Chapter 2 Flashcards

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1
Q

S. O. A. P

A

Subjective
Objective
Assessment
Plan

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2
Q

Acute

A

It just started recently or is a sharp, severe symptom

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3
Q

Chronic

A

It has been going on for a while now

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4
Q

Exacerbation

A

It is getting worse

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5
Q

Abrupt

A

All of a sudden

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6
Q

Febrile

A

To have a fever

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7
Q

Afebrile

A

To not have a fever

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8
Q

Malaise

A

Not feeling well

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9
Q

Progressive

A

More and more each day

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10
Q

Symptom

A

Something a patient feels

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11
Q

Noncontributory

A

Not related to this specific problem

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12
Q

Lethargic

A

A decrease in level of consciousness

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13
Q

Genetic/hereditary

A

It runs in the family

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14
Q

Alert

A

Able to answer questions

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15
Q

Oriented

A

Beating aware of who’s he or she is, where he or she is, and the current time

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16
Q

Marked

A

It really stands out

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17
Q

Unremarkable

A

Another way of saying normal

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18
Q

Auscultation

A

To listen

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19
Q

Percussion

A

To hit something and listen to the resulting sound, or feel for the resulting vibration

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20
Q

Palpation

A

To feel

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21
Q

Impression

A

Another way of saying assessment

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22
Q

Diagnosis

A

What the healthcare professional thinks the patient has

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23
Q

Differential diagnosis

A

A list of conditions the patient may have based on the symptoms exhibited and the results of the exam

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24
Q

Benign

A

Safe

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25
Q

Malignant

A

Dangerous, a problem

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26
Q

Degeneration

A

To be getting worse

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27
Q

Remission

A

To get better or improve

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28
Q

Idiopathic

A

No known specific cause

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29
Q

Localized

A

Stays in a certain part of the body

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30
Q

Systemic/generalized

A

All over the body (or most of it)

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31
Q

Prognosis

A

The chances for things getting better or worse

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32
Q

Occult

A

Hidden

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33
Q

Lesion

A

Diseased tissue

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34
Q

Recurrent

A

To have again

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35
Q

Sequela

A

A problem resulting from a disease or injury

36
Q

Pending

A

Waiting for

37
Q

Pathogen

A

The organism that causes the problem

38
Q

Morbidity

A

The risk for being sick

39
Q

Mortality

A

The risk for dying

40
Q

Etiology

A

The cause

41
Q

Disposition

A

What happened to the patient at the end of the visit

42
Q

Discharge

A

To send home
Fluid coming out of a part of the body

43
Q

Palliative

A

Treating the symptoms, but not actually getting rid of the cause

44
Q

Observation

A

Watch, keep an eye on

45
Q

Reassurance

A

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

46
Q

Supportive care

A

To treat the symptoms and make the patient feel better

47
Q

Sterile

A

Extremely clean, germ free conditions

48
Q

Prophylaxis

A

Preventive treatment

49
Q

Proximal

A

Closer in to the center

50
Q

Distal

A

Farther away from the center

51
Q

Lateral

A

Out to the side

52
Q

Medial

A

Toward the middle

53
Q

Ventral/antral/anterior

A

The front

54
Q

Dorsal/posterior

A

The back

55
Q

Cranial

A

Toward the top

56
Q

Caudal

A

Toward the bottom

57
Q

Superior

A

Above

58
Q

Inferior

A

Below

59
Q

Prone

A

Lying down on belly

60
Q

Supine

A

Lying down on back

61
Q

Contralateral

A

Opposite side of

62
Q

Ipsilateral

A

Same side

63
Q

Unilateral

A

One side

64
Q

Bilateral

A

Both sides

65
Q

Dorsum

A

The top of the hand or foot

66
Q

Plantar

A

The sole of the foot

67
Q

Palmar

A

The palm of the hand

68
Q

Sagittal

A

Divides the body along a hypothetical plane from right to left

69
Q

Coronal

A

Divides the body along a hypothetical plane from front to back

70
Q

Transverse

A

Divides the body from top to bottom

71
Q

Chief complaint

A

The main reason for the patient’s visit

72
Q

History of present illness

A

The story of the patient’s problem

73
Q

Review of systems

A

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

74
Q

Past medical history

A

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

75
Q

Past surgical history

A

Any of the patients pass surgeries

76
Q

Family history

A

Any significant illnesses that run in the patient’s family

77
Q

Social history

A

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

78
Q

Clinic note

A

Documents a visit

79
Q

Consult note

A

Provides an expert opinion on a more challenging problem

80
Q

Emergency department note

A

Documents an emergency department visit

81
Q

Admission summary

A

Documents the admission of a patient to the hospital

82
Q

Discharge summary

A

Describes when and why the patient was admitted, documents a longer stay

83
Q

Operative report

A

Documents a surgery in detail

84
Q

Daily hospital note/progress note

A

Documents daily hospital visit

85
Q

Radiology report

A

Explains reason for image, how image was performed, what was seen on image, radiologist’s assessment

86
Q

Pathology report

A

Provides reasons for test, what was seen on the test, and an assessment

87
Q

Prescription

A

Provides directions for a medication