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Medical Term Ch 2
SOAP Method and General Terms
| Term | Definition | S.O.A.P Type |
|---|---|---|
| acute | started recently or is a sharp, severe symptom | Subjective |
| chronic | has been going on for a while | Subjective |
| exacerbation | is getting worse | Subjective |
| abrupt | all of a sudden | Subjective |
| febrile | to have a fever | Subjective |
| afebrile | to NOT have a fever | Subjective |
| malaise | not feeling well | Subjective |
| progressive | more and more each day | Subjective |
| symptom | something a patient feels | Subjective |
| noncontributory | not related to this specific problem | Subjective |
| lethargic | a decrease in level of consciousness; in a medical record, this is a general indication that the patient is really sick | Subjective |
| genetic/hereditary | it runs in the family | Subjective |
| alert | able to answer questions; responsive; interactive | Objective |
| oriented | being aware of who they are, where they are, and the current time; patient aware of all three is "oriented times 3" | Objective |
| marked | it really stands out | Objective |
| unremarkable | another way of saying normal | Objective |
| auscultation | to listen | Objective |
| percussion | to hit something and listen to the resulting sound or feel for the resulting vibration | Objective |
| palpation | to feel | Objective |
| impression | another way of saying assessment | Assessment |
| diagnosis | what health care professional thinks the patient has | Assessment |
| differential diagnosis | a list of condition the patient may have based on the symptoms exhibited and the results of the exam | Assessment |
| benign | safe | Assessment |
| malignant | dangerous; a problem | Assessment |
| degeneration | to be getting worse | Assessment |
| remission | to get better or improve; does not mean cure; mostly from discussing cancer | Assessment |
| idiopathic | no known specific cause; it just happens | Assessment |
| localized | stays in a certain area of the body | Assessment |
| systemic/generalized | all over the body ( or most of it) | Assessment |
| prognosis | the chances for things getting better or worse | Assessment |
| occult | hidden | Assessment |
| lesion | diseased tissue | Assessment |
| recurrent | to have again | Assessment |
| sequela | a problem resulting from a disease or injury | Assessment |
| pending | waiting for | Assessment |
| pathogen | organism that causes the problem | Public Health |
| morbidity | the risk for being sick | Public Health |
| mortality | the risk for dying | Public Health |
| etiology | the cause | Public Health |
| 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 the visit(home, ICU, normal hospital bed) | Plan |
| discharge | literally, to unload; it has two meanings: 1. to send home (unload the patient from the health care setting to home) 2. fluid coming out of a part of the body (body unloading a fluid) | Plan |
| palliative | treating the symptoms, but not actually getting rid of the cause | Plan |
| observation | watch, keep an eye on | Plan |
| reassurance | to tell the patient that the problem is not serious or dangerous | Plan |
| supportive care | to treat the symptoms and make the patient feel better | Plan |
| sterile | extremely clean, germ-free conditions; especially important during medical procedures and surgery` | Plan |
| prophylaxis | preventive treatment | Public Health |
Created by:
Camoore745
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