Chapter 2 Test Flashcards
SOAP
S - subjective
O - objective
A - assessment
P - plan
acute
just started recently or is a sharp severe pain
chronic
has been going on for a while
exacerbation
getting worse
abrupt
all of a sudden
febrile
to have a fever
afebrile
to not have a fever
malaise
not feeling well
progressive
more and more each day
symptom
something a patient feels
noncontributory
not related to a specific problem
lethargic
decrease in level of conciousness
genetic/hereditary
runs in the family
alert
able to answer questions, responsive, interactive
oriented
being aware of who you are, where you are, and the current time
marked
really stands out
unremarkable
normal
auscultation
to listen
percussion
to hit something and listen to the resulting sound or feel the vibration
palpation
to feel
impression
assessment
diagnosis
what the health care professional thinks the patient has
differential diagnosis
list of conditions the patient may have based on symptoms and results of exams
benign
safe
malignant
dangerous; a problem
degeneration
to be getting worse
remission
to get better or improve
idiopathic
no known specific cause
localized
stays in one part of the body
systemic/generalized
all over the body
prognosis
chances of things getting better or worse
occult
hidden
lesion
diseased tissue
reccurent
to have again
sequela
a problem resulting from a disease or injury
pending
waiting for
pathogen
organism that causes the problem
morbidity
risk for being sick
mortality
risk for dying
etiology
the cause
prophylaxis
preventative treatment
disposition
what happened to the patient at the end of the visit
discharge
to send home, unload; fluid coming out of a part of the body
palliative
treating the symptoms, but not actually getting rid of the cause
observation
watch, keep an eye on
reassurance
to tell the patient a problem is not serious/dangerous
supportive care
treat the symptoms and make the patient feel better
sterile
extremely clean, germ free conditions
proximal
closer in the center
distal
farther away from the center
lateral
out to the side
medial
toward the middle
ventral/antral/anterior
the front
dorsal/posterior
the back
cranial
toward the top
caudal
toward the bottom
superior
above
inferior
below
prone
lying down on belly
supine
lying down on back
contralateral
opposite side
ipsilateral
same side
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 surgery
(R)
right
(L)
left
(B)
bilateral
VS
vital signs
T
temperature
BP
blood pressure
HR
heart rate
RR
respiratory rate
Ht
height
Wt
weight
BMI
body mass index
I/O
intake/output
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 systems
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
heads, eyes, ears, nose, throat
PERRLA
pupils are equal, round, and reactive to light and accomodation
NAD
no acute distress
CV
cardiovascular
RRR
regular rate and rhythm
CTA
clear to auscultation
WDWN
well developed well nourished
A&O
alert and oriented
WNL
within normal limits
NOS
not otherwise specified
NEC
not elsewhere classified
PO
per os (by 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
label
BID
twice a day
TID
three times a day
Q
every
QD
daily
QID
four times daily
QHS
at night
AC
before meals
PC
after meals
prn
as needed
ad lib
as desired
