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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
Created by: aliciatakemura
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