logistical things like who did the procedure and where and when.
Reference range (lab results)
For many medical tests, the results are dynamic and don’t directly correspond to something like a percentage. You’ll receive raw numbers representing your cholesterol or blood sugar or whatever else. The reference range is a set of values given to you as a frame of reference to help you understand your results, like the “healthy range” of outcomes for a test.
Lipid panel: LDL vs. HDL
Low-density lipoprotein (LDL) and high-density lipoprotein (HDL) are the two forms of cholesterol measured by a standard lipid panel. HDL is the “good” cholesterol, with higher values that correspond with a lowered risk of cardiovascular disease and stroke. HDLs clear from the body through your liver, which is designed to process fats. LDLs, the “bad” cholesterol, instead deposit in your arteries and can lead to heart disease.
Complete blood count (CBC)
A complete blood count is just what it sounds like: a medical survey of all the different parts that make up your blood, each with possible causes that should be evaluated afterward. The items measured include red and white blood cells as well as hemoglobin and platelets. Elevated white blood cells, which are responsible for fighting off disease, can indicate underlying conditions like cancer.
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