Chapter 2-General

Question 1

SOAP Method

Answer 1

Subjective (patient experiences, personal/family medical history, duration of problem, quality of problem, exacerbating/relieving factors for problem); Objective (patient’s physical exam, lab findings, imaging studies); Assessment (diagnosis, identification of a problem, differential diagnosis): Plan (course of action, treatment, procedure, or further collection of data)

Question 2

Chief complaint

Answer 2

main reason for patient’s visit

Question 3

History of present illness

Answer 3

story of the patient’s problem

Question 4

Review of systems

Answer 4

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

Question 5

Past medical history

Answer 5

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

Question 6

Past surgical history

Answer 6

Any of patient’s past surgeries

Question 7

Family history

Answer 7

Any significant illnesses that run in the patient’s family

Question 8

Social history

Answer 8

Record of habits like smoking, drinking, drub abuse, and sexual practices that can impact health

Question 9

Summary of Health Record Notes*

Answer 9

Review on page 66

Question 10

Impression

Answer 10

Another way to say assessment

Question 11

diagnosis

Answer 11

what the health care professional thinks the patient has

Question 12

differential diagnosis

Answer 12

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

Question 13

benign

Answer 13

safe

Question 14

malignant

Answer 14

dangerous; a problem

Question 15

degeneration

Answer 15

to be getting worse

Question 16

etiology

Answer 16

the cause

Question 17

remission

Answer 17

to get better or improve; most often used when discussing cancer (does NOT mean cured)

Question 18

idiopathic

Answer 18

no known specific cause; it just happens

Question 19

localized

Answer 19

stays in a certain part of the body

Question 20

systemic, generalized

Answer 20

all over the body (or most of it)

Question 21

morbidity

Answer 21

risk for being sick

Question 22

mortality

Answer 22

risk for dying

Question 23

prognosis

Answer 23

chances for things to get better or worse

Question 24

occult

Answer 24

hidden

Question 25

pathogen

Answer 25

the organism that causes the problem

Question 26

lesion

Answer 26

diseased tissue

Question 27

recurrent

Answer 27

to have again

Question 28

sequelae

Answer 28

to have a problem resulting from disease or injury

Question 29

pending

Answer 29

waiting for

Question 30

disposition

Answer 30

what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, ICU, normal hospital bed)

Question 31

discharge

Answer 31

1. to send home | 2. fluid coming out of a part of the body

Question 32

prophylaxis

Answer 32

preventative treatment

Question 33

palliative

Answer 33

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

Question 34

observation

Answer 34

to watch, keep an eye on

Question 35

reassurance

Answer 35

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

Question 36

supportive care

Answer 36

to treat the symptoms and make the patient feel better

Question 37

sterile

Answer 37

extremely clean, germ free conditions; especially important during medical procedures and surgery

Question 38

proximal

Answer 38

closer to the center

Question 39

distal

Answer 39

further away from the center

Question 40

lateral

Answer 40

out to the side

Question 41

medial

Answer 41

toward the middle

Question 42

ventral/antral/anterior

Answer 42

the front

Question 43

dorsal/posterior

Answer 43

the back

Question 44

cranial

Answer 44

toward the top

Question 45

caudal

Answer 45

toward the bottom

Question 46

superior

Answer 46

above

Question 47

inferior

Answer 47

below

Question 48

prone

Answer 48

lying on belly

Question 49

supine

Answer 49

lying down on back

Question 50

contralateral

Answer 50

opposite side

Question 51

ipsilateral

Answer 51

same side

Question 52

unilateral

Answer 52

one side

Question 53

bilateral

Answer 53

both sides

Question 54

dorsum

Answer 54

top of hand or foot

Question 55

plantar

Answer 55

sole of the foot

Question 56

palmar

Answer 56

palm of hand

Question 57

saggital plane

Answer 57

divides the body in slices right to left (cuts between the eyes

Question 58

coronal plane

Answer 58

divides the body into slices from front to back (filing cabinet)

Question 59

transverse

Answer 59

divides the body from top to bottom