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Ch. 2 : Assessment

QuestionAnswer
SOAP S: Subjective (how a patient experiences and personally describes problem in addition to personal and family medical history.) O: Objective data ( patient’s physical exam, any laboratory findings, and imaging studies.) A: Assessment ( diagnosis, differe
Diagnosis What the health care professional thinks the patient has. (Dx)
Differential Diagnosis A list of conditions the patient may have based on the symptoms exhibited and the results of the exam. (DDx)
Benign Safe.
Malignant Dangerous, a problem.
Palliative Treating the symptoms, but not actually getting rid of the cause.
Etiology The cause.
Malaise Not feeling well.
Idiopathic A disease with no known specific cause; it just happens. Ex. Idiopathic epilepsy
Febrile To have a fever.
Systemic / Generalized All over the body (or most of it)
Morbidity The risk of being sick.
Mortality The risk for dying.
Prognosis The chances for things getting better or worse.
Occult Hidden.
PO Per os (by mouth)
Lesion Diseased tissue.
CCU Coronary Care Unit
Sequelae A problem resulting from a disease or injury.
Exacerbation It is getting worse.
Created by: BriannaKay19
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