CH.2 Gen Terms & SOAP

Question 1

SOAP
S: Blue 
O: Red
A: Yellow
P: Green

Answer 1

Subjective-
duration, quality, worse or better factors
Objective-
“it really stands out”, physical exam, lab, imaging (tests)
Assessment-
“impression”
diagnosis (ID the problem) or list of possibilities for diagnosis
Plan -
“disposition”
action, treatment (medicine/procedure), more data needed

Question 2

acute

Answer 2

it just started recently, sharp/serve symptom

Question 3

chonic

Answer 3

it has been going on for a while

Question 4

exacerbation

Answer 4

it is getting worse

Question 5

abrupt

Answer 5

all of a sudden

Question 6

febrile

Answer 6

to have a fever

Question 7

afebrile

Answer 7

to not have a fever

Question 8

malaise

Answer 8

not feeling well

Question 9

progressive

Answer 9

more and more each day

Question 10

symptom

Answer 10

something a patient feels

Question 11

noncontributory

Answer 11

not related to this specific problem

Question 12

lethargic

Answer 12

decrease in consciousness; indication the patient is really sick

Question 13

genetic/hereditary

Answer 13

runs in te family

Question 14

alert

Answer 14

able to answer questions, responsive, interactive

Question 15

oriented & oriented x3

Answer 15

being aware who and where they are, current time

Question 16

marked

Answer 16

stands out

Question 17

unremarkable

Answer 17

synonym for normal

Question 18

auscultation

Answer 18

listen

Question 19

percussion

Answer 19

to hit something and listen to the resulting sound or feel for vibration EX. drums

Question 20

palpation

Answer 20

to feel

Question 21

impression

Answer 21

another way of saying assessment

Question 22

diagnosis

Answer 22

what the health care professional thinks the patient has

Question 23

benign

Answer 23

safe

Question 24

malignant

Answer 24

dangerous, a problem

Question 25

degeneration

Answer 25

to be getting worse

Question 26

etiology

Answer 26

the cause

Question 27

remission

Answer 27

to get better or improve; does not mean cure

Question 28

idiopathic

Answer 28

no known specific case, just happens

Question 29

localized

Answer 29

stays in a certain part of a body

Question 30

systemic/generalized

Answer 30

all over the body,

Question 31

morbidity

Answer 31

risk of being sick

Question 32

mortality

Answer 32

risk for dying

Question 33

prognosis

Answer 33

the chances for things getting better or worse

Question 34

occult

Answer 34

hidden

Question 35

pathogen

Answer 35

organism that causes the problem

Question 36

lesion

Answer 36

diseased tissue

Question 37

recurrent

Answer 37

to have again

Question 38

sequelae

Answer 38

problem resulting from a disease or injury

Question 39

pending

Answer 39

waiting for

Question 40

Terms associated with:

Front

Answer 40

ventral, anterior, antral

Question 41

sagittal

Answer 41

divides body into right and left

Question 42

disposition

Answer 42

what happened to patient at the end of visit; end of ED notes to reference where the patient went after visit

Question 43

discharge

Answer 43

to unload; send home or fluid coming out of a part of the body

Question 44

prophylaxis

Answer 44

preventative treatment

Question 45

palliative

Answer 45

treating symptoms, not actually getting rid of the cause

Question 46

observation

Answer 46

to watch, keep an eye on

Question 47

resassurance

Answer 47

to tell the patient that the problem is not serious or dangerous

Question 48

supportive care

Answer 48

to treat the symptoms and make the patient feel better

Question 49

sterile

Answer 49

extremely clean, germ free, esp in medical procedures and surgery

Question 50

contralateral

Answer 50

opposite side

Question 51

ipsilateral

Answer 51

same side

Question 52

coronal

Answer 52

divides body into front and back

Question 53

transverse

Answer 53

divides body from top to bottom

Question 54

Abbreviation indicating something given via the rectum

Answer 54

PR