13.2 Medical Word Building, Positions, Tests, and Treatment Terms

Build the word

Many medical terms combine a prefix, root/combining form, and suffix. For example, tachy-card-ia combines rapid (tachy-), heart (card), and condition (-ia). Arthr-itis combines joint and inflammation. Word parts provide a hypothesis, not permission to invent spelling. Similar sounds can name different structures or drugs.

Common prefixes:

Common suffixes include -itis inflammation, -ectomy removal, -otomy incision, -algia pain, -emia blood condition, -pathy disease, -scopy visual examination, and -plasty repair.

Direction, position, and laterality

Anterior/posterior mean front/back; superior/inferior mean above/below; medial/lateral mean toward/away from midline; proximal/distal mean nearer/farther from attachment. Supine means lying face up; prone means face down. Ipsilateral is same side; contralateral is opposite side.

Right versus left can determine the disputed injury. Capture bilateral (both sides), unilateral (one side), and specific level such as L4-L5 exactly. Do not “correct” a clinician whose stated side conflicts with an exhibit; preserve the testimony and let counsel clarify.

Signs, symptoms, and diagnosis

A symptom is experienced and reported by a patient, such as pain or nausea. A sign is observed or measured, such as fever or abnormal reflex. A diagnosis identifies a condition; a differential diagnosis considers competing explanations. Prognosis predicts likely course. Etiology concerns cause. Acute commonly means sudden or short-course; chronic persists over time, but precise definitions vary by condition.

Tests and imaging

• X-ray/radiograph: image using ionizing radiation.
• CT: computed tomography using X-rays and computer reconstruction.
• MRI: magnetic resonance imaging using magnetic fields and radiofrequency, not ionizing X-rays.
• Ultrasound: imaging using sound waves.
• ECG/EKG: electrical activity of the heart.
• EEG: electrical activity of the brain.
• EMG: muscle electrical activity, often paired with nerve-conduction study.
• CBC: complete blood count.

Record contrast use, body part, view, result, and date as stated. Do not expand an acronym incorrectly when context is uncertain.

Treatment and procedure terms

Conservative treatment may include rest, medication, therapy, or other nonoperative care. Surgery includes procedures identified by body part and action. -ectomy removes; -otomy incises; -ostomy creates an opening. Anesthesia can be local, regional, monitored, or general. Physical therapy, occupational therapy, and speech-language therapy have different focuses.

A contraindication is a reason a treatment may be inadvisable; an adverse effect is an unwanted effect; an allergy is an immune-mediated reaction. Do not treat them as interchangeable.

Numbers, doses, and negation

Medication name, strength, dose, route, frequency, and duration are separate. 0.5 mg differs from 5 mg; mcg differs from mg. “No evidence of fracture” reverses “evidence of fracture.” Ask for repetition when audio makes a material number or negation unclear. Obtain spellings from authorized medical records or the witness.

Reporter boundary

The reporter is not diagnosing. If an expert uses a term unexpectedly, capture it and verify spelling later. Do not change ileum to ilium, peroneal to perineal, or a brand to a generic without authoritative confirmation. Sound-alike awareness is a cue to verify.

Exam application

Medical testimony often combines a sound-alike word, laterality, and a number. “Left peroneal nerve, 0.5 milligrams” could become dangerously different if rendered as perineal, right, or 5 milligrams. When the audio is unclear, request repetition under protocol and obtain approved records or spelling afterward. Do not diagnose from word parts or correct the clinician from general knowledge. Word building narrows possibilities; the authoritative speaker and case material establish the actual term.

Also distinguish what a result represents. MRI uses magnetic fields and radiofrequency; CT uses X-rays. A symptom is reported, a sign is observed, a diagnosis identifies a condition, and prognosis concerns expected course. These categories help the reporter follow testimony and detect a likely transcription ambiguity without substituting medical judgment.

Review checkpoint

Build a personal verification list of dangerous pairs: hypo/hyper, brady/tachy, -ectomy/-otomy/-ostomy, afferent/efferent, ileum/ilium, and peroneal/perineal. Their sounds overlap while meanings diverge.

During review, search the authoritative medical exhibit or ask the witness through an approved channel; do not trust autocorrect. Preserve decimal-leading zeros, units, and laterality exactly. A transcription that changes 0.5 mg to 5 mg or left to right creates a substantive error far more serious than imperfect punctuation.