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Med Term Chpt 2

Intro to Health Records

TermDefinition
SOAP method subjective, objective, assessment, plan
subjective what the patient says
objective what the test reveal, body images, provider observations
assessment the analyisis of the subjective and objective information, performed by the health care provider
plan the course of action for the patient
acute occurs recently, or sharp severe symptoms
chronic a problem that occurs for a while
abrupt occurs suddenly
febrile has a fever
afebrile does not have a fever
malaise not feeling well
progressive worsening of symptoms
exacerbation worsening of a condition
symptom what the patient feels
noncontributory patient's symptom is not related to the current problem
lethargic a decrease in level of consciousness
genetic/hereditary it runs in the family
alert patient can answer questions, responsive, interactive
oriented patient knows who they are, where they are, and what time it is (current date/time)
auscultation to listen (with a stehoscope)
percussion to hit or strike and then listen for the sound, the returned sound indicates the condition of the body
palpation to feel something, how something feels can indicate it's condition, be it normal or abnormal
unremarkable normal
marked it stands out
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 profession CANNOT yet determine the diagnosis
benign not cancerous
malignant cancerous
degeneration getting worse
etilogy the cause
idopathic no known cause
remission no longer having the symptoms of a disease, usually used when referring to cancer
recurrent to have again
mobidity risk of being sick or diseased
mortality risk for dying
prognosis chance of getting better or worse
localized one area
system/generalized over a large area of body system
occult hidden
pathogen organism that causes the disease
lesion diseased tissue
sequelae result of disease or injury
pending waiting for
dispostion where the patient went at the conclusion for the visit
discharge to send home, fluid coming out of a part of the body
prophylaxis preventative treatment
palliative relieve symptoms, but not cure
observation to watch
reassurance actions that make the patient feel better
supportive care treat symptoms to make the patient feel better
sterile extremely clean, germ-free conditions
proximal pertaining to the trunk of the body-closer to the
distal pertaining to the trunk of the body-further away
lateral away from the center of the body
medial closer to the center of the body
ventral, antral, anterior front of the body
dorsal/posterior back of the body
superior above
inferior below
cranial/caudal head/tail
supine lying on the back
prone lying on the belly
ipsilateral same side
contralateral opposite side
unilateral/bilateral one side/two sides
plantar/palmar sole of the foot, palm of hand
dorsum top/back (hand/foot)
coronal plane divides anterior and posterior
sagittal plane divides body right and left
transverse plane divides body top and bottom
chief complaint/ CC main reason for the patient's visit
history of present illness/ HPI story of the patient's problem
review of systems /ROS description of individual body systems in order to discover andy symptoms not directly related to the main problem
past medical history /PMHx other significant past illnesses
past surgical history / PSHx any of the patient's past surgeries
family history any significant illnesses that run in the patient's family
social history a record of habits like smoking, drinking, drug abuse..
I/O fluid input/output
H&P history and physical
PE physical exam
PCP primary care provider
f/u follow up
h/o history of
PERRLA pupils equal, round and reactive to light and accommodation
NOS not otherwise specified
RRR regular rate and rhythm
CTA clear to auscultation
A&O alert and oriented
NAD no acute distress
PO by mouth (per os)
NPO nothing by mouth (nil per os)
IV intravenous
SC subcutaneous
CVL central venous line
IM intramuscular
PR per rectum (anal)
prn as needed
QID 4x's a day
QD every day
AC before meals
TID 3xs a day
BID 2sx a day
PC after meals
QHS at night
Created by: cynmur1110
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