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MED TERM ch 2
flash cards from ch 2 in module 1
| Term | Definition |
|---|---|
| S.O.A.P | Subjective, Objetcive, Assessment, Plan |
| Subjective | how the patient experienced and personally describes the problem and family medical history |
| Objective | the patients physical exams, lab findings, and imaging |
| Assessment | health care providers logical analysis |
| Plan | course of action consistent with the assessment. Treatment with medicine or a procedure. |
| acute (ah-KYOOT) | it just started recently OR a sharp, sever symptom |
| chronic (KRAWN-ik) | has been going on for a while |
| exacerbation (eks-As-er-BAY-shun) | it is getting worse |
| abrupt (ah-BRUPT) | all of a suddent |
| afebrile (uh-FEB-ril) | to not have a fever |
| febrile (FEH-brail) | to have a fever |
| malaise (mah-LAYZ) | not feeling well |
| progressive (proh-GREH-siv) | more and more each day |
| symptom (SIM-tom) | something a patient feels |
| noncontributory (NON-kon-TRIH-byoo-TOR-ee) | not related tot he specific problem |
| lethargic (lah-THAR_jik) | i decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick |
| genetic/hereditary (jen-ET-ik, heh-RED-ih-TER-ee) | it runs in the family |
| alert (ah-LERT) | able to answer questions; responsive; interactive |
| oriented (OR-ee-EN-ted) | being aware of who they are, where they are, and current time; knowing all three is "oriented x 3" |
| marked (MARKT) | really stands out |
| unremarkable (in-ree-MAR-kuh-bul) | another way of saying normal |
| auscultation (aw-skul-TAY-shun) | to listen |
| percussion (per-KUSH-un) | to hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument |
| palpation (pal-PAY-shun) | to feel |
| impression (im-PRESH-un) | another way of saying assessment |
| diagnosis (DAI-ag-NOH-sis) | what the health care professional things the patient has |
| differential diagnosis (DIF-eh-REN-chal DAI-ag-NOH-sis) | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam |
| benign (beh-NAIN) | safe |
| malignant (mah-LIG-nant) | dangerous, a problem |
| degeneration (dee-JEN-eh-RAY-shun) | to be getting worse |
| remission | to get better or improve (usually with cancer) |
| idiopathic | no known specific cause |
| localized | stayes in a certain part of the body |
| systemic/generalized | all over the body (or most of it) |
| prognosis | the chances for getting things better or worse |
| occult (ah-KULT) | hidden |
| lesion | diseased tissue |
| recurrent | to have again |
| sequela (seh-KWEL-eh) | a problem resulting from a disease or injury |
| pending | waiting for |
| pathogen | the organism that causes the problem |
| morbidity | the risk of being sick |
| mortality | the risk of dying |
| etiology (EET-ee-AWL-oh-jee) | 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, ICE, normal hospital bed) |
| discharge | literally to unload, has 2 meaning: 1. to send home 2. fluid coming out of a body part |
| palliative | treating the symptoms, but not actually getting rid of the cause |
| abservation | watching, keep an eye on |
| reassurance | to tell the patient tat the problem is not serious or dangerous |
| supportive care | to threat the symptoms and make the patient feel better |
| sterile | extremely clean, germ-free conditions; especially important during medical procedures and surgery |
| prophylaxiss | preventative treatment |
| proximal | closer to the center |
| distal | farther away from the center |
| lateral | out to the side |
| medial | toward the midle |
| 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 | top of the hand or foot |
| plantar | the sole of the foot |
| palmar | the palm of the hand |
| sagittal | splits body in left to right |
| coronal (frontal) | splits body in from and back |
| transverse | splits body in top and bottom |
| physician | a skilled health care provider who attended and graduated medical school |
| pediatrician | a physician with special training in caring for children |
| surgeon | physician qualified to treat patients surgically |
| anesthesiologist | physician with special training in sedation and pain control |
| epidemiologist (EP-ih-DEE-mee-AWL-uh-jist) | specialist in the study of the causes and distributions of diseases in populations and the use of this data to enhance public health |
| physicians assistant (PA) | a midlevel health care provider who works under the license of a supervising physician |
| nurse practitioner | nurse with postgrad training that serves as a midlevel healthcare provider |
| emergency medical technician | trained in emergency medical transport and care before |
| speech therapist | evaluates and treats problems with speech and/or swallowing |
| occupational therapist | evaluates and treats problems with performing daily activites at home, school, and work |
| physicial therapist | evaluates patients physical impairments including disabilities or recovery form injury |
| respiratory therapist | specially trained in treated a patients respiratory issues under the guidance of a health care provider |
| dietician | evaluates the nutritional status of a patient and developing an appropriate diet plan |
| licensed practican nurse (LPN), licensed vocational nurse (LVN | trained and certified to provide basic care to a patient |
| registered nurse (RN) | advanced level nurse who has completedd an associates or bachelors degree, often helps with patient care planning and patient educaton |
| medical assistent | trained to carry out basic administrative and clinical tasks under the guidance o a health care provider |
| pathologist | trained in both evaluating the causes and effect 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 purposed |
| radiologist | physician specially trained in evaluating images of the body to diagnose illness or injury |
| radiology technician | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| ultrasonographer | trained to preform ultrasound imaging on a patient |
| pharmacist | trained and licensed in the preparing and dispensing of medicine |
| pharmacy technician | 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 | main reason for the patients visit |
| history of present illness | story of patients current problem |
| review of symptoms | description of individuals body systems in order to discover any symptoms not directly related to the main problem |
| past medical history | other significant past illnesses, like high blood pressure, asthma, or diabetes |
| past surgical history | any of the patients past surgeries |
| family history | any significant illnesses that run in the patients family |
| social history | a record of habits like smoking, vaping, drinking, drug abuse, and sexual practices that ca impact health |
| clinic note | medical professional, in a clinic, documents a visit, SOAP, new patient: includes more history, separate form; repeat patient: streamlined note |
| consult note | physician; usually a specialist, clinic or hospital, provides an expert opinion on a more challenging problem, SOAP, can be in the form of a letter ti the PCP |
| emergency department noite | ED medical staff, emergency department, documents ED visit, SOAP, The A includes the emergency department course |
| edmission summary | hospital medical professional, hospital, documents the admission of a patient to the hospital, SO A/P, (S, O = very thorough, A = differential diagnosus, P = further testing and care, A+P = problem based approach) |
| discharge summary | medical proifessional, hospital, decribes when and why the patient was admitted; documents a longer stay, ASOP, startes with A |
| Operative report | surgeon, documents a surgery in detail, ASOP |
| daily hospital note/progress note | medical professional, inpatient health care faciltiy, documents daily hospital visit, SO A/P (S - focuses on how patients condition has changes since the previous note, A - sometimes includes a differential diagnosis) |
| radiology report | radiologist, ecplains reason for imaging, haor image was perfomred, what was seen on image, radiologists assessments; sometimes a recommendation, SOA, (usually includes only SOA but many include P if it recommends further studies should be performed) |
| pathology report | pathologist, provides reasons for test, what was soon on the test, and an assessment, SOA |
| Prescription | medical professional, provides directions for a medication, P (1. Medicines name, 2. instructions for patient, 3. how much medicine should be given, 4. refills if any, 5. health care professionals signature and whether generic substitution is allowed) |
| 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-anesthetic care unit |
| L&D | labor and delivery |
| OR | operating room |
| post-op | after surgery |
| pre-op | before surgery |
| (R) | right |
| (L) | left |
| (B) | bilateral |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Ht | hieght |
| Wt | weight |
| BMI | body mass index |
| I/O | intake/output with fluids a patient has taken (IV or mouth and produced urine) |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | prescription |
| H&P | history and physical |
| Hx | history |
| CC | chief complaint |
| HPI | history of present illness |
| ROS | review of systems |
| PMHx | past medical history |
| FHx | family hostory |
| NKDA | no known drug allergies |
| PE | physcial 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 throat |
| PERRLA | pupils are equal, round, and reactive to light and accommodation |
| NAP | 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 specific |
| NEC | not elsewhere classified |
| PO | per os (by mouth) |
| NPO | nil per os (not by mouth) |
| PR | per rectum (anal) |
| IM | intramuscular |
| SC | subcutaneous |
| IV | intravenous |
| CVL | central venous line |
| PICC | periphery inserted central catheter |
| Sig | instructions short for "signa", from latin, for "label" |
| BID | bis in die (twice daily) |
| TID | ter in die (three times daily) |
| Q | every (x) (example: Q4hr means every four hours |
| QD* | quaque die (daily) |
| QID* | quarter in die (4 times daily) |
| QHS | quaque hopra somni (at night) |
| AC | ante cibum (before meals) |
| PC | post cibum (after meals) |
| prn | per re nata (as needed) |
| ad lib | as desired |
Created by:
mattrich_57