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HLHS CH2

TermDefinition
S.O.A.P. subjective, objective, assessment, plan
subjective Patient's description of problem and additional details such as duration
objective Data collected. example: labs, images, physical and any other tests conducted
assessment diagnosis, possible diagnoses or identification of problem
plan next steps. example: treatment, medicine, procedure or additional testing
acute just started recently or is a sharp, severe symptom
chronic has been going on for a while
febrile to have a fever
Afebrile to NOT have a fever
malaise not feeling well
lethargic a decrease in level of consciousness
oriented aware of who, when, where (who they are, where they are, and current date and time)
marked it really stands out
unremarkable normal
auscultation to listen
impression assessment (just another way to say it)
differential diagnosis a list of possible conditions
malignant dangerous
idiopathic just happens, no specific known cause
systemic or generalized all over or most of body
prognosis chances of things getting better or worse
occult hidden
lesion deceased tissue
sequela problem resulting from disease or injury
morbidity the risk for being sick
pathogen organism that causes the problem
mortality risk for dying
etiology the cause
disposition what happened to patient after visit example: went home, ICU,
palliative treating symptoms but not getting rid of cause
supportive care to treat symptoms and make patient feel better
prophylaxis preventive treatment
cranial towards top
caudal toward the bottom
discharge (to unload) to send home or fluid coming out of a part of the body
proximal closer in to the center
distal farther away from center
lateral out to the side
medial toward the middle
ventral, antral, anterior the front
dorsal, posterior the back
superior above
inferior bellow
prone lying down on belly
supine lying down on back
contralateral opposite side
ipsilateral same side
unilateral one side
bilateral both sides
dorsum top of hand or foot
plantar the sole of the foot
palmar the palm of the hand
sagittal divides the body from right to left
coronal divides the body from front to back
transverse divides the body from top to bottom
review of systems description of individual body systems in order to discover any symptoms not directly related to the main problem
(R), (L) right, left
(B) bilateral
VS vital signs
T temperature
HR heart rate
RR respiratory rate
Ht height
Wt weight
I/O intake/output (amount of fluids a patient takes in and produces)
Dx diagnosis
DDx differential diagnosis
Tx treatment
H&P history and physical
Hx history
CC chief complaint
HPI history of present illness
ROS review of systems
NKDA no known drug allergies
PE physical exam
Pt patient
h/o history of
f/u follow up
SOB, SOA shortness of (breath, air)
HEENT head, eyes, ears, nose and throat
PERRLA pupils are equal, round and reactive to light and accommodation
NAD no acute distress
CV cardiovascular
RRR regular rate and rhythm
CTA clear to auscultation
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 skin)
IV intravenous
CVL central venous line
PICC peripherally inserted central catheter
Sig instructions short for signa (label)
BID twice daily (bis in die)
TID 3 times daily (ter in die)
Q every_____(4hrs, 3days)
QD daily (quaque die)
QID 4 times daily (quater in die)
QHS at night (quaque hora somni)
AC before meals (ante cibum)
PC after meals (post cibum)
prn as needed (per re nata)
ad lib as desired
Created by: sab707
 

 



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