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Ch.2
Medical
Question | Answer |
---|---|
S | Subjective Subject to how a patient experiences and personally describes problems and length of problem. Personal/family medical issues. Worsening or reliving factors |
O | Objective Data (Exam, Labs, images) |
A | Assessment Logical analysis, diagnosis, identification of problem, list of possibilities for the diagnosis (differential diagnosis) |
P | Plan Course of action consistent with assessment. Can be medicine, further data or procedure. |
Acute | It just started recently or is a sharp, severe symptom |
Chronic | It has been going on for a while |
Exacerbation | Getting worse |
Abrupt | all of a sudden |
febrile | to have a fever |
afebrile | not have a fever |
malaise | not feeling well |
progressive | more and more each day |
symptom | something a patient feels/experiences |
noncontributory | not related to this specific problem |
lethargic | a decrease in level of consciousness: patient is really sick |
genetic/ hereditary | runs in family |
alert | responsive, interactive, able to answer questions |
oriented | aware of who/where they are, time, "Oriented x3 |
marked | it really stands out |
unremarkable | normal |
auscultation | to listen |
percussion | to hit something and listening to the resulting sound or feeling resulting vibration. |
palpation | feel |
impression | assessment |
diagnosis | what HCP thinks patient has |
differential diagnosis | list of conditions the patient may have based on symptoms exhibited and results of exam |
benign | safe |
malignant | dangerous, a bad problem |
degeneration | to be getting worse |
etiology | the cause |
remission | to get better or improve |
idiopathic | no known cause, spontaneous |
localized | stays in a certain part of the body |
systemic/generalized | all (or most) over body |
morbidity | risk of being sick |
mortality | risk of dying |
prognosis | the chances of things getting better or worse |
occult | hidden |
pathogen | the organism that causes the problem |
lesion | diseased tissue |
recurrent | to have again |
sequelae | a problem resulting from injury or disease |
pending | waiting for |
disposition | what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after visit. |
discharge | to send home or fluid coming from part of body Literal meaning : to unload |
prophylaxis | preventative treatment |
palliative | treating the symptoms but not getting rid of cause |
supportive care | to treat the symptoms and make the Pt feel better |
proximal | closer to center (elbow) |
distal | father away from center (wrist) |
lateral | to the side |
medial | toward the middle |
ventral/antral/anterior | the front |
dorsal/posterior | the back |
cranial | toward the top |
caudal | toward the bottom |
superior | above |
inferior | below |
prone | lying down on belly |
supine | lying down on back |
contralateral | opposite side |
ipsilateral | same side |
unilateral | one side |
bilateral | both sides |
dorsum | the top of the hand or foot |
plantar | the sole of the foot |
palmar | the palm of the hand |
sagittal | divides body in slices right and left |
coronal | divides body front and back (anterior and posterior) |
transverse | divides the body from top and bottom (in half at waist) |
prone | lying down on belly |
supine | lying down on back |
I/O | intake and outake: the amount of fluids a patient has taken in and produced(usually just urine output) |
HEENT | Head eyes ears nose throat |
PERRLA | pupils are equal round and reactive to light and accomodation |
CTA | Clear to ausculation (description of normal sounding lungs) |
A & O | Alert and Oriented |
BID | 2x/daily |
TID | 3x/day |
Q | Every X, Q4hr = every 4 hr |
QD | daily |
QID | 4x/day |
QHS | at night |
AC | before meals |
PC | after meals |
prn | as needed |
ad lib | as desired |
HPI | history of present illness |
ROS | Review of systems |