Chapter 2 Flashcards
acute
Started recently, sharp, severe symptom
Chronic
been going on awhile
exacerbation
getting worse
abrupt
all of a sudden
febrile
to have a fever
afebrile
not have a fever
malaise
not feeling well
progressive
more and more each day
symptom
something a patient feels
noncontributory
not related to this specific problem
lethargy
a decrease in level of consciousnesses,in medical record this usually indicated the patient is very sick
genetic/ hereditary
runs in the family
alert
able to answer questions, responsive, active
oriented
being aware of themselves, where they are, current time
all three oriented x 3
marked
it really stands out
unremarkable
another way of saying normal
auscultation
to listen
percussion
to hit something and listen for the resulting sound
palpation
to feel
impression
another way of saying assessment
diagnosis
what the health care professional thinks the patient has
differential diagnosis
a list of conditions the patient may have based on symptoms exhibited and the results of exam
benign
safe
malignant
dangerous, a problem
degeneration
to be getting worse
remission
to get better or improve, most often used when talking about cancer
localized
stays in a certain part of the body
systemic/ generalized
all over the body
prognosis
the chances of things getting better or worse
occult
hidden
lesion
diseased tissue
recurrant
to have again
sequela
a problem resulting from injury or disease
pending
waiting on
pathogen
organism that causes the problem
morbidity
at risk for being sick
mortality
risk of dying
etiology
the cause
disposition
what happened to the patient at the end of the visit
discharge
literally to unload: has 2 meanings
1. to send home ( unload the patient)
2.Fluid coming out of the body (body unloading fluid)
pallative
treating the symptoms, but not actually getting rid of the cause
observation
watch, keep an eye out
reassurance
to tell the patient that the problem is not serious
supportive care
to treat the symptoms and make the patient feel better
sterile
extremely clean, germ free conditions
prophylaxis
preventative treatment
SOAP method, S is for…
Subjective
SOAP method, O is for…
Objective
SOAP method, A is for…
Assessment
SOAP method, P is for…
Plan
Caudal
Toward the bottom or tail
Dorsum
top of hand or foot
palmar
palm of hand
CCU
coronary care unit
ECU
emergency care unit
ER
emergency room
ED
emergency department
ICU
intensive care unit
PICU
pediatric intensive care unit
NICU
neonatal intensive care unit
SICU
surgical intensive care unit
PACU
post-anesthesia care unit
L&D
labor and delivery
OR
operating room
post-op
after surgery
pre-op
before sugery
VS
vital signs
T
temperature
BP
blood pressure
HR
heart rate
RR
respiratory rate
I/O
Input/ output- what the patient has had to eat or drink
Dx
diagnosis
DDx
differential diagnosis
Tx
treatment
Rx
prescription
H&P
history and physical
Hx
history
CC
chief complaint
HPI
history of present illness
ROS
review of symptoms
PMHx
past medical history
FHx
family history
NKDA
no known drug allergies
PE
physical exam
Pt
patient
y/o
years old
h/o
history of
PCP
primary care provider
f/u
follow up
SOB
shortness of breath
HEENT
Head eyes ears nose throat
PERRLA
pupils are equal, round, and reactive to light and accommodation
NAD
no acute distress
CV
cardiovascular
RRR
regular rate and rhythm
CTA
clear to auscultation (normal sounding lungs
WDWN
well develpoed, well nourished
A&O
alert and oriented
WNL
within normal limits
NOS
not otherwise speified
NEC
not elsewhere classified
PO
per os (mouth)
NPO
nil per os (nothing by mouth)
PR
per rectum
IM
intramuscular
SC
subcutaneous
IV
intravenous
CVL
central venous line
PICC
peripherally inserted central catheter
Sig
short for sigma (label), instructions
BID
twice daily, bis in die- two in a day
TID
thre times daily ter in die
Q
every x
ie. Q4hr, every 4 hours
QD
daily, quaque die
QID
4 times a day, quarter in die
QHS
at night, quaque hora somni
AC
before meals, ante cidum
PC
after meals, post cibum
prn
as needed, per re nata
ad lib
as desired
