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Mohammed/Chapter 2
| Question | Answer |
|---|---|
| Assessment | is the gathering and analyzing of the facts about the patient. The facts come from the subjective and objective information. |
| Impression | – another word for assessment |
| Diagnosis | using the subjective and objective data to determine the patient’s condition |
| Differential diagnosis | based on the subjective and objective data, the health care professional cannot yet determine the diagnosis; for example, vague chest pain could lead to a differential diagnosis of pneumonia or a heart condition |
| Etiology | the cause |
| Idiopathic | – no known cause |
| Benign | not cancerous |
| malignant | cancerous |
| remission | no longer having the symptoms of the disease. usually used when referring to cancer |
| Morbidity | – risk of being sick or diseased |
| Mortality | risk for dying |
| Prognosis | chance of getting better |
| Localized | – one area |
| Systemic/generalized | – over a large area or body system |
| Pathogen | – organism that causes the disease |
| Lesion | – diseased tissue |
| Disposition | – where the patient went at the conclusion of the visit. Examples would be home, hospital, or a nursing home. |
| Observation | – to watch |
| Reassurance | actions that make the patient feel better |
| Supportive care – | treat symptoms to make the patient feel better |
| Palliative | – relieve symptoms, but not cure |
| Body Planes and Orientation | |
| Proximal vs. distal | – refers to the attachment to the trunk; used when describing the upper extremities (arms) and lower extremities (legs) |
| Lateral vs. medial – | describes the relationship to the center |
| Anterior/antral/ventral | all mean front when referring to the human |
| Posterior/dorsal | – all mean back when referring to the human |
| Cranial vs. caudal | – cranial means head, caudal means tail; used when describing areas of the trunk, head, and neck |
| Superior vs. inferior | – top and bottom |
| Supine | – lying on the back; patient is looking up, supine; lying on the spine |
| Prone | – lying on the belly |
| psilateral | – same side |
| contralateral | -opposite side |
| Unilateral | means one side |
| bilateral | means two sides. |
| Plantar | refers to the sole of the foot |
| Palmer | refers to the palm of the hand. |
| Dorsum | refers to the back of something, such as the hand or foot. |
| The coronal plan | divides the body into anterior and posterior halves. |
| The sagittal plane | divides the body into right and left. |
| The transverse plane | divides the body into superior and inferior (top and bottom). |
| pre-op | . This area prepares the patient for surgery. |
| OR | operation room |
| PACU | post-anesthesia care unit |
| PO | to postoperative care |
| ICU | intensive care unit |
| CCU | the coronary care unit |
| SICU | surgical ICU; |
| NICU | is the neonatal (newborn) ICU. |
| ER | emergency room |
| ED | emergency department |
| ECU | an emergency care unit |
| L&D | labor and delivery, |
| HR | Heart Rate |
| RR | Respiratory Rate |
| BP | Blood Pressure |
| T | Temperature |
| I/O | input/output |
| DX | Diagnosis |
| DDX | differential diagnosis |
| TX | Treatment |
| RX | prescription |
| HX | history |
| PMHx | medical history |
| FHx | family history |
| H$P | – the history and physical |
| CC | – the patient’s chief complaint |
| HPI | history of present illness |
| ROS | – review of systems |
| PE | physical exam |
| PCP | – primary care provider |
| PERRLA | pupils equal, round, and reactive to light and accommodation |
| NOS | not otherwise specified |
| RRR | regular, rate, rhythm |
| CTA | clear to auscultation |
| A&O | alert and oriented |
| NAD | no acute distress |
| PO | per os. (by mouth) |
| IV | intravenous |
| SC | subcutaneous |
| CVL | central venous line |
| IM | intramuscular |
| PR | per rectum (anal) |
| NPO | nil per os (nothing by mouth) |
| QID | four times a day |
| QD | every day |
| AC | as needed |
| TID | three times a day |
| BID | two times a da |
| PC | after meals |
| QHS | at night |
| PM | as needed |
Created by:
NuhaMohammed2
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