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MED104 CH2
Vocab
| Term | Definition |
|---|---|
| SOAP | Subjective, Objective, Assessment, Plan |
| Subjective | problem in the patient's own words |
| Objective | the patient’s physical exam, any laboratory findings, and imaging studies performed at the visit |
| Assessment | logical analysis; could be a diagnosis, an identification of a problem, or a list of possibilities for the diagnosis |
| Plan | course of action consistent with the assessment |
| acute | just started recently, sharp, severe |
| chronic | been going on for a while |
| exacerbation | getting worse |
| abrupt | all of a sudden |
| febrile | to have a fever |
| afebrile | to not have a fever |
| malaise | not feeling well |
| progressive | more and more each day |
| symptom | something a patient feels |
| noncontributory | not related to this specific problem |
| lethargic | decrease in level of consciousness; indication that patient is really sick |
| genetic hereditary | runs in the family |
| alert | able to answer questions; responsive; interactive |
| oriented | being aware of who they are, where they are, and current time; aware of all 3 is "oriented x3" |
| marked | really stands out |
| unremarkable | normal |
| auscultation | to listen |
| percussion | to hit something and listen to the resulting sound or feel for the resulting vibration |
| palpation | to feel |
| impression | assessment |
| diagnosis | what the health care worker thinks the patient has |
| differential diagnosis | list of conditions the patient may have based on the symptoms exhibited and results of the exam |
| benign | safe |
| malignant | dangerous; problem |
| degeneration | getting worse |
| remission | get better; improve |
| idiopathic | no know specific cause |
| localized | stays in a certain part of the body |
| systemic generalized | all over the body, or most of it |
| prognosis | chances for things getting better or worse |
| occult | hidden |
| lesion | diseased tissue |
| recurrent | to have again |
| sequela | problem resulting from a disease or injury |
| pending | waiting for |
| pathogen | organism that causes the problem |
| morbidity | the risk for being sick |
| mortality | the risk for dying |
| etiology | the cause |
| disposition | what happened to the patient after the visit (home, ICU, etc) |
| discharge | unload; to send home; fluid coming out of a part of a body |
| pallative | treating the symptoms, but not getting rid of the cause |
| observation | watch/keep an eye on |
| reassurance | tell the patient the problem is not serious or dangerous |
| supportive care | treat the symptoms and make the patient feel better |
| sterile | extremely clean, germ-free conditions |
| prophylaxis | preventative treatment |
| proximal | closer in to the center (close) |
| distal | farther away from the center (far) |
| lateral | out to the side |
| medial | towards 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 the back |
| contralateral | opposite side |
| ipsilateral | same side |
| unilateral | one side |
| bilateral | both sides |
| dorsum | the top of of the hand or foot |
| plantar | the sole of the foot |
| palmar | the palm of the hand |
| sagittal | divides the body along a plane from right to left |
| coronal | divides the body from front to back |
| transverse | divides the body from top to bottom |
| physician | attended/graduated from medical school |
| pediatrician | physician for children |
| surgeon | physician qualified to treat patients surgically |
| anesthesiologist | physician with special training in pain sedation and pain control |
| epidemiologist | specialist in the study of the causes and distribution of diseases in populations |
| physician assistant (PA) | midlevel provider who works under the license of a supervising physician |
| nurse practitioner (NP) | nurse with postgraduate training that serves as a midlevel healthcare provider; under a licensed physician |
| emergency medical technician (EMT) | specially trained in the emergency care of a patient before and/or during transport to medical facility |
| speech therapist | specially trained in evaluating and treating problems with speech and/or swallowing |
| occupational therapist | specially trained in evaluating and treating problems with performing daily activities at home, school, or work |
| physical therapist | specialist trained in evaluating and treating physical impairments including disabilities or recovery from an injury |
| respiratory therapist | specially trained in treating patient's respiratory issues under the guidance of a health care provider |
| dietician | specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan |
| licensed practical nurse (LPN) licensed vocational nurse (LVN) | trained and certified to provide basic patient care |
| registered nurse (RN) | advanced level nurse who has completed as associate/bachelor program; assists with patient care planning and education |
| medical assistant | trained to carry out basic admin and clinical tasks under the guidance of a health care provider |
| pathologist | physician with special training in evaluating the causes and effects of disease and also lab medicine |
| medical laboratory technician | trained in performing laboratory testing on bodily fluids |
| phlebotomist | trained in the removal of blood from the body for diagnostic or therapeutic purposes |
| radiologist | physician specially trained in evaluating images of the body to diagnose illness or injury |
| radiology technician | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| ultrasonographer | trained in performing ultrasound imaging on a patient |
| pharmacist | trained and licensed in preparing and dispensing medicine |
| pharmacy technician | trained to assist a pharmacist |
| patient service coordinator | handles admin tasks and coordinates patient care |
| medical transcriptionist | trained in converting the voice-recorded dictations of health care providers into to text format |
| chief complaint | the main reason for the patient's visit |
| history of present illness | story of the patient's problem |
| review of systems | description of individual body systems in order to discover any symptoms not directly related to the main problem |
| past medical history | patient's past surgeries |
| family history | other significant past illnesses that run in the family |
| social history | record of habits like smoking, drinking, drug abuse, and sexual practices |
| Clinic note | documents a visit |
| consult note | provides an expert opinion on a more challenging problem; can be a letter |
| emergency department note | documents an ER visit |
| admission summary | documents the admission of a patient to the hospital |
| discharge summary | describes when and why the patient was admitted; documents a longer stay |
| operative report | documents a surgery in detail |
| daily hospital note progress note | documents daily hospital visit |
| radiology report | explains reason for image, how it was performed, what was found, the assessment, and recommendation |
| pathology report | provides reasons for test, what was found, and assessment |
| prescription | provides directions for a medication |
| CCU | coronary care unit |
| ECU | emergency care unit |
| ER | emergency room |
| ED | emergency department |
| ICU | intensive care unit |
| PICU | pediatric intensive care unit |
| NICU | neonatal intensive care unit |
| SICU | surgical intensive care unit |
| PACU | post-anesthesia care unit |
| L&D | labor and delivery |
| OR | operating room |
| post-op | after surgery |
| pre-op | before surgery |
| ♂ | male |
| ♀ | female |
| (R) | right |
| (L) | left |
| (B) | bilateral |
| ↑ | increased |
| ↓ | decreased |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Ht | height |
| Wt | weight |
| BMI | body mass index |
| I/O | intake/output; the amount of fluids a patient has taken in and produced |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | prescription |
| H&P | history & physical |
| Hx | history |
| CC | chief complaint |
| HPI | history of present illness |
| ROS | review of systems |
| PMHx | past medical history |
| FHx | family history |
| NKDA | no known drug allergies |
| PE | physical exam |
| Pt | patient |
| y/o | years old |
| h/o | history of |
| PCP | primary care physician |
| f/u | follow up |
| SOB | shortness of breath |
| HEENT | head, eyes, ears, nose, throat |
| PERRLA | pupils are equal, round, and reactive to light and accommodations |
| NAD | no acute distress |
| CV | cardiovascular |
| RRR | regular rate and rhythm |
| CTA | clear to auscultation (normal sounding lungs) |
| WDWN | well developed, well nourished |
| A&O | alert and oriented |
| WNL | within normal limits |
| NOS | not otherwise specified |
| NEC | not elsewhere classified |
| PO | per os (by mouth) |
| NPO | nil per os (nothing by mouth) |
| PR | per rectum |
| IM | intramuscular |
| SC | subcutaneous (under the skin) |
| IV | intravenous |
| CVL | central venous line |
| PICC | peripherally inserted central catheter |
| Sig | instructions |
| BID | twice daily |
| TID | three times daily |
| Q | every (as in every 3 days) |
| QD | daily |
| QID | four times daily |
| QHS | at night |
| AC | before meals |
| PC | after meals |
| prn | as needed |
| ad lib | as desired |
Created by:
hmarie94
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