Acquiring Medical Language Chapt 2
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| SOAP Method | S = Subjective: what the patient says
O = Objective: what the tests reveal
A = Assessment: the analysis of the subjective
and objective information; performed by
the health care provider
P = Plan: the course of action for the patient
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| Abrupt | sudden and unexpected
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| Malaise | a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify
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| Symptom | a physical or mental feature which is regarded as indicating a condition of disease, particularly such a feature that is apparent to the patient
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| Noncontributory | not playing a part in bringing something about.
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| Lethargic | Close to death
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| Impression | The impression may include a short sentence with a diagnosis. Other times the impression may include multiple sentences or impression points. There may be more then one diagnosis. There may be an explanation of the findings.
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| Diagnosis | the identification of the nature of an illness or other problem by examination of the symptoms
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| Differential diagnosis | the process of differentiating between two or more conditions which share similar signs or symptoms.
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| Benign vs. malignant | The tumor doesn’t contain cancerous cells. and The tumor contains cancerous cells
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| Degeneration | the state or process of being or becoming degenerate; decline or deterioration
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| Etiology vs. idiopathic | An idiopathic disease is any disease with an unknown cause or mechanism of apparent spontaneous origin.[
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| Remission | Abatement or lessening in severity of the symptoms of a disease.
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| Recurrent | occurring often or repeatedly
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| Morbidity | the condition of suffering from a disease or medical condition
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| Mortality | the state of being subject to death
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| Prognosis | the likely course of a disease or ailment
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| Localized vs. systemic/generalized | A systemic illness is one that affects the entire body, rather than a single organ or body part. Many organs and tissues might be involved in the complex disease process.
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| Occult | to refer to pathology that cannot be seen on more or more modalities.
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| Pathogen | a bacterium, virus, or other microorganism that can cause disease.
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| Lesion | a region in an organ or tissue which has suffered damage through injury or disease, such as a wound, ulcer, abscess, or tumor
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| Sequela | A condition which is the consequence of a previous disease or injury
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| Pending | Info has not been sent to the carrier yet.
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| Disposition | The destination of the patient after hospital discharge
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| Discharge | To tell someone offically, that they can or must leave a place or situation
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| Prophylaxis | Action taken to prevent disease, especially by specified means or against a specified disease
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| Palliative | Relieving symptoms without without dealing with the cause of the condition
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| Observation | The action or process of observing something or someone carefully or in order to gain info
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| Reassurance | Removing someone's doubts our fears
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| Supportive care | Palliative care
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| Sterile | Free of bacteria or other living microorganisms
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| physician fih-ZISH-un | a skilled health care provider who attended and
graduated medical school
There are two types who practice in America: medical
doctor (MD) and doctor of osteopathy (DO).
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| pediatrician pee-dee-ah-TRISH-un | a physician with special training in caring for children
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| surgeon SIR-jen | physician qualified to treat patients surgically, that
is, by means of operation or invasive procedure
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| anesthesiologist AN-es-THEE-zee-AWL-oh-jist | a physician with special training in pain sedation and
pain control
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| physician assistant (PA) fih-ZISH-un ah-SIS-tant | a midlevel health care provider who works under the
license of a supervising physician; requires
postgraduate training
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| nurse practitioner (NP) NIRS prak-TISH-ih-ner | a nurse with postgraduate training that serves as
a midlevel health care provider; works under the
license of a supervising physician
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| emergency medical technician (EMT) eh-MIR-jen-see MED-ih-kal tek-NISH- un | specially trained in the emergency care of a
patient before and/or during transport to medical
facility
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| speech therapist SPEECH THER-ah-pist | specially trained in evaluating and treating
problems with speech and/or swallowing
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| occupational therapist aw-kyoo-PAY-shuh-nal THER-ah-pist | specially trained in evaluating and treating
problems with performing daily activities at home,
school, or work
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| physical therapist FIZ-ih-kal THER-ah-pist | specially trained in evaluating and treating
physical impairments including disabilities or
recovery from an injury
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| respiratory therapist res-PIR-ah-toh-ree THER-ah-pist | specially trained in treating patient’s respiratory
issues under the guidance of a health care provider
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| dietician dai-ah-TIH-shun | specially trained in evaluating the nutritional status
of a patient and developing an appropriate diet plan
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| licensed practical nurse (LPN) LAI-senzd PRAK-tih-kal NIRS | trained and certified to provide basic care to a
patient
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| licensed vocational nurse (LVN) LAI-senzd voh-KAY-shun-al NIRS | A nurse that provides basic patient care.
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| registered nurse (RN) REH-jis-terd NIRS | an advanced level nurse who has completed an
associate’s or bachelor’s degree; often assists with
patient care planning and patient education
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| medical assistant MED-ih-kal ah-SIS-tant | trained to carry out basic administrative and clinical
tasks under the guidance of a health care provider
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| pathologist pah-THAWL-oh-jist | a physician with special training in both evaluating the
causes and effects of disease and in laboratory medicine
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| medical laboratory technician MED-ih-kal LAB-rah-TOR-ee tek-NISH-un | trained in performing laboratory testing on bodily fluids
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| phlebotomist fle-BAWT-oh-mist | trained in the removal of blood from the body for diagnostic
or therapeutic purposes
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| radiologist ray-dee-AWL-oh-just | a physician specially trained in evaluating images of the
body to diagnose illness or injury
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| radiology technician ray-dee-AWL-oh-jee tek-NISH-un | trained to perform radiologic testing or administer radiation
therapy under the direction of a health care provider
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| ultrasonagrapher UL-trah-soh-NAWG-rah-fer | trained in performing ultrasound imaging on a patient
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| pharmacist FAR-mah-sist | trained and licensed in preparing and dispensing
medicine
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| pharmacy technician FAR-mah-see tek-NISH-un | rained to assist a pharmacist with pharmacy-
related tasks
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| patient service coordinator PAY-shent SIR-vis coh-OR-dih-nay-tor | handles administrative tasks and coordinates
patient care
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| medical transcriptionist MED-ih-kal tranz-KRIP-shon-ist | trained in converting the voice-recorded dictations
of health care providers into text format
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| Chief complaint | The main reason for the patient’s visit
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| History of present illness | The story of the patient’s problem
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| Review of systems | Description of individual body systems in
order to discover any symptoms not directly
related to the main problem
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| Past medical history | Other significant past illnesses, like high blood
pressure, asthma, or diabetes
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| Past surgical history | Any of the patient’s past surgeries
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| Family history | Any significant illnesses that run in the
patient’s family
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| Social history | A record of habits like smoking, drinking, drug
abuse, and sexual practices that can impact
health
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| ♂ | male
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| ♀ | Female
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| (R) | Right
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| (L) | Left
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| (B) | bilateral (both sides)
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| ↑ | Increased
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| ↓ | Decreased
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| PERRLA | alert and oriented
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| NOS | regular rate and rhythm
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| RRR | no acute distress
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| CTA | pupils equal, round, and reactive to light and
accommodation
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| A&O | not otherwise specified
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| NAD | clear to auscultation
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| PO | intravenous
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| IV | central venous line
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| SC | per rectum (anal)
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| CVL | per os (by mouth)
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| IM | subcutaneous
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| PR | nil per os (nothing by mouth)
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| NPO | intramuscular
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| prn | three times a day
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| QID | as needed
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| QD | four times a day
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| AC | before meals
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| TID | every day
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| BID | after meals
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| PC | at night
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| QHS | two times a day
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