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Chapter 2 HlHS101

TermDefinition
S.O.A.P Subjective, Objective, Assessment, Plan
S in S.O.A.P Definition Subjective: what the patient says (symptoms, history, complaints)
O in S.O.A.P Definition Objective: what the provider observes (vitals, exam findings, labs)
A in S.O.A.P Definition Assessment: the provider’s diagnosis or clinical impression
P in S.O.A.P Definition Plan: treatment, tests, follow‑up, medications
Febrile having a fever
Afebrile without fever
Malaise a general feeling of discomfort, weakness, or “not feeling well.”
Auscultation listening to the internal sounds of the body, usually with a stethoscope.
Idiopathic unknown cause
Sequela a condition that occurs as a result of a previous disease, injury, or illness.
Etiology the cause or origin of a disease or condition
Palliative relieving symptoms without curing the underlying disease.
Ventral the front or belly side of the body
Dorsal the back side of the body
Caudal toward the tail or lower part of the body
Created by: l4
 

 



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