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SOAP Terms

Chapter 2

TermDefinition
Acute it just started recently or is a sharp, severe symptom S
Chronic it has been going on for a while now S
Exacerbation it is getting worse S
Abrupt all of a sudden S
Febrile to have fever S
Afebrile to not have fever S
Malaise not feeling well S
Progressive more and more each day S
Symptom something a patient feels S
Noncontributory not related to this specific problem S
Lethargic a decrease in the level of consciousness S
Genetic it runs in the family S
Hereditary it runs in the family S
Alert Able to answer questions; interactive; responsive O
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 x3" O
Marked it really stands out O
Unremarkable hearts another way of saying normal O
Ausculation to listen O
Percussion to hit something and listen to the resulting sound or feel for the instrument O
Palpation to feel O
Impression another way of saying assessment A
Daignosis what the health care professional thinks the patient may have A
Differential diagnosis a list of conditions the patient may have based on the symptoms exhibited and the results of the exam A
Benign safe A
Malignant dangerous; a problem A
Degeneration to be getting worse A
Remission to get better or improve; most often used when discussing cancer; remission does not mean cure A
Idiopathic no known specific cause A
Localized stays in a certain part of the body A
Systemic/ Generalized all over the body ( or most of it ) A
Prognosis the changes for things getting better or worse A
Occult hidden A
Lesion diseased tissue A
Recurrent to have again A
Sequela a problem resulting from a disease or injury A
Pending waiting for A
Pathogen the organism that causes the problem
Morbidity the risk for being sick
Mortality the risk for dying
Ethology the cause
Disposition what happened to the patient at the end of the visit; often used at the end of EDF notes to reference where the patient went after the visit (home, the ICU, normal hospital bed) P
Discharge to unload; it has two meanings 1. to send home 2. fluid coming out of a part of the body P
Palliative treating the symptoms, but not actually getting rid of the cause P
Observation watch, keep an eye on P
Reassurance to tell the patient that the problem is not serious or dangerous P
Supportive care to treat the symptoms and make the patient feel better P
Sterile extremely clean, germ-free conditions; especially important during medical procedures and surgery P
Prophylaxis preventative treatment
Created by: Ishage4612
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