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Chapter 2

Vocab Words

Subjective How a patient experiences and personally describes the problem as well as personal and family medical history
Objective The patient's physical examination, any labatory findings, and imaging studies performed.
Assessment Could be a diagnosis, which is known as a differential diagnosis.
Plan A course of action consistent with assessment. A plan could be a treatment with medication or a procedure.
Malalse Not feeling well
Lethargic A decrease in a level of consciousness in medical records, this is generally an indication that the patient is really sick.
Auscultation To listen
Alert Able to answer questions, responsive, interactive
Idiopathic No known specific cause, it just happens
Sequela A problem resulting from diseases or injury
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