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HEAL 132 > ch. 2 > Flashcards

ch. 2 Flashcards

1
Q

health records

A 
contain info about patient
 Previous illnesses and
treatments
 Continuing medical
problems
 History of family illnesses
 Current medications
 The health record contains the
data that will determine the
patient’s care plan.
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2
Q

SOAP Method

A 
four
different types of information
documented by health care
providers in a medical note:
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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3
Q

Subjective

A

 These are the problems that the patient states
he/she has.
 Those problems are then translated into medical
terms.
 This is so that you can correctly communicate the
problems to all health care providers

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4
Q

Objective

A

 This is the data collected by the health care
provider.
 This information also includes data obtained from
lab tests or special images of the patient’s body.

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5
Q

Assessment

A

 This is the combination of the subjective and
objective information.
 This information leads to a conclusion about the problem
known as the diagnosis.
 If a single cause isn’t evident, a differential diagnosis—a
list of the most likely causes—may be needed.

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6
Q

Plan

A

 The plan is what the provider recommends to the
patient regarding their current health status.
 This can include medication, surgery, and/or
further tests, among other options.

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7
Q

Acute

A

just started, very sharp, sudden onset, time period varie

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8
Q

Chronic

A

long term, going on for a long time, time period varies

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9
Q

Abrupt

A

sudden

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10
Q

Febrile

A

have a fever

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11
Q

afebrile

A

don’t have a fever

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12
Q

malaise

A

not feeling well

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13
Q

progressive

A

more and more

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14
Q

exacerbation

A

things are getting worse

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15
Q

symptom

A

something the patient feels

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16
Q

noncontributory

A

unrelated

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17
Q

lethargic

A

sluggish, decrease in level of consciousness

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18
Q

genetic/hereditary

A

got it from ancestors

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19
Q

Alert

A

awake and responsive

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20
Q

oriented

A

knows who where and when (A and O times 3)

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21
Q

Auscultation

A

to listen

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22
Q

Percussion

A

hit and listen, feel for vibration

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23
Q

Palpation

A

to feel

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24
Q

Unremarkable

A

nothing remarkable, dont see anything

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25
Q

Marked

A

stands out

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26
Q

Impression

A

your assessment

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27
Q

Diagnosis

A

what you think is going on

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28
Q

Differential Diagnosis

A

list of possible diagnosis

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29
Q

Benign

A

safe

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30
Q

Malignant

A

dangerous

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31
Q

Degeneration

A

getting worse

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32
Q

Etiology

A

cause

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33
Q

Idiopathic

A

no known cause

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34
Q

Remission

A

to get better or improve, not a cure!

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35
Q

Recurrent

A

to have again

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36
Q

Morbidity

A

risk for being sick

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37
Q

Mortality

A

risk for dying

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38
Q

Prognosis

A

chance of getting better or worse

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39
Q

Localized

A

stays in a certain area/part

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40
Q

Systemic/generalized

A

all over

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41
Q

occult

A

hidden

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42
Q

pathogen

A

organism causing a problem

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43
Q

lesion

A

diseased tissue

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44
Q

sequelae

A

problem from a disease or injury

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45
Q

pending

A

waiting for

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46
Q

disposition

A

what happened at end of visit

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47
Q

discharge

A

send home, or sent to alternative place (hospice, nursing home, rehab, medical housing etc)

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48
Q

Prophylaxis

A

preventative treatment

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49
Q

palliative

A

treatment for symptoms only

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50
Q

observation

A

to watch

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51
Q

reassurance

A

to tell patient it’s prob not serious

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52
Q

supportive care

A

treatment for symptoms, mental health profs, social work help etc

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53
Q

sterile

A

clean, germ free

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54
Q

proximal

A

apply to limbs, closer to trunk

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55
Q

distal

A

apply to limbs, further from trunk

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56
Q

anterior

A

toward front

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57
Q

posterior

A

toward back

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58
Q

ventral

A

front

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59
Q

dorsal

A

back

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60
Q

medial

A

toward central

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61
Q

lateral

A

away from central

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62
Q

superior

A

toward top

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63
Q

inferior

A

toward back

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64
Q

supine

A

flat on back

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65
Q

pront

A

flat on stomach

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66
Q

contralateral

A

opposite side LOOK UP

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67
Q

ipsalateral

A

same side LOOK UP

68
Q

dorsum

A

top of hand or foot

69
Q

palmar

A

palm of hand

70
Q

plantar

A

bottom of foot

71
Q

coronal plane

A

divides you into front and backside

72
Q

Transverse plane

A

can be anywhere from top to bottom of your body

73
Q

Sagittal plane

A

down your body in line with spine

74
Q

physician

A

a skilled health care provider who attended and graduated
medical school; There are two types in America: medical
doctor (MD) and doctor of osteopathy (DO).

75
Q

pediatrician

A

a physician with special training in caring for children

76
Q

surgeon

A

a physician qualified to treat patients surgically, that is, by
means of operation or invasive procedure

77
Q

anesthesiologist

A

a physician with special training in pain sedation and pain

control

78
Q

physician assistant (PA)

A

a midlevel health care provider who works under the license

of a supervising physician; requires postgraduate training

79
Q

nurse practitioner (NP)

A

a nurse with postgraduate training that serves as a midlevel
health care provider; works under the license of a
supervising physician

80
Q

emergency medical technician (EMT)

A

specially trained in the emergency care of a patient before

and/or during transport to medical facility

81
Q

speech therapist

A

specially trained in evaluating and treating problems with

speech and/or swallowing

82
Q

occupational therapist

A

specially trained in evaluating and treating problems with

performing daily activities at home, school, or work

83
Q

physical therapist

A

specially trained in evaluating and treating physical

impairments including disabilities or recovery from an injury

84
Q

respiratory therapist

A

specially trained in treating patient’s respiratory issues under
the guidance of a health care provider

85
Q

dietician

A

specially trained in evaluating the nutritional status of a patient
and developing an appropriate diet plan

86
Q

licensed practical nurse (LPN)

A

trained and certified to provide basic care to a patient

87
Q

licensed vocational nurse (LVN)

A

LOOK UP

88
Q

registered nurse (RN)

A

an advanced level nurse who has completed an associate’s or
bachelor’s degree; often assists with patient care planning and
patient education

89
Q

medical assistant

A

trained to carry out basic administrative and clinical tasks

under the guidance of a health care provider

90
Q

pathologist

A

a physician with special training in both evaluating the causes
and effects of disease and in laboratory medicine

91
Q

medical laboratory technician

A

trained in performing laboratory testing on bodily fluids

92
Q

phlebotomist

A

trained in the removal of blood from the body for diagnostic or
therapeutic purposes

93
Q

radiologist

A

a physician specially trained in evaluating images of the body to
diagnose illness or injury

94
Q

radiology technician

A

trained to perform radiologic testing or administer radiation
therapy under the direction of a health care provider

95
Q

ultrasonagrapher

A

trained in performing ultrasound imaging on a patient

96
Q

pharmacist

A

trained and licensed in preparing and dispensing

medicine

97
Q

pharmacy technician

A

trained to assist a pharmacist with pharmacy-related

tasks

98
Q

patient service coordinator

A

handles administrative tasks and coordinates patient care

99
Q

medical transcriptionist

A

trained in converting the voice-recorded dictations of health care providers into text format

100
Q

Chief complaint

A

The main reason for the patient’s visit

101
Q

History of present illness

A

The story of the patient’s problem

102
Q

Review of systems

A

Description of individual body systems in order to discover any symptoms not directly related to the main problem

103
Q

Past medical history

A

Other significant past illnesses, like high blood pressure, asthma, or diabetes

104
Q

Past surgical history

A

Any of the patient’s past surgeries

105
Q

Family history

A

Any significant illnesses that run in the patient’s family

106
Q

Social history

A

A record of habits like smoking, drinking, drug
abuse, and sexual practices that can impact
health

107
Q

Pre-op

A

before surgery

108
Q

OR

A

operating room

109
Q

PACU

A

post anesthesia care unit

110
Q

Post-op

A

after surcery

111
Q

ICU

A

intensive care unit

112
Q

CCU

A

coronary care unit (cardiovasc sys)

113
Q

SICU

A

surgical intensive care unit

114
Q

PICU

A

pediatric intensive care unit

115
Q

NICU

A

neonatal intensive care unit

116
Q

ER

A

emergency room

117
Q

ED

A

emergency dept

118
Q

ECU

A

emergency care unit

119
Q

L&D

A

labor and delivery

120
Q

VS

A

vital signs

121
Q

RR

A

respiratory rate

122
Q

BP

A

blood pressure

123
Q

T

A

temp

124
Q

Ht

A

height

125
Q

Wt

A

weight

126
Q

BMI

A

body mass index

127
Q

I/O

A

intake and output

128
Q

Dx

A

diagnosis

129
Q

DDx

A

differential diagnosis

130
Q

Tx

A

treatment

131
Q

Rx

A

prescription

132
Q

Hx

A

history

133
Q

PMHx

A

prior medical or past medical history

134
Q

FHx

A

fam history

135
Q

H&P

A

history and physical

136
Q

CC

A

chief complaint

137
Q

HPI

A

history of present illness

138
Q

ROS

A

review of systems

139
Q

PE

A

physical exam

140
Q

PCP

A

primary care physician

141
Q

NKDA

A

no known drug allergies

142
Q

Pt

A

patient

143
Q

y/o

A

years old

144
Q

h/o

A

history of

145
Q

f/u

A

follow up

146
Q

PERRLA

A

pupils equal, round, and reactive to light

and accommodation

147
Q

NOS

A

not otherwise specified

148
Q

RRR

A

regular rate and rhythm

149
Q

CTA

A

clear to auscultation

150
Q

A&O

A

alert and oriented

151
Q

NAD

A

no acute distress

152
Q

PO

A

per os (by mouth)

153
Q

IV

A

intravenous

154
Q

SC

A

subcutaneous

155
Q

CVL

A

central venous line

156
Q

IM

A

intramuscular

157
Q

PR

A

per rectum (anal), usually when have severe nausea/vomiting

158
Q

NPO

A

nil per os (nothing by

mouth)

159
Q

prn

A

as needed

160
Q

QID

A

four times a day

161
Q

QD

A

everyday

162
Q

AC

A

before meals

163
Q

TID

A

three times a day

164
Q

BID

A

twice a day

165
Q

PC

A

after meals

166
Q

QHS

A

at night

HEAL 132 (8 decks)

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