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Mohammed/Chapter 2
Question | Answer |
---|---|
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 |