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Medical Terminology
Chapter 2
Term | Definition |
---|---|
PMHx | Past Medical History |
I/O | Intake/Output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output) |
IV | Intravenous |
Pathologist | a physician with special training in both evaluating the causes and effects of disease and in laboratory (path/o=suffering, disease) (-logist=specialist in study of) |
Ausculation | to listen |
SOAP method | Subjective Objective Assessment Plan |
Subjective | Problem in patients own words duration quality of problem any exacerbating or relieving factors of that problem |
Objective | Investigate process objective data comprise patient's physical exam lab findings, imaging studies performed at visit |
Assessment | upon gathering pertinent info, health care provider formulates a logical analysis. a diagnosis, identification of a problem or list of Possibilities for the diagnosis Known as Differential diagnosis |
Plan | Course of action consistent with assessment could be a treatment with medicine or a procedure. Could consist of collecting further data to help arrive at a more accurate diagnosis |