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HLHS 101 Ch. 2

Chapter 2 word parts, terms and/or abbreviations

TermDefinition
SOAP S- SUBJECTIVE O- OBJECTIVE A-ASSESSMENT P-PLAN
Subjective How the patient describes the problem including patient medical hx and family hx.
Objective Consists of patient physical exam, lab results, or imaging studies that are performed.
Assessment Either: -Diagnosis -Identification of a Problem or -Differential Diagnosis
Plan The course of action chosen to resolve a diagnosis, or to give a more accurate diagnosis, in conjunction with the assessment.
Acute Symptoms recently began, or are sharp & sudden symptoms.
Chronic Condition started some time ago, and has not yet resolved.
Febrile Feverish or having a fever.
Malaise Generally feeling unwell.
Noncontributory Not related to a specific condition or problem.
Alert Able to respond or answer questions; interacts with others.
Oriented Aware of surroundings, who he/she is, awareness to time/date.
Unremarkable Another way of saying that results/situation is normal.
Auscultation To listen.
Palpation To feel.
Diagnosis The condition that a HCP thinks the patient has.
Differential Diagnosis A list of conditions that the patient may have based on s/sx and exam results.
Benign Safe
Malignant Dangerous/Problematic
Idiopathic No known cause; it just happens.
Prognosis Outlook for things either getting better, or worse
Recurrent Will have/Can have again
Sequela A problem or condition stemming from an injury or disease
Mortality The risk for dying.
Etiology The cause of a problem or condition.
Discharge 1. To send home from healthcare setting. 2. Fluid coming out of a body part.
Observation To keep an eye on.
Sterile Extremely clean; important for certain medical procedures and during surgeries.
Prophylaxis Preventative Treatment
Medical Assistant Trained to carry out basic administrative and clerical tasks under the guidance of a HCP
Physician Two Types: MD (Medical Doctor) or DO (Doctor of Osteopathy)
Epidemiologist Specialist in the study of cause/distribution of diseases in population, who uses the data to enhance public health
Created by: emilyjmaloy
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