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Chapter 2
soap notes
Term | Definition |
---|---|
supportive care | treat the symptoms to make the patient feel better |
palliative care | treating the symptoms, but not getting rid of the cause |
prophylaxis | preventative treatment |
proximal | close to the center |
distal | farther away from the center |
lateral | out to the side |
medial | toward the middle |
ventral antral anterior | stomach , the front |
dorsal posterior | the back |
cranial | top |
caudal | bottom |
superior | above |
inferior | below |
supine | laying on the back |
contralateral | opposite side |
ipsilateral | same side |
unilateral | one side |
bilateral | both sides |
dorsum | top of the hand or foot |
plantar | sole of the foot |
palmar | palm of the hand |
sagittal | sliced in half left to right |
coronal | sliced from front to back |
transverse | divides top to bottom |
CCU | coronary care unit |
ECU | emergency care unit |
ER | emergency room |
ED | emergency department |
ICU | intensive care unit |
PICU | pediatric intensive care unit |
NICU | Neonatal intensive care unit |
SICU | surgical intensive care unit |
PACU | postanesthesia care unit |
L&D | labor and delivery |
OR | operating room |
post-op | after surgery |
pre-op | before surgery |
VS | vital signs |
T | temperature |
BP | blood pressure |
HR | heart rate |
RR | respiratory rate |
Ht | height |
Wt | weight |
BMI | body mass index |
I/O | intake/output |
Dx | diagnosis |
DDx | differential diagnosis |
Tx | treatment |
Rx | prescription |
H&P | history and physical |
Hx | history |
CC | chief complaint |
HPI | history of present illness |
SOB | shortness of breath |
NAD | no acute distress |
RRR | regular rate and rhythm |
CTA | clear to ascultation (normal sounding lungs) |
WDWN | well developed well nourished |
A&O | alert and oriented |
WNL | within normal limits |
NOS | not otherwise specified |
NEC | not elsewhere classfied |
PO | By mouth (per os) |
NPO | nothing by mouth (nil per os) |
PR | per rectum |
IM | intramuscular |
SC | subcutaneous |
IV | intravenous |
CVL | central venous line |
PICC | peripherally inserted central catheter |
sig | instructions short for SIGNA |
ad lib | as desired |
BID | twice daily "two in day" bis in die |
TID | three times daily "three in a day" ter in die |
QD | daily "each day" quaque die |
QID | four times daily" four times in a day" quater in die |
QHS | at night, at the hour of sleep |
AC | before meals "ante cibum" |
PC | after meals "post cibum" |
prn | as needed, per re nata, as need arises |