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HLHS101 Ch. 2
Medical Terminology Chapter 2.
| Term | Definition |
|---|---|
| SOAP | Acronym for the four types of data documented by heath care providers in a medical note. |
| S = | Subjective: What patient says |
| O = | Objective: What tests reveal |
| A = | Assessment: Analysis of subjective/objective information by heath care provider |
| P = | Plan: Course of action for patient |
| Subjective | Problems patient states they have. Translated into medical terms. |
| Acute | Condition that comes on suddenly and worsens quickly |
| Chronic | Condition that is long-lasting and develops slowly |
| Abrupt | Similar to acute, quick onset and rapid progression |
| Febirel | Feverish |
| Afebrile | Free from fever |
| Malaise | Vague sense of discomfort, being unwell |
| Progressive | symptoms that gradually worsens |
| Exacerbation | Sudden worsening of existing condition |
| Symptom | Subjective evidence of disease |
| Noncontributory | Patients history/test results provide no meaningful information to diagnose/treat health issue |
| Lethargic | Abnormal drowsiness |
| Genetic/Hereditary | Related to DNA/genes |
| Objective | Data collected by heath care provider. Information gathered from tests and images of patient's body. |
| Alert | Patient is awake, responsive, and oriented |
| Oriented | Patient is aware of identity, surroundings, and circumstances |
| Auscultation | Diagnostic method used during physical examination listening to internal body noise |
| Percussion | Physical examination technique when examiner taps body's surface to evaluate density of underlying structures |
| Palpation | Physical examination technique where examiner uses sense of touch to examine body |
| Unremarkable | Normal, healthy, no significant abnormalities |
| Marked | Findings show condition/symptom |
| Assessment | Combination of subjective and objective information. Leads to conclusion about problem/diagnosis. If single cause ins't evident, differential diagnosis may be needed. |
| Impression | Doctor's interpretation based on symptoms/examinations/tests |
| Diagnosis | Identification of disease |
| Differential diagnosis | Conditions patient may have based on symptoms shown as results of the exam |
| Benign | Not cancerous |
| Malignant | Cancerous |
| Degeneration | Gradual breakdown of cells |
| Etiology | Exact cause of disease/condition |
| Idiopathic | Spontaneous condition/symptom with unknown cause |
| Remission | Period where disease is inactive |
| Recurrent | Condition returning after improvement |
| Morbidity | State of being unhealthy or having condition |
| Mortality | State of being mortal |
| Prognosis | Prediction of the course of a disease |
| Localized | Condition restricted to a specific part of body |
| Systemic/generalized | Condition affecting the entire body |
| Occult | Hidden |
| Pathogen | Organiim/agent that causes disease |
| Lesion | Abnormal/damaged tissue |
| Sequela | Persistent condition resulting from prior illness |
| Pending | Result that is waiting for final confirmation |
| Plan | Recommended actions by provider to patient regarding current health status. |
| Disposition | Final plan for patient at the end of care |
| Discharge | Removing patient from care or a bodily fluid coming from body |
| Prophylaxis | Any measure taken to prevent spread of disease |
| Palliative | Any measure taken to relieve the patient of discomfort |
| Observation | Collection of data |
| Reassurance | Action to relieve patients fear/anxiety about health |
| Supportive care | Any measure taken to alleviate discomfort alongside treating illness |
| Sterile | Absence of germs/pathogens |
| Superior | Upper part of body |
| Inferior | Lower part of body |
| Anterior | Front part of body |
| Posterior | Back part of body |
| Proximal | Torso side of limb |
| Distal | Non-torso side of limb |
| Cranial | Upper part of skull |
| Caudal | Lower part of skull |
| Supine | Laying on back |
| Prone | Laying on stomach |
| Contralateral control | One side of brain controlling other side of body |
| Ipsilateral control | One side of brain controlling same side of body (face) |
| Left hemisphere | Left side of brain, controls right side of body. |
| Right hemisphere | Right side of brain, controls left side of body. |
| Unilateral | Affecting one side of body |
| Bilateral | Affecting both sides of body |
| Dorsum | Back/top surface of body part |
| Palmar | Front/bottom surface of body part |
| Physician | Licensed medical professional who practices medicine and healthcare |
| Pediatrician | Physician who specializes in adolescents |
| Surgeon | Medical doctor focused on performing operations |
| Anesthesiologist | Doctor who specializes in anesthesia |
| Physician assistant (PA) | Medical professional who practices medicine alongside physicians |
| Nurse practitioner (NP) | Advanced Practice Registered Nurse with master's or doctoral degree |
| Emergency medical technician (EMT) | Healthcare professional who provides out-of-hospital life support and transportation |
| Speech therapist | Healthcare professional specialized in speech |
| Occupational therapist | Healthcare professional specialized in daily living/working activities |
| Physical therapist | Healthcare professional specialized in movement |
| Respiratory therapist | Healthcare professional specialized in respiratory problems |
| dietician | Healthcare professional specialized in diets |
| licensed practical nurse (LPN) | Healthcare professional who provides basic medical care under physicians and registered nurses |
| Licensed vocational nurse (LVN) | Entry-level healthcare professional providing basic medical and bedside care |
| Registered nurse (RN) | Licensed healthcare professional who provides direct patient care and work alongside physicians |
| Medical assistant | Healthcare professional who supports physicians, tasked with clinical and administrative duties |
| Pathologist | Medical doctor who diagnoses disease via tissues, cells, and body fluids |
| Medical laboratory technician | Healthcare professional who collects specimens and preforms tests on blood, tissue, and body fluids |
| Phlebotomist | Healthcare professional who draws blood |
| Radiologist | Medical doctor who specializes in diagnosing/treating conditions through graphs from imaging machines |
| Radiology technician | Healthcare professional who operates medical imaging equipment |
| Ultrasonographer | Healthcare professional who operates medical imaging equipment that use high-frequency sound waves |
| Pharmacist | Healthcare provider who prepares/dispenses prescription drugs |
| Pharmacy technician | Healthcare professional who works under a licensed pharmacist |
| Patient service coordinator | Healthcare administrative professional acting as primary liaison between patients and medical staff |
| Medical transcriptionist | Healthcare professional who converts voice-recorded dictations from doctors into written medical reports |
| Chief complaint | Primary symptom/condition |
| History of present illness | Chronological narrative of health issues/symptoms |
| Review of systems | Structured inventory of body systems designed to uncover symptoms patient may be experiencing or has experienced |
| Past medical history | Comprehensive record of patient's overall health |
| Past surgical history | Record of all previous operations patient has gone under |
| Family history | Record of medical conditions/issues in patients biological family |
| Social history | Part of health record documenting lifestyle habits |
| Clinic Note | Medical record made by healthcare provider after patient encounter |
| Consult Note | Medical report generated by healthcare provider after evaluating patient |
| Emergency Department Note | Critical medical document summarizing patient's emergency room visit |
| Admission Summary | Medical document created by healthcare provider when patient is received into hospital for overnight care or specialized treatment |
| Discharge Summary | Medical document created when patient leaves hospital |
| Operative Report | Medical document that details events of surgical procedure |
| Daily Hospital Note/Progressive Note | Medical record updated by healthcare providers |
| Radiology Report | Medical document radiologist created after examining medical imaging graphs |
| Pathology Report | Medical document Written by pathologist detailing examination of tissue, cell, or fluid sample |
| Prescription | Written order from licensed healthcare provider to a pharmacist |
| Pre-op | Care/tests/appointments before surgical procedure |
| OR | Operating Room |
| PACU | Post-Anesthesia Care Unit |
| Post-op | Period after surgical operation |
| ICU | Intensive Care Unit |
| CCU | Coronary Care Unit |
| SICU | Surgical Intensive Care Unit |
| PICU | Pediatric Intensive Care Unit |
| NICU | Neonatal Intensive Care Unit |
| ER | Emergency Room |
| ED | Emergency Department |
| ECU | Emergency Care Unit |
| L&D | Labor and Delivery |
| ♂ | Male |
| ♀ | Female |
| (R) | Right |
| (L) | Left |
| (B) | Bilateral |
| ↑ | Increased |
| ↓ | Decreased |
| Vs | Vital signs made up of HR, RR, BP, and T. |
| HR | Heart rate |
| RR | Respirator rate |
| BP | Blood pressure |
| T | Temperature |
| HT | Height |
| Wt | Weight |
| BMI | Body mass index |
| I/O | Input/output |
| Dx | Diagnosis |
| DDx | Differential diagnosis |
| Tx | Treatment |
| Rx | Prescription |
| Hx | History |
| PMHx | Past medical history |
| FHx | Family history |
| H&P | History and physical |
| CC | Chief complaint |
| HPI | History of present illness |
| ROS | Review of systems |
| PE | Physical exam |
| PCP | Primary care provider |
| NKDA | No known drug allergies |
| Pt | Patient |
| y/o | Years old |
| h/o | History of |
| f/u | Follow up |
| A&O | Alert and oriented |
| PERRLA | Pupils equal, round, and reactive to light and accommodation |
| NOS | Not otherwise specified |
| RRR | Regular rate and rhythm |
| CTA | Clear to auscultation |
| NAD | No acute distress |
| PO | Per os (by mouth) |
| IV | Intravenous |
| SC | Subcutaneous |
| CVL | Central venous line |
| IM | Intramuscular |
| PR | Per rectum |
| NPO | Nil per os (nothing by mouth) |
| PRN | As needed |
| QID | Four times a day |
| QD | Once a day |
| AC | Before meals |
| TID | Three times a day |
| BID | Twice a day |
| PC | After meals |
| QHS | Every night |
Created by:
Clonnan59
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