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HLHS Ch1&2
Chapter 2 terms
| Term | Definition |
|---|---|
| What does SOAP stand for? | 4 general parts of a medical note S: subjective. O: objective A: assessment P: plan |
| febrile | to have a fever |
| noncontributory | not related to this specific problem |
| malaise | not feeling well |
| What is a differential diagnosis | the thought process behind a patient’s diagnosis and a list of possible causes for the patient’s problem |
| What does Subjective cover in a medical note? | Problem in patient's words, how long, what causes worse or makes better. |
| What does Objective cover in a medical note? | patient’s physical exam, any laboratory findings, and imaging studies performed at the visit. |
| What does ROS mean? | review of systems |
| CVL | central venous line |
| NKDA | no known drug allergies |
| What does assessment cover in a medical note? | formulates a logical analysis, diagnosis, an identification of a problem, or a list of possibilities for the diagnosis, which is known as a differential diagnosis. |
| What does assessment cover in a medical note? | plan could be a treatment with medicine or a procedure, course of action consistent with his or her assessment, consist of collecting further data to help arrive at a more accurate diagnosis. |
| SOB | shortness of breath |
| HEENT | head, ears, eyes, nose, throat |
| PERRLA | pupils are equal, round, and reactive to light and accommodation |
| RRR | regular rate and rhythm (description of a normal heart on exam) |
| PMHx | past medical history |
| PO/NPO | By mouth/Nothing by mouth |
| IV | Intravenous |
| PICC | peripherally inserted central catheter |
| Why is medical language used? | medical professionals can communicate clearly and quickly with each other using a common language, and patients can be comforted and assured that the medical professional understands their symptoms and is in control of the diagnosis and treatment process. |
| What is the origin of medical language | Greek and Latin |
| c (before a, o, u) | K |
| c (before e, i, y) | s |
| ch | k |
| g (before a, o, u) | g |
| g (before e, i, y) | j |
| ph | f |
| pn | n |
| pt (initial) | t (pterigium) |
| rh, rrh | r |
| x (initial) | z (xeroderma) |
| arthr/o | joint |
| cardi/o | heart |
| enter/o | intestine |
| gastr/o | stomach |
| hepat/o | liver |
| neur/o | nerve |
| hem/o hemat/o | blood |
| my/o muscul/o | muscle |
| angi/o vas/o vascul/o | vessel |
| derm/o dermat/o cutane/o | skin |
| pneum/o pneumo/o pulmon/o | lung |
| gen/o | creation |
| hydro/o | water |
| morph/o | change |
| myc/o | fungus |
| necr/o | death |
| orth/o | straight |
| path/o | suffering, disease |
| py/o | pus |
| plas/o | formation |
| scler/o | hard |
| sten/o | narrowing |
| troph/o | nourishment/development |
| xen/o | foreign |
| -ac -al | pertaining to |
| -ar -ary | pertaining to |
| -eal -ous | pertaining to |
| -ic -tic | pertaining to |
| -ia -ism | condition |
| -ium | tissue, structure |
| -y | condition, procedure |
| -icle -ole | small |
| -ule -ula | small |
| -iatrics -iatry | medical science |
| -iatrist | specialist in medicine of |
| -ist | specialist |
| -logist | specialist in study of |
| -logy | study of |
| -algia -dynia | pain |
| -cele | hernia |
| -emia | blood condition |
| -iasis | presence of |
| -lysis | loosen, break down |
| -malacia | abnormal softening |
| -megaly | enlargment |
| -oid | resembling |
| -oma | tumor |
| -osis | condition |
| -pathy | disease |
| -penia | deficiency |
| -ptosis | drooping |
| -rrhage | excessive flow |
| -rrhea | flow |
| -rrhexis | rupture |
| -spasm | involuntary contraction |
| -gram | written record |
| -graph | instrument used to produce a record |
| -graphy | writing procedure |
| -meter | instrument used to measure |
| -metry | process of measuring |
| -desis | binding, fixation |
| -pexy | surgical fixation |
| -rrhaphy | suture |
| -stomy | creating of an opening |
| -tomy | incision |
| a- | not |
| anti- | against |
| de- | down, away from |
| ante- | before |
| brady- | slow |
| tachy- | fast |
| ab- | away |
| ad- | toward |
| circum- peri- | around |
| dia- | through |
| e- ec- ex- | out |
| ecto- exo- extra- | outside |
| en- endo- intra- | in, inside |
| epi- | upon |
| inter- | between |
| hemi- semi- | half |
| mono- uni- | one |
| oligo- | few (think oligarchs) |
| pan- | all |
| con- syn- sym- | with |
| dys- | bad |
| eu- | good |
| eponym | a word formed by including the name of the person who discovered or invented what is being described. |
| prone | lying down on belly |
| scan of body divides the body in slices right to left | sagittal |
| QHS | at the hour of sleep |
| a soap note is: | a pattern used in writing, a way of thinking |
| differential diagnosis | a list of possible causes of the patient’s problem or complaint |
| past medical history, family history | Subjective |
| cause of the problem | assessment |
| data collected to assist in understanding the nature of the problem | objective |
| description of the problem in the patients own words | subjective |
| auscultation | to listen |
| etiology | the cause |
| idiopathic | no known cause |
| morbidity | risk for being sick |
| occult | hidden |
| sequelae | a problem resulting from a disease |
| palliative | treating the symptoms but not getting rid of the cause |
| prophylaxis | preventive treatment |
| caudal | toward the bottom |
| supine | lying down on back |
| contralateral | opposite side |
| ipsilateral | same side |
| dorsum | top of hand or foot |
| plantar | sole of foot |
| palmar | palm of hand |
| I/O | intake/output |
| Dx/ DDX | diagnosis/differential diagnosis |
| H&P | history and physical |
| Pt | patient |
| f/u | follow up |
| BID/TID | twice daily (bidaily) three times (thrice daily) |
| Q | every X iQ3 every 3 days |
| QD/QID/QHS | daily/4xday/taken at night |
| AC/PC | before means/aftermeals |
| prn | as needed |
| ad lib | as desired |
| Temp, HR, BP General feeling, observations of the body like HEENT would be which part of the SOAP method | objective |
| The elbow is _____ to the wrist | proximal |
| When putting together medical terms, use a combing vowel: to join a root to any suffix beginning with a consonant, to join two roots together or to join two roots together even when the second root begins with a vowel. | ALL OF THEM |
| When translating a medical term, one can usually figure out the definition by | interpreting the suffix first, then the prefix, and finally the root or roots. |
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