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Medical Terminology > Unit 2 - Health Records > Flashcards

Unit 2 - Health Records Flashcards

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USMLE® Step 1 flashcards
1
Q

SOAP

A

Subjective, Objective, Assessment, Plan

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2
Q

acute

A

started recently or sharp severe symptom

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3
Q

chronic

A

been going on for a while now

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4
Q

exacerbation

A

getting worse

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5
Q

abrupt

A

all of a sudden

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6
Q

febrile

A

to have fever

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7
Q

afrebrile

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 specific problem

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12
Q

lethargic

A

decrease level of consciousness

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13
Q

genetic/hereditary

A

runs in the family

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14
Q

alert

A

able to answer questions; responsive; reactive

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15
Q

oriented

A

being aware of who, where and current time

all three is “oriented x3”

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16
Q

marked

A

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 and listen to resulting sound or feel for resulting vibration

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20
Q

palpation

A

to feel

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21
Q

impression

A

another way pf saying assessment

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22
Q

diagnosis

A

what health professional thinks the patient has

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23
Q

differential diagnosis

A

list of conditions the patient may have eased on symptoms exhibited and results of 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

etiology

A

the cause

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28
Q

remission

A

to get better or improve; does not mean cured

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29
Q

idiopathic

A

no known specific cause; it just happens

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30
Q

localized

A

stays in a certain part of the body

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31
Q

systemic/generalized

A

all over the body

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32
Q

morbidity

A

the risk for dying

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33
Q

prognosis

A

chances for things to get better or worse

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34
Q

occult

A

hidden

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35
Q

pathogen

A

organism causing the problem

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36
Q

lesion

A

diseased tissue

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37
Q

recurrent

A

to have again

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38
Q

sequelae

A

a problem resulting from disease or injury

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39
Q

pending

A

waiting for

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40
Q

disposition

A

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

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41
Q

discharge

A

“unload”

  1. to send patient home (unload patient)
  2. fluid coming out of a part of the body
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42
Q

prophylaxis

A

preventative treatment

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43
Q

palliative

A

treating the symptoms, but not getting rid of the cause

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44
Q

observation

A

watch, keep an eye on

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45
Q

reassurance

A

to tell patient that the problem id not serious or dangerous

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46
Q

supportive care

A

to treat the symptoms and make patient feel better

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47
Q

sterile

A

extremely clean, germ-free conditions

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48
Q

proximal

A

closer to the center

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49
Q

distal

A

away from the center

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50
Q

lateral

A

out to the side

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51
Q

medial

A

towards the middle

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52
Q

ventral/antral/anterior

A

the front

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53
Q

dorsal/posterior

A

the back

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54
Q

cranial

A

toward the top

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55
Q

caudal

A

towards the bottom

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56
Q

superior

A

above

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57
Q

inferior

A

below

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58
Q

prone

A

lying on the belly

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59
Q

supine

A

lying on the back

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60
Q

contralateral

A

opposite side

61
Q

ipsilateral

A

same side

62
Q

unilateral

A

one side

63
Q

bilateral

A

both sides

64
Q

dorsum

A

top of hand or foot

65
Q

plantar

A

sole of the foot

66
Q

palmer

A

palm of the hand

67
Q

sagittal

A

divides body in slices right to left

68
Q

coronal

A

divides body in slices front to back

69
Q

transverse

A

divides body from top to bottom

70
Q

CCU

A

coronary care unit

71
Q

ECU

A

emergency care unit

72
Q

ER

A

emergency room

73
Q

ED

A

emergency department

74
Q

ICU

A

intensive care unit

75
Q

PICU

A

pediatric intensive care unit

76
Q

NICU

A

neonatal ICU

77
Q

SICU

A

surgical ICU

78
Q

PACU

A

post-anesthesia care unit

79
Q

L&D

A

Labor and delivery

80
Q

OR

A

operating room

81
Q

VS

A

vital signs

82
Q

T

A

temperature

83
Q

BP

A

blood pressure

84
Q

HR

A

heart rate

85
Q

RR

A

respiratory rate

86
Q

Ht

A

height

87
Q

Wt

A

weight

88
Q

BMI

A

body mass index

89
Q

I/O

A

intake/output; amount of fluids a patient has taken and produced

90
Q

Dx

A

diagnosis

91
Q

DDx

A

differential diagnosis

92
Q

Tx

A

treatment

93
Q

Rx

A

prescription

94
Q

H&P

A

history and physical

95
Q

Hx

A

history

96
Q

CC

A

chief complaint

97
Q

HPI

A

history of present illness

98
Q

ROS

A

review of symptoms

99
Q

PMHx

A

past medical history

100
Q

FHx

A

family history

101
Q

NKDA

A

no known drug allergies

102
Q

PE

A

physical exam

103
Q

Pt

A

patient

104
Q

y/o

A

years old

105
Q

h/o

A

history of

106
Q

PCP

A

primary care physician

107
Q

f/u

A

follow up

108
Q

SOB

A

shortness of breath (SOA)

109
Q

HEENT

A

head, eyes, ears, nose, throat

110
Q

PERRLA

A

pupils are equal, round, reactive to light and accommodation

111
Q

NAD

A

no acute distress

112
Q

CV

A

cardiovascular

113
Q

RRR

A

regular rate and rhythm

114
Q

CTA

A

clear to auscultation (normal sounding lungs)

115
Q

WDWN

A

well developed, well nourished

116
Q

A&O

A

alert and oriented

117
Q

WNL

A

within normal limits

118
Q

NOS

A

not otherwise specified

119
Q

NEC

A

not elsewhere classified

120
Q

PO

A

per os (by mouth)

121
Q

NPO

A

nil per os (nothing by mouth)

122
Q

PR

A

per rectum (anal)

123
Q

IM

A

intramuscular

124
Q

SC

A

subcutaneous (under the skin)

125
Q

IV

A

intravenous

126
Q

CVL

A

central venous line

127
Q

PICC

A

peripherally inserted central catheter

128
Q

Sig

A

instructions

129
Q

BID

A

twice daily

130
Q

TID

A

three times daily

131
Q

Q

A

every x

example Q4hr every 4 hours

132
Q

QD

A

daily

133
Q

QID

A

four times daily

134
Q

QHS

A

at night

135
Q

AC

A

before meals

136
Q

PC

A

after meals

137
Q

prn

A

as needed

138
Q

ad lib

A

as desired

139
Q

Clinic Note

A

SOAP
medical professional
documents visit

140
Q

Consult Note

A

SOAP
clinic or hospital
provides expert opinion

141
Q

ED Note

A

SOAP
ED staff
documents ED visit

142
Q

Admissions Summary

A

SO A/P
hospital professional
documents admission

143
Q

Discharge Summary

A

ASOP
medical professional
describes when/why patient was admitted

144
Q

Operative Report

A

ASOP
surgeon
documents surgery in detail

145
Q

Daily hospital report/Progress Note

A

SO A/P
medical professional
documents daily hospital visit

146
Q

Radiology Report

A

SOA
radiologist
explains reason for image, how it was performed, what was seen, assessment, recommendation

147
Q

Pathology Report

A

SOA
pathologist
provides reason for test, what was seen, assessment

148
Q

Prescription

A

P
medical professional
provides direct for meds

Medical Terminology (13 decks)

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