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Medical Records

Chapter 2 Medical Records & Abbreviations Flash Cards

Auscultation (aws-kul-TAY-shun) To listen. (Usually referred to for listening to the sounds of the heart, GI tract and lungs via stethoscope.)
Sequelea (seh-KWEL-uh) A problem resulting from disease or injury.
Impression (im-PREH-shun) Also known as the Assessment; part of the S.O.A.P method. Information and data gathered from labs, imaging and other tests run. Could be a Diagnosis - Dx, An identification of a problem or a list of possibilities aka a DDx - Differential Diagnosis.
Sagittal (SA-jih-tal) Divides the body into R/L slices or portions. Latin for: Arrow "sagitta" (to divide the body in half.)
Ipsilateral (IP-shi-LA-ter-al) On the same side. Example: Patient has Right Ipsilateral fractures on the femur and humerus. (Fractured the arm and leg on the right side.)
Caudal (KOW-dal) Toward the bottom. Latin for "tail." Think of the dog image with an arrow from the head to and through the tail.
Palliative (PA-lee-ah-tive) Treating a patient for symptoms, but not ridding the cause.
NEC NOS Not Elsewhere Classified. Not Otherwise Specified.
NAD No Acute Distress Ex. Patient shows NAD at visit.
ROS Review of Symptoms. Anything else NOT directly related to the CC or Chief Complaint (reason for the visit.) S part of S.O.A.P (Subjective)
Created by: MCasler
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