Chapter 5: Medical Terminology

Question 1

Name the components of medical chart organization

Answer 1

Demographics and insurance 
Flow sheets 
Physician orders 
Visit notes
Laboratory notes
Radiology notes 
Consultant notes 
Other communications

Question 2

What is the SOAP note?

Answer 2

SOAP note is a method employed by healthcare professionals to create patient charts. Consists of the following:
S= Subjective (what the pt tells you)
O= Objective (info from PE, labs and radiology)
A= Assessment (Dx and DDx)
P= Plan (tx, further tests, etc)

Question 3

CC

Answer 3

chief complain of pt

Question 4

HPI

Answer 4

history of present illness

Question 5

ROS

Answer 5

review of systems

Question 6

PMHx

Answer 6

past medical history

Question 7

PSHx

Answer 7

past surgical Hx

Question 8

SHx & FHx

Answer 8

social and family Hx

Question 9

NKDA

Answer 9

no known drug allergies

Question 10

PE

Answer 10

physical exam

Question 11

(+)

Answer 11

present

Question 12

(-)

Answer 12

absent or negative

Question 13

nl

Answer 13

normal

Question 14

wnl

Answer 14

within normal limits

Question 15

CBC

Answer 15

complete blood count

Question 16

Chem 7 (or Chem 8, 14, 20)

Answer 16

chemistry panels of 7,8,14, or 20 chemistry tests

Question 17

BMP

Answer 17

basic metabolic panel

Question 18

CMP

Answer 18

complete metabolic panel

Question 19

LFTs

Answer 19

liver function test

Question 20

ABG

Answer 20

arterial blood gas

Question 21

UA

Answer 21

urinary analysis

Question 22

HbA1C

Answer 22

diabetes blood test

Question 23

HEENT

Answer 23

head, ears, eyes, nose, and throat

Question 24

Occipital

Answer 24

back of the head

Question 25

Photophobia

Answer 25

intolerant of light

Question 26

Phonophobia

Answer 26

intolerant of sounds

Question 27

Diplopia

Answer 27

double vision

Question 28

Epistaxis

Answer 28

nosebleed

Question 29

Rhinorrhea

Answer 29

runny nose or nasal discharge

Question 30

Otorrhea

Answer 30

discharge from the ear

Question 31

Tinnitus

Answer 31

ringing from the ear

Question 32

NCAT

Answer 32

normocephalic, atrumatic

Question 33

PERRL

Answer 33

pupils equal round and reactive to light

Question 34

Erythmea

Answer 34

redness

Question 35

Exudate (tonsilar)

Answer 35

most coonly white spots on the tonsils, but can be any fluid or cellular matter deposited on any tissue

Question 36

Purulent

Answer 36

consisting of pus

Question 37

Injected

Answer 37

blood vessel congestion such as red eye