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Medical Terminology

Chapter 2

TermDefinition
Subjective - S main reason for visit, description and timing of problem, previous, family and surgical Hx. Current meds and allergies. CC in Pt's own words.
Objective - O physical exam, labs, imaging, and other data to assist in understanding the nature of the Pt's problem.
Assessment - A facts are recorded, data put together to reach a conclusion. Diagnosis or Differential Diagnosis.
Plan - P medicine, home remedies, another provider/consult, surgery, wait and see if it improves. Course of action consistent with the assessment.
Acute Chronic *started recently, sharp, severe pain. *has been going on for awhile now.
Exacerbation Abrupt *getting worse *sudden
Febrile Afebrile *fever *no fever
Malaise Progressive *not feeling well *more and more each day
Symptom Noncontributory *what Pt feels *not related to this specific problem
Lethargic Genetic/Hereditary *decrease in consciousness, really sick *runs in the family
Created by: mvoegtlin
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