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HLHS > Chapter 2 Vocab > Flashcards

Chapter 2 Vocab Flashcards

1
Q

What does the acronym SOAP mean?

A

Subjective, Objective, Assessment, and Plan

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2
Q

Why do we use the acronym SOAP?

A

To understand the four general parts of a medical note

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3
Q

Subjective part of a medical note

A

The problem in the patient’s own words.

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4
Q

What does the subjective part of a medical note include?

A

The duration of the problem, the quality of the problem, and any exacerbating or relieving factors for that problem.

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5
Q

What is the objective data in a medical note?

A

The patient’s physical exam, any laboratory findings, and imaging studies performed at the visit.

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6
Q

What is the assessment of a medical note?

A

The logical analysis that a health providers formulates, after gathering all the pertinent information.

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7
Q

What are some examples of what an assessment could be in a medical note?

A

A diagnosis, an identification of a problem, or a list of possibilities for the diagnosis (differential diagnosis)

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8
Q

What is a plan of a medical note?

A

A course of action consistent with his or her assessment

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9
Q

What are some types of plans that would be in a medical note?

A

Treatment with medicine, procedure, collecting more data to arrive at a more accurate diagnosis, etc

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10
Q

Acute

A

It just started recently or is a sharp, severe symptom

ah-KYOOT

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11
Q

Chronic

A

It has been going on for a while now

KRAH-nik

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12
Q

Exacerbation

A

It is getting worse

ek-SAS-er-BAY-shun

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13
Q

Abrupt

A

All of the sudden

ah-BRUPT

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14
Q

Febrile

A

To have a fever

FEH-brail

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15
Q

Afebrile

A

To not have a fever

AY-FEH-brail

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16
Q

Malaise

A

Not feeling well

mah-LAYZ

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17
Q

Progressive

A

More and more each day

proh-GREH-siv

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18
Q

Symptom

A

Something a patient feels

SIM-tom

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19
Q

Noncontributory

A

Not related to this specific problem

NON-kon-TRIB-yoo-TOH-ree

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20
Q

Legarthic

A

A decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick

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21
Q

Genetic/Hereditary

A

It runs in the family

jih-NEH-tik, hah-REH-dih-TEH-ree

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22
Q

Alert

A

Able to answer questions; responsive; interactive

ah-LERT

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23
Q

Oriented

A

Being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is “oriented x 3”
(OR-ee-EN-ted)

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24
Q

Marked

A

It really stands out

MARKT

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25
Q

Unremarkable

A

Another way of saying normal

un-ree-MARK-ah-bul

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26
Q

Auscultation

A

To listen

aws-kul-TAY-shun

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27
Q

Percussion

A

To hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument
(per-KUH-shun)

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28
Q

Palpation

A

To feel

pal-PAY-shun

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29
Q

Impression

A

Another way of saying assessment

im-PREH-shun

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30
Q

Diagnosis

A

What the health care professional thinks the patient has

DAI-ag-NOH-sis

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31
Q

Differential Diagnosis

A

A list of conditions the patient may have based on the symptoms exhibited and the results of the exam
(dih-fer-EN-shal DAI-ag-NOH-sis)

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32
Q

Benign

A

Safe

ben-NAIN

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33
Q

Malignant

A

Dangerous; a problem

mah-LIG-nant

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34
Q

Degeneration

A

To be getting worse

dee-jen-er-AY-shun

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35
Q

Etiology

A

The cause

ee-tee-AW-loh-jee

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36
Q

Remission

A

To get better or improve; most often used when discussing cancer; remission does not mean cure
(reh-MIH-shun)

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37
Q

Idiopathic

A

No known specific cause; it just happens

ih-dee-oh-PA-thik

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38
Q

Localized

A

Stays in a certain part of the body

LOH-kah-LAIZD

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39
Q

Systemic / Generalized

A

All of the body (or most of it)

sih-STEM-ik, jen-er-ah-LAIZD

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40
Q

Morbidity

A

The risk for being sick

mor-BID-ih-tee

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41
Q

Mortality

A

The risk for dying

mor-TA-lih-tee

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42
Q

Prognosis

A

The chances for things getting better or worse

prawg-NOH-sis

43
Q

Occult

A

Hidden

ah-KULT

44
Q

Pathogen

A

The organism that causes the problem

PATH-oh-jin

45
Q

Lesion

A

Diseased tissue

LEE-shun

46
Q

Recurrent

A

To have again

ree-KUR-ent

47
Q

Sequelae

A

A problem resulting for a disease or injury

seh-KWEL-ah

48
Q

Pending

A

Waiting for

PEN-ding

49
Q

Disposition

A

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, the ICU, normal hospital bed)
(dis-poh-ZIH-shun)

50
Q

Discharge

A

Literally, to unload; it has two meanings:
1.) To send home (to unload the patient from the health care setting to home)
2.) fluid coming out of a part of the body (your body unloading a fluid)
(DIS-charj)

51
Q

Prophylaxis

A

Preventative Treatment

PROH-fuh-LAK-sis

52
Q

Palliative

A

Treating the symptoms, but not actually getting rid of the cause
(PA-lee-ah-tiv)

53
Q

Observation

A

Watch, keep and eye on

OB-zer-VAY-shun

54
Q

Reassurance

A

To tell the patient that the problem is not serious or dangerous
(ree-ah-SHUR-ants)

55
Q

Supportive care

A

To treat the symptoms and make the patient feel better

suh-POR-tiv kehr

56
Q

Sterile

A

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

57
Q

Proximal

A

Closer to the center (usual referring to your trunk)

PRAWK-sih-mal

58
Q

Distal

A

Farther away from the center (usually referring to your trunk)
(DIH-stal)

59
Q

Lateral

A

Out to the side

LA-ter-al

60
Q

Medial

A

Toward the middle

MEE-dee-al

61
Q

Ventral/Antral/Anterior

A

The front

VEN-tral/AN-tral/an-TIH-ree-or

62
Q

Dorsal/Posterior

A

The back

DOR-sal/pohs-TEER-ee-or

63
Q

Cranial

A

Toward the top

KRAY-nee-al

64
Q

Caudal

A

Toward the bottom

KOW-dal

65
Q

Superior

A

Above

soo-PIH-ree-or

66
Q

Inferior

A

Below

In-FIH-ree-or

67
Q

Prone

A

Lying down on belly

PROHN

68
Q

Supine

A

Lying down on back

SOO-pain

69
Q

Contralateral

A

Opposite side

KON-trah-LA-ter-al

70
Q

Ipsilateral

A

Same side

IP-sih-LA-ter-al

71
Q

Unilateral

A

One side

YOO-nih-LA-ter-al

72
Q

Bilateral

A

Both sides

BAI-LA-ter-al

73
Q

Dorsum

A

Top of the hand or foot

DOR-sum

74
Q

Plantar

A

The sole of the foot

PLAN-tar

75
Q

Palmar

A

The palm of the hand

PAL-mar

76
Q

Sagittal

A

Divides the body in slices right to left

SA-jih-tal

77
Q

Coronal

A

Divides the body into slices from front to back

kah-ROH-nal

78
Q

Transverse

A

Divides the body from top to bottom

trans-VERS

79
Q

Physician

A

A skilled health care provided who attended and graduated medical school
(fuh-ZIH-shun)

80
Q

Pediatrician

A

A physician with special training in caring for children

PEE-dee-ah-TRIH-shun

81
Q

Surgeon

A

A physician qualified to treat patients surgically, that is, by means of operation or invasive procedure
(SIR-jen)

82
Q

Anesthesiologist

A

A physician with special training in pain sedation and pain control
(AN-ehs-THEE-zee-AW-loh-jist)

83
Q

Physician Assistant (PA)

A

A midlevel health care provider who works under the license of a supervising physician; requires postgraduate training
(fuh-ZIH-shun ah-SIS-tant)

84
Q

Nurse Practitioner (NP)

A

A nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician
(NIRS prak-TIH-shuh-ner)

85
Q

emergency Medical Technician (EMT)

A

Specially trained in the emergency care of a patient before and/or during transport to medical facility
(eh-MIR-jen-see MEh-dih-kal tek-NIH-shun)

86
Q

Speech Therapist

A

Specially trained in evaluating and treating problems with speech and/or swallowing
(SPEECH THEH-rah-pist)

87
Q

Occupational Therapist

A

Specially trained in evaluating and treating problems with performing daily activities at home, school, or work
(aw-kyoo-PAY-shuh-nal THEH-rah-pist)

88
Q

Physical Therapist

A

Specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury
(FIH-zih-kal THEH-rah-pist)

89
Q

Respiratory Therapist

A

Specially trained in treating patient’s respiratory issues under the guidance of a health care provider
(reh-sprah-TOR-ee THEH-rah-pist)

90
Q

Dietician

A

Specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan
(dai-ah-TIH-shun)

91
Q

Licensed Practical Nurse (LPN)

A

Trained and certified to provide basic care to a patient

LAI-senzd PRAK-tih-kal NIRS

92
Q

Licensed Vocational Nurse

A

Trained and certified to provide basic care to a patient

LAI-senzd voh-KAY-shun-al NIRS

93
Q

Registered Nurse (RN)

A

An advanced level nurse who has completed an associate’s or bachelor’s degree; often assists with patient care planning and patient education
(REH-jis-terd NIRS)

94
Q

Medical Assistant

A

Trained to carry out basic administrative and clinical tasks under the guidance of a health care provider
(MEH-dih-kal ah-SIS-tant)

95
Q

Pathologist

A

A physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
(pah-THAW-loh-jist)

96
Q

Medical Laboratory Technician

A

Trained in performing laboratory testing on bodily fluids

meh-DIH-kal LAH-broh-tor-ee tek-NIH-shun

97
Q

Phlebotomist

A

Trained in the removal of blood from the body for diagnostic or therapeutic purposes
(fleh-BOH-tow-mist)

98
Q

Radiologist

A

A physician specially trained in evaluating images of the body to diagnose illness or injury
(ray-dee-AW-loh-jist)

99
Q

Radiology Technician

A

Trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
(ray-dee-AW-loh-jee tek-NIH-shun)

100
Q

Ultrasonagrapher

A

Trained in performing ultrasound imaging on a patient

ul-trah-saw-NAW-grah-fir

101
Q

Pharmacist

A

Trained and licensed in preparing and dispensing medicine

FAR-mah-sist

102
Q

Pharmacy Technician

A

Trained to assist a pharmacist with pharmacy-related tasks

FAR-mah-see tek-NIH-shun

103
Q

Patient Service Coordinator

A

Handle administrative tasks and coordinates patient care

PAY-shent SIR-vis coh-OR-dih-nay-tor

104
Q

Medical Transcriptionist

A

Trained in converting the voice-recorded dictations of health care providers into text format
(MEH-dih-kal tran-SKRIP-shun-ist)

HLHS (3 decks)

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