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What part of SOAP? How a patient experiences and personallydescribes the problem as well as personal and family medical issues.
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HLHS 101- M01- Chp 2
Chapter 2 Acquiring Medical Language
| Term | Definition |
|---|---|
| SOAP | subjective, objective, assessment, plan |
| What part of SOAP? How a patient experiences and personallydescribes the problem as well as personal and family medical issues. | Subjective |
| What part of SOAP? The patient’s physical exam, any laboratory findings, and imaging studies performed at the visit. | Objective |
| What part of SOAP? A diagnosis, an identification of a problem, or a list of possibilities for the diagnosis, which is known as a differential diagnosis. | Assessment |
| What part of SOAP? A treatment with medicine or a procedure. It could also consist of collecting further data to help arrive at a more accurate diagnosis. | Plan |
| Acute | started recently |
| Chronic | has been going on for a while |
| Exacerbation | getting worse |
| Abrupt | all of a sudden |
| Febrile | to have a fever |
| Malaise | not feeling well |
| Progressive | more and more each day |
| Symptom | something a patient feels |
| Noncontributory | not related to this specific problem |
| Lethargic | a decrease in level of consciousness |
| genetic/hereditary | runs in the family |
| Alert | responsive, interactive |
| Oriented | aware of who he or she is, where he or she is, and the current time |
| Marked | really stands out |
| Unremarkable | normal |
| Auscultation | to listen |
| Percussion | to hit something and listen to the resulting sound |
| Palpation | to feel |
| Impression | assessment |
| Diagnosis | what the health care professional thinks the patient has |
| Differential diagnosis | list of conditions the patient may have based on symptoms and results of the exam |
| Benign | safe |
| Malignant | dangerous, a problem |
| Degeneration | getting worse |
| Remission | to get better or improve |
| Idiopathic | no known cause |
| Localized | stays in a certain part of the body |
| systemic/generalizes | all over the body |
| Prognosis | chance for getting better or worse |
| Occult | hidden |
| Lesion | diseased tissue |
| Recurrent | to have again |
| Sequela | a problem resulting from a disease or injury |
| Pending | waiting for |
| Pathogen | the organism that cause the problem |
| Morbidity | the risk for being sick |
| Mortality | the risk for dying |
| Etiology | the cause |
| Disposition | what happened to the patient at the end of the visit (where they went- home, ICU, hospital bed, etc.) |
| Discharge | to send home, or fluid coming out of a body part |
| Palliative | treating the symptoms, but not getting rid of the cause |
| Observation | watch, keep an eye on |
| Reassurance | to tell the patient that the problem is not serious or dangerous |
| Supportive care | to treat the symptoms and make the patient feel better |
| Sterile | extremely clean, germ-free conditions |
| Prophylaxis | preventative treatment |
| Chief complaint | main reason for patient’s visit |
| History of present illness | the story of the patient’s problem |
| Review of systems | description of individual body systems in order to discover any symptoms not directly related to the main problem |
| Past medical history | other significant past illnesses |
| Past surgical history | 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, and sexual practices that can impact health |
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