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Ch. 2 Flashcards

Acquiring Medical Language Chapter 2 Introduction to Health Records

TermDefinition
Subjective Is subject to how a patient experiences and personally describes the problem as well as personal and family medical histories.
Objective Comprises the patient’s physical exam, any laboratory findings, and imaging studies performed at visit.
Assessment A diagnosis, an identification of a problem, or a list of possibilities for the diagnosis, which is known as a differential diagnosis.
Plan Course of action consistent with the assessment.
Exacerbation (eks-AS-er-BAY-shun) It is getting worse.
Malaise (mah-LAYZ) Not feeling well.
Unremarkable (un-ree-MAR-kah-bul) Another way of saying normal.
Sequela (seh-KWEL-eh) A problem resulting from a disease or injury.
Prophylaxis (proh-fih-LAK-sis) Preventive treatment.
Idiopathic (ID-ee-oh-PATH-ik) No known specific cause; it just happens.
Created by: Kait.baker93
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