Chapter 2 Acquiring Medical Language
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| SOAP | subjective, objective, assessment, plan
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| What part of SOAP? How a patient experiences and personallydescribes the problem as well as personal and family medical issues. | Subjective
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| What part of SOAP? The patient’s physical exam, any laboratory findings, and imaging studies performed at the visit. | Objective
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| 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
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| 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
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| Acute | started recently
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| Chronic | has been going on for a while
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| Exacerbation | getting worse
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| Abrupt | all of a sudden
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| Febrile | to have a fever
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| Malaise | not feeling well
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| Progressive | more and more each day
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| Symptom | something a patient feels
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| Noncontributory | not related to this specific problem
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| Lethargic | a decrease in level of consciousness
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| genetic/hereditary | runs in the family
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| Alert | responsive, interactive
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| Oriented | aware of who he or she is, where he or she is, and the current time
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| Marked | really stands out
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| Unremarkable | normal
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| Auscultation | to listen
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| Percussion | to hit something and listen to the resulting sound
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| Palpation | to feel
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| Impression | assessment
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| Diagnosis | what the health care professional thinks the patient has
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| Differential diagnosis | list of conditions the patient may have based on symptoms and results of the exam
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| Benign | safe
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| Malignant | dangerous, a problem
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| Degeneration | getting worse
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| Remission | to get better or improve
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| Idiopathic | no known cause
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| Localized | stays in a certain part of the body
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| systemic/generalizes | all over the body
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| Prognosis | chance for getting better or worse
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| Occult | hidden
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| Lesion | diseased tissue
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| Recurrent | to have again
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| Sequela | a problem resulting from a disease or injury
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| Pending | waiting for
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| Pathogen | the organism that cause the problem
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| Morbidity | the risk for being sick
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| Mortality | the risk for dying
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| Etiology | the cause
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| Disposition | what happened to the patient at the end of the visit (where they went- home, ICU, hospital bed, etc.)
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| Discharge | to send home, or fluid coming out of a body part
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| Palliative | treating the symptoms, but not getting rid of the cause
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| Observation | watch, keep an eye on
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| Reassurance | to tell the patient that the problem is not serious or dangerous
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| Supportive care | to treat the symptoms and make the patient feel better
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| Sterile | extremely clean, germ-free conditions
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| Prophylaxis | preventative treatment
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| Chief complaint | main reason for patient’s visit
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| History of present illness | the story of the patient’s problem
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| Review of systems | description of individual body systems in order to discover any symptoms not directly related to the main problem
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| Past medical history | other significant past illnesses
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| Past surgical history | any of the patient’s past surgeries
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| Family history | any significant illnesses that run in the patient's family
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| Social history | a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
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If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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