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Medical Term Ch 2

SOAP Method and General Terms

TermDefinitionS.O.A.P Type
acute started recently or is a sharp, severe symptom Subjective
chronic has been going on for a while Subjective
exacerbation is getting worse Subjective
abrupt all of a sudden Subjective
febrile to have a fever Subjective
afebrile to NOT have a fever Subjective
malaise not feeling well Subjective
progressive more and more each day Subjective
symptom something a patient feels Subjective
noncontributory not related to this specific problem Subjective
lethargic a decrease in level of consciousness; in a medical record, this is a general indication that the patient is really sick Subjective
genetic/hereditary it runs in the family Subjective
alert able to answer questions; responsive; interactive Objective
oriented being aware of who they are, where they are, and the current time; patient aware of all three is "oriented times 3" Objective
marked it really stands out Objective
unremarkable another way of saying normal Objective
auscultation to listen Objective
percussion to hit something and listen to the resulting sound or feel for the resulting vibration Objective
palpation to feel Objective
impression another way of saying assessment Assessment
diagnosis what health care professional thinks the patient has Assessment
differential diagnosis a list of condition the patient may have based on the symptoms exhibited and the results of the exam Assessment
benign safe Assessment
malignant dangerous; a problem Assessment
degeneration to be getting worse Assessment
remission to get better or improve; does not mean cure; mostly from discussing cancer Assessment
idiopathic no known specific cause; it just happens Assessment
localized stays in a certain area of the body Assessment
systemic/generalized all over the body ( or most of it) Assessment
prognosis the chances for things getting better or worse Assessment
occult hidden Assessment
lesion diseased tissue Assessment
recurrent to have again Assessment
sequela a problem resulting from a disease or injury Assessment
pending waiting for Assessment
pathogen organism that causes the problem Public Health
morbidity the risk for being sick Public Health
mortality the risk for dying Public Health
etiology the cause Public Health
disposition what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit(home, ICU, normal hospital bed) Plan
discharge literally, to unload; it has two meanings: 1. to send home (unload the patient from the health care setting to home) 2. fluid coming out of a part of the body (body unloading a fluid) Plan
palliative treating the symptoms, but not actually getting rid of the cause Plan
observation watch, keep an eye on Plan
reassurance to tell the patient that the problem is not serious or dangerous Plan
supportive care to treat the symptoms and make the patient feel better Plan
sterile extremely clean, germ-free conditions; especially important during medical procedures and surgery` Plan
prophylaxis preventive treatment Public Health
Created by: Camoore745
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