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Med Term 101 - Ch 2
| Question | Answer |
|---|---|
| SOAP - | subjective, objective, assessment, plan |
| diagnosis - | identification of the actual problem |
| differential diagnosis - | a list of possibilities for the diagnosis |
| acute - | it just started recently or is a sharp, severe symptom |
| chronic - | it has been going on for a while now |
| exacerbation - | it is getting worse |
| abrupt - | all of a sudden |
| febrile - | to have a fever |
| Afebrile - | to not have a fever |
| malaise - | not feeling well |
| progressive - | more and more each day |
| symptom - | something a patient feels |
| noncontributory - | not related to this specific problem |
| lethargic - | a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick |
| genetic/hereditary - | it runs in the family |
| alert - | able to answer questions; responsive; interactive |
| oriented - | being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is "oriented x 3" |
| marked - | it really stands out |
| unremarkable - | another way of saying normal |
| Auscultation - | to listen |
| Percussion - | to hit something and listen to the resulting sound or feel for the resulting vibration |
| Palpation - | to feel |
| impression | another way of saying assessment |
| diagnosis | what the health care professional thinks the patient has |
| differential diagnosis | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam |
| benign | safe |
| malignant | dangerous; a problem |
| degeneration | to be getting worse |
| remission | to get better or improve; most often used when discussing cancer; remission does not mean cure |
| idiopathic | no known specific cause; it just happens |
| localized | stays in a certain part of the body |
| systemic/generalized | all of the body (or most of it) |
| prognosis | the chances for things getting better or worse |
| occult | hidden |
| lesion | diseased tissue |
| recurrent | to have again |
| sequela | a problem resulting from a disease or injury |
| pending | waiting for |
| pathogen | the organism that causes the problem |
| mortality | the risk of dying |
| etiology | the cause |
| 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, the ICU, normal hospital bed) |
| discharge | literally, to unload; it has two meanings: 1. to send home (to unload the patient from the health care setting to home) 2. fluid coming out of a part of the body (your body unloading fluid) |
| palliative | treating the symptoms, but not actually getting rid of the cause |
| observation | watch, keep and eye on |
| reassurance | to tell the patient that the problem is not serious or dangerous |
| supportive care | to treat the symptoms and make the patient feel better |
| sterile | extremely clean, germ-free conditions; especially important during medical procedures and surgery |
| prophylaxis | preventive treatment |
| proximal | closer in to the center (close) |
| distal | farther away from the center (far) |
| lateral | out to the side |
| medial | toward the middle |
| ventral/antral/anterior | the front |
| dorsal/posterior | the back |
| cranial | toward the top |
| caudal | toward the bottom |
| superior | above |
| inferior | below |
| prone | lying down on belly |
| supine | lying down on back |
| contralateral | opposite side |
| ipsilateral | same side |
| unilateral | one side |
| bilateral | both sides |
| dorsum | the top of the hand or foot |
| plantar | the sole of the foot |
| palmar | the palm of the hand |
| sagittal | divides the body along the hypothetical plane from right to left |
| coronal | divides the body along a hypothetical plane from front to back |
| transverse | divides the body from top to bottom |
| physician | a skilled health care provided who attended and graduated medical school |
| pediatrician | a physician with special training in caring for children |
| surgeon | a physician qualified to treat patients surgicall, that is, by means of operation or invasive procedure |
| anesthesiologist | a physician with special training in pain sedation and pain control |
| epidemiologist | a specialist in the study of the causes and distribution of diseases in populations and the use of this data to enhance public health |
| physician assistant (PA) | a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training |
| nurse practitioner (NP) | a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician |
| EMT | specially training in the emergency care of a patient before and/or during transport to medical facility |
| speech therapist | specially trained in evaluating and treating problems with speech and/or swallowing |
| OT Occupational therapist | specially training in evaluating and treating problems with performing daily activities at home, school, or work |
| PT physical therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury |
| respiratory therapist | specially trained in treating patient's respiratory issues under the guidance of a health care provider |
| dietician | specially training in evaluating the nutritional status of a patient and developing an appropriate diet plan |
| LPN licensed practical nurse LVN licensed vocational nurse | trained and certified to provide basic care to a patient |
| RN registered nurse | an advanced level nurse who has completed an associate's or bachelor's degree; often assists with patient care planning and patient education |
| medical assistant | trained to carry out the basic administrative and clinical tasks under the guidance of a health care provider |
| pathologist | a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
| medical laboratory technician | trained in performing laboratory testing on bodily fluids |
| phlebotomist | trained in the removal of blood from the body for diagnostic or therapeutic purposes |
| radiologist | a physician specially trained in evaluating images of the body to diagnose illness or injury |
| radiology tech | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| ultrasonographer | trained in performing ultrasound imaging on a patient |
| pharmacist | trained and licensed in preparing and dispensing medicine |
| pharmacy tech | trained to assist a pharmacist with pharmacy related tasks |
| patient service coordinator | handles administrative tasks and coordinates patient care |
| medical transcriptionist | trained in converting the voice-recorded dictations of health care providers into text format |
| chief complaint | the main reason for the patient's visit |
| history of present illness | the story of the patient's problem |
| review of systems | descriptions of the individual body systems in order to discover any symptoms not directly related to the main problem |
| past medical history | other significant pass illnesses, like high blood pressure, asthma or disabetes |
| past surgical history | any of the patient's past surgeries |
| family history | any significant illness that run in the patient's family |
| social history | a record of habits like smoking, drinking, drug abuse and sexual practices that can impact health |
| clinic note | documents a visit |
| consult note | provides an expert opinion on a more challenging problem |
| emergency department note | documents an emergency department visit |
| admission summary | documents the admission of a patient to the hospital |
| discharge summary | describes when and why the patient was admitted; documents a longer stay |
| operative report | docments a surgery in detail |
| daily hospital note/progress note | documents daily hospital visit |
| radiology report | explains reason for image, how image was performed, what was seen on on image, radiologist's assessment; sometimes a recommendation |
| pathology report | provides reasons for test, what was seen on the test; and an assessment |
| prescription | provides directions for a medication |
| CCU | coronary care unit |
| ECU | emergency care unit |
| ER | emergency room |
| ED | emergency department |
| ICU | intensive care unit |
| PICU | pediatric intensive care unit |
| NICU | neonatal intensive care unit |
| SICU | surgical intensive care unit |
| PACU | post-anesthesia care unit |
| L&D | labor and delivery |
| OR | operating room |
| post-op | after surgery |
| pre-op | before surgery |
| ♂ | male |
| ♀ | female |
| (R) | right |
| (L) | left |
| (B) | bilateral (both sides) |
| ↑ | increased |
| ↓ | decreased |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Ht | height |
| Wt | weight |
| BMI | body mass index |
| I/O | intake/output; the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output) |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | prescription |
| H&P | history and physical |
| Hx | history |
| CC | chief complaint (the main reason for the visit) |
| HPI | history of present illness (story of the symptoms) |
| ROS | review of systems (anything else not directly related to the chief complaint) |
| PMHx | past medical history |
| FHx | family history |
| NKDA | no known drug allergies |
| PE | physical exam |
| Pt | patient |
| y/o | years old |
| h/o | history of |
| PCP | primary care provider |
| f/u | follow up |
| SOB | shortness of breath |
| 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 (normal sounding lungs) |
| WDWN | well developed, well nourished (growing/grown appropriately, does not appear to be malnourished) |
| A&O | alert and orientated |
| 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 (anal) |
| IM | intramuscular |
| SC | subcutaneous (under the skin) |
| IV | intravenous |
| CVL | central venous line |
| PICC | peripherally inserted central catheter |
| Sig | instructions short for signa - latin ''label'' |
| BID | twice daily (bis in die) |
| TID | three times daily (ter in die) |
| Q | every x (Q4hr - every 4 hours) |
| QD | daily (quaque die) |
| QID | four times daily (quuater 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 |
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