MDCG Medical Exam key terms

A patient's voluntary agreement to a test or treatment after receiving clear information about its purpose, benefits, risks, and reasonable alternatives, including the option to decline.

A clinician's bedside judgment that a patient can understand relevant information, appreciate the consequences of choices, reason through options, and communicate a consistent decision about their own care.

A written or witnessed statement made while a patient has capacity, naming a surrogate or specifying preferred treatments, that guides care if the patient later loses the ability to decide.

The professional duty to keep patient information private and share it only with those involved in care or where law permits or requires disclosure, such as reportable diseases or imminent harm.

Failure to meet the accepted standard of care that causes harm, established by showing a duty to the patient, a breach of that duty, causation, and resulting damages.

The level and type of care that a reasonably competent clinician with similar training would provide in similar circumstances, often established through guidelines, expert testimony, and customary practice.

A documented medical order, authorized by the patient or surrogate, instructing clinicians not to attempt cardiopulmonary resuscitation if the patient suffers cardiac or respiratory arrest.

A conversation among clinicians, the patient, and family that clarifies the patient's values and priorities and aligns treatment plans, including intensity of intervention, with those preferences.

The structured interview and hands-on assessment that generate the initial differential diagnosis and direct subsequent testing, forming the foundation of every clinical encounter.

A systematic series of questions covering each organ system to uncover symptoms the patient may not volunteer, helping to broaden or narrow the diagnostic possibilities.

A ranked list of possible conditions that could explain a patient's presentation, refined over time as history, examination, and test results make some options more or less likely.

The estimated likelihood that a patient has a condition before a test is performed, which determines how much a positive or negative result actually changes the clinical picture.

Sensitivity is the proportion of truly diseased patients who test positive; specificity is the proportion of truly healthy patients who test negative. Both describe test performance independent of how common the disease is.

The probability that a patient with a positive test result actually has the disease. It rises as disease prevalence in the tested population rises, unlike sensitivity and specificity.

The number of patients who must receive an intervention for one additional patient to benefit, calculated as the reciprocal of the absolute risk reduction.

The ratio of the risk of an outcome in an exposed group to the risk in an unexposed group, expressing how many times more or less likely the outcome is with exposure.

The arithmetic difference in event rates between a control group and a treated group, showing the actual change in risk rather than a proportional one.

The ratio of the odds of exposure among cases to the odds of exposure among controls, commonly used in case-control studies and as an approximation of relative risk for rare outcomes.

An observational design that identifies people with an outcome and comparable people without it, then looks back at prior exposures. It is efficient for rare diseases but vulnerable to recall and selection bias.

A distortion that arises when the groups compared differ systematically in ways related to both exposure and outcome, often because of how participants were recruited or retained.

Distortion of an exposure-outcome association by a third factor that is linked to both, creating an apparent relationship that does not reflect a causal effect of the exposure.

An experimental study in which participants are assigned by chance to intervention or control groups, so that known and unknown confounders are expected to balance between groups.

An analysis that includes every participant in the group to which they were originally assigned, regardless of whether they completed or adhered to the assigned treatment.

Systematically developed statements that translate evidence into recommendations for specific clinical circumstances, intended to support but not replace individualized clinician judgment.

How the body handles a drug over time, encompassing absorption, distribution, metabolism, and elimination, which together determine the concentration of drug at its site of action.

The time required for the plasma concentration of a drug to fall by half, useful for estimating how long a drug persists and how long to wait to reach steady state with repeated dosing.

The condition reached during regular dosing when the amount of drug entering the body equals the amount being eliminated, so concentrations fluctuate within a stable range.

A measure of a drug's safety margin, comparing the dose that produces toxicity with the dose that produces the desired effect; a narrow index demands closer monitoring.

Any injury resulting from medication use, including allergic reactions, dosing errors, interactions, and expected side effects, whether or not the medication was prescribed appropriately.

A structured process of comparing a patient's complete medication list across care transitions to identify omissions, duplications, and dangerous interactions before orders are written.

The transfer of patient information and responsibility between clinicians or teams, ideally using a standardized structure so that critical details and pending tasks are not lost.

A retrospective, team-based method for investigating a serious adverse event by tracing contributing system factors and identifying changes that would prevent recurrence.

A clearly identifiable, serious patient harm incident that is largely preventable, such as wrong-site surgery or transfusion of the wrong blood type, and that signals a system failure.

Individually identifiable health information held or transmitted by a covered entity or its business associate, subject to privacy and security rules governing its use and disclosure.

The translation of diagnoses, procedures, and services into standardized alphanumeric codes used for billing, claims processing, and population health statistics.

The practice of ensuring that the medical record accurately and completely reflects the patient's severity of illness, care provided, and outcomes, supporting both quality measurement and correct reimbursement.

The rapid sorting of patients by urgency of need so that limited resources are directed first to those who will deteriorate or die without prompt intervention.

A prioritized approach to the deteriorating patient that sequentially evaluates airway, breathing, circulation, disability, and exposure, treating each threat before moving on.

Life-threatening organ dysfunction caused by a dysregulated host response to infection, requiring prompt recognition, cultures, antibiotics, and fluid resuscitation to limit mortality.