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HLHS > Chapter 2 Vocab > Flashcards

Chapter 2 Vocab Flashcards

(104 cards)

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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
Unremarkable
Another way of saying normal | un-ree-MARK-ah-bul
26
Auscultation
To listen | aws-kul-TAY-shun
27
Percussion
To hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument (per-KUH-shun)
28
Palpation
To feel | pal-PAY-shun
29
Impression
Another way of saying assessment | im-PREH-shun
30
Diagnosis
What the health care professional thinks the patient has | DAI-ag-NOH-sis
31
Differential Diagnosis
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)
32
Benign
Safe | ben-NAIN
33
Malignant
Dangerous; a problem | mah-LIG-nant
34
Degeneration
To be getting worse | dee-jen-er-AY-shun
35
Etiology
The cause | ee-tee-AW-loh-jee
36
Remission
To get better or improve; most often used when discussing cancer; remission does not mean cure (reh-MIH-shun)
37
Idiopathic
No known specific cause; it just happens | ih-dee-oh-PA-thik
38
Localized
Stays in a certain part of the body | LOH-kah-LAIZD
39
Systemic / Generalized
All of the body (or most of it) | sih-STEM-ik, jen-er-ah-LAIZD
40
Morbidity
The risk for being sick | mor-BID-ih-tee
41
Mortality
The risk for dying | mor-TA-lih-tee
42
Prognosis
The chances for things getting better or worse | prawg-NOH-sis
43
Occult
Hidden | ah-KULT
44
Pathogen
The organism that causes the problem | PATH-oh-jin
45
Lesion
Diseased tissue | LEE-shun
46
Recurrent
To have again | ree-KUR-ent
47
Sequelae
A problem resulting for a disease or injury | seh-KWEL-ah
48
Pending
Waiting for | PEN-ding
49
Disposition
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
Discharge
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
Prophylaxis
Preventative Treatment | PROH-fuh-LAK-sis
52
Palliative
Treating the symptoms, but not actually getting rid of the cause (PA-lee-ah-tiv)
53
Observation
Watch, keep and eye on | OB-zer-VAY-shun
54
Reassurance
To tell the patient that the problem is not serious or dangerous (ree-ah-SHUR-ants)
55
Supportive care
To treat the symptoms and make the patient feel better | suh-POR-tiv kehr
56
Sterile
Extremely clean, germ-free-conditions; especially important during medical procedures and surgery
57
Proximal
Closer to the center (usual referring to your trunk) | PRAWK-sih-mal
58
Distal
Farther away from the center (usually referring to your trunk) (DIH-stal)
59
Lateral
Out to the side | LA-ter-al
60
Medial
Toward the middle | MEE-dee-al
61
Ventral/Antral/Anterior
The front | VEN-tral/AN-tral/an-TIH-ree-or
62
Dorsal/Posterior
The back | DOR-sal/pohs-TEER-ee-or
63
Cranial
Toward the top | KRAY-nee-al
64
Caudal
Toward the bottom | KOW-dal
65
Superior
Above | soo-PIH-ree-or
66
Inferior
Below | In-FIH-ree-or
67
Prone
Lying down on belly | PROHN
68
Supine
Lying down on back | SOO-pain
69
Contralateral
Opposite side | KON-trah-LA-ter-al
70
Ipsilateral
Same side | IP-sih-LA-ter-al
71
Unilateral
One side | YOO-nih-LA-ter-al
72
Bilateral
Both sides | BAI-LA-ter-al
73
Dorsum
Top of the hand or foot | DOR-sum
74
Plantar
The sole of the foot | PLAN-tar
75
Palmar
The palm of the hand | PAL-mar
76
Sagittal
Divides the body in slices right to left | SA-jih-tal
77
Coronal
Divides the body into slices from front to back | kah-ROH-nal
78
Transverse
Divides the body from top to bottom | trans-VERS
79
Physician
A skilled health care provided who attended and graduated medical school (fuh-ZIH-shun)
80
Pediatrician
A physician with special training in caring for children | PEE-dee-ah-TRIH-shun
81
Surgeon
A physician qualified to treat patients surgically, that is, by means of operation or invasive procedure (SIR-jen)
82
Anesthesiologist
A physician with special training in pain sedation and pain control (AN-ehs-THEE-zee-AW-loh-jist)
83
Physician Assistant (PA)
A midlevel health care provider who works under the license of a supervising physician; requires postgraduate training (fuh-ZIH-shun ah-SIS-tant)
84
Nurse Practitioner (NP)
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
emergency Medical Technician (EMT)
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
Speech Therapist
Specially trained in evaluating and treating problems with speech and/or swallowing (SPEECH THEH-rah-pist)
87
Occupational Therapist
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
Physical Therapist
Specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury (FIH-zih-kal THEH-rah-pist)
89
Respiratory Therapist
Specially trained in treating patient's respiratory issues under the guidance of a health care provider (reh-sprah-TOR-ee THEH-rah-pist)
90
Dietician
Specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan (dai-ah-TIH-shun)
91
Licensed Practical Nurse (LPN)
Trained and certified to provide basic care to a patient | LAI-senzd PRAK-tih-kal NIRS
92
Licensed Vocational Nurse
Trained and certified to provide basic care to a patient | LAI-senzd voh-KAY-shun-al NIRS
93
Registered Nurse (RN)
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
Medical Assistant
Trained to carry out basic administrative and clinical tasks under the guidance of a health care provider (MEH-dih-kal ah-SIS-tant)
95
Pathologist
A physician with special training in both evaluating the causes and effects of disease and in laboratory medicine (pah-THAW-loh-jist)
96
Medical Laboratory Technician
Trained in performing laboratory testing on bodily fluids | meh-DIH-kal LAH-broh-tor-ee tek-NIH-shun
97
Phlebotomist
Trained in the removal of blood from the body for diagnostic or therapeutic purposes (fleh-BOH-tow-mist)
98
Radiologist
A physician specially trained in evaluating images of the body to diagnose illness or injury (ray-dee-AW-loh-jist)
99
Radiology Technician
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
Ultrasonagrapher
Trained in performing ultrasound imaging on a patient | ul-trah-saw-NAW-grah-fir
101
Pharmacist
Trained and licensed in preparing and dispensing medicine | FAR-mah-sist
102
Pharmacy Technician
Trained to assist a pharmacist with pharmacy-related tasks | FAR-mah-see tek-NIH-shun
103
Patient Service Coordinator
Handle administrative tasks and coordinates patient care | PAY-shent SIR-vis coh-OR-dih-nay-tor
104
Medical Transcriptionist
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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