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Mohammed/Chapter 2

QuestionAnswer
Assessment is the gathering and analyzing of the facts about the patient. The facts come from the subjective and objective information.
Impression – another word for assessment
Diagnosis using the subjective and objective data to determine the patient’s condition
Differential diagnosis based on the subjective and objective data, the health care professional cannot yet determine the diagnosis; for example, vague chest pain could lead to a differential diagnosis of pneumonia or a heart condition
Etiology the cause
Idiopathic – no known cause
Benign not cancerous
malignant cancerous
remission no longer having the symptoms of the disease. usually used when referring to cancer
Morbidity – risk of being sick or diseased
Mortality risk for dying
Prognosis chance of getting better
Localized – one area
Systemic/generalized – over a large area or body system
Pathogen – organism that causes the disease
Lesion – diseased tissue
Disposition – where the patient went at the conclusion of the visit. Examples would be home, hospital, or a nursing home.
Observation – to watch
Reassurance actions that make the patient feel better
Supportive care – treat symptoms to make the patient feel better
Palliative – relieve symptoms, but not cure
Body Planes and Orientation
Proximal vs. distal – refers to the attachment to the trunk; used when describing the upper extremities (arms) and lower extremities (legs)
Lateral vs. medial – describes the relationship to the center
Anterior/antral/ventral all mean front when referring to the human
Posterior/dorsal – all mean back when referring to the human
Cranial vs. caudal – cranial means head, caudal means tail; used when describing areas of the trunk, head, and neck
Superior vs. inferior – top and bottom
Supine – lying on the back; patient is looking up, supine; lying on the spine
Prone – lying on the belly
psilateral – same side
contralateral -opposite side
Unilateral means one side
bilateral means two sides.
Plantar refers to the sole of the foot
Palmer refers to the palm of the hand.
Dorsum refers to the back of something, such as the hand or foot.
The coronal plan divides the body into anterior and posterior halves.
The sagittal plane divides the body into right and left.
The transverse plane divides the body into superior and inferior (top and bottom).
pre-op . This area prepares the patient for surgery.
OR operation room
PACU post-anesthesia care unit
PO to postoperative care
ICU intensive care unit
CCU the coronary care unit
SICU surgical ICU;
NICU is the neonatal (newborn) ICU.
ER emergency room
ED emergency department
ECU an emergency care unit
L&D labor and delivery,
HR Heart Rate
RR Respiratory Rate
BP Blood Pressure
T Temperature
I/O input/output
DX Diagnosis
DDX differential diagnosis
TX Treatment
RX prescription
HX history
PMHx medical history
FHx family history
H$P – the history and physical
CC – the patient’s chief complaint
HPI history of present illness
ROS – review of systems
PE physical exam
PCP – primary care provider
PERRLA pupils equal, round, and reactive to light and accommodation
NOS not otherwise specified
RRR regular, rate, rhythm
CTA clear to auscultation
A&O alert and oriented
NAD no acute distress
PO per os. (by mouth)
IV intravenous
SC subcutaneous
CVL central venous line
IM intramuscular
PR per rectum (anal)
NPO nil per os (nothing by mouth)
QID four times a day
QD every day
AC as needed
TID three times a day
BID two times a da
PC after meals
QHS at night
PM as needed
Created by: NuhaMohammed2
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