Chapter 2

Question 1

S. O. A. P

Answer 1

Subjective
Objective
Assessment
Plan

Question 2

Acute

Answer 2

It just started recently or is a sharp, severe symptom

Question 3

Chronic

Answer 3

It has been going on for a while now

Question 4

Exacerbation

Answer 4

It is getting worse

Question 5

Abrupt

Answer 5

All of a sudden

Question 6

Febrile

Answer 6

To have a fever

Question 7

Afebrile

Answer 7

To not have a fever

Question 8

Malaise

Answer 8

Not feeling well

Question 9

Progressive

Answer 9

More and more each day

Question 10

Symptom

Answer 10

Something a patient feels

Question 11

Noncontributory

Answer 11

Not related to this specific problem

Question 12

Lethargic

Answer 12

A decrease in level of consciousness

Question 13

Genetic/hereditary

Answer 13

It runs in the family

Question 14

Alert

Answer 14

Able to answer questions

Question 15

Oriented

Answer 15

Beating aware of who’s he or she is, where he or she is, and the current time

Question 16

Marked

Answer 16

It really stands out

Question 17

Unremarkable

Answer 17

Another way of saying normal

Question 18

Auscultation

Answer 18

To listen

Question 19

Percussion

Answer 19

To hit something and listen to the resulting sound, or feel for the resulting vibration

Question 20

Palpation

Answer 20

To feel

Question 21

Impression

Answer 21

Another way of saying assessment

Question 22

Diagnosis

Answer 22

What the healthcare professional thinks the patient has

Question 23

Differential diagnosis

Answer 23

A list of conditions the patient may have based on the symptoms exhibited and the results of the exam

Question 24

Benign

Answer 24

Safe

Question 25

Malignant

Answer 25

Dangerous, a problem

Question 26

Degeneration

Answer 26

To be getting worse

Question 27

Remission

Answer 27

To get better or improve

Question 28

Idiopathic

Answer 28

No known specific cause

Question 29

Localized

Answer 29

Stays in a certain part of the body

Question 30

Systemic/generalized

Answer 30

All over the body (or most of it)

Question 31

Prognosis

Answer 31

The chances for things getting better or worse

Question 32

Occult

Answer 32

Hidden

Question 33

Lesion

Answer 33

Diseased tissue

Question 34

Recurrent

Answer 34

To have again

Question 35

Sequela

Answer 35

A problem resulting from a disease or injury

Question 36

Pending

Answer 36

Waiting for

Question 37

Pathogen

Answer 37

The organism that causes the problem

Question 38

Morbidity

Answer 38

The risk for being sick

Question 39

Mortality

Answer 39

The risk for dying

Question 40

Etiology

Answer 40

The cause

Question 41

Disposition

Answer 41

What happened to the patient at the end of the visit

Question 42

Discharge

Answer 42

To send home Fluid coming out of a part of the body

Question 43

Palliative

Answer 43

Treating the symptoms, but not actually getting rid of the cause

Question 44

Observation

Answer 44

Watch, keep an eye on

Question 45

Reassurance

Answer 45

To tell the patient that the problem is not serious or dangerous

Question 46

Supportive care

Answer 46

To treat the symptoms and make the patient feel better

Question 47

Sterile

Answer 47

Extremely clean, germ free conditions

Question 48

Prophylaxis

Answer 48

Preventive treatment

Question 49

Proximal

Answer 49

Closer in to the center

Question 50

Distal

Answer 50

Farther away from the center

Question 51

Lateral

Answer 51

Out to the side

Question 52

Medial

Answer 52

Toward the middle

Question 53

Ventral/antral/anterior

Answer 53

The front

Question 54

Dorsal/posterior

Answer 54

The back

Question 55

Cranial

Answer 55

Toward the top

Question 56

Caudal

Answer 56

Toward the bottom

Question 57

Superior

Answer 57

Above

Question 58

Inferior

Answer 58

Below

Question 59

Prone

Answer 59

Lying down on belly

Question 60

Supine

Answer 60

Lying down on back

Question 61

Contralateral

Answer 61

Opposite side of

Question 62

Ipsilateral

Answer 62

Same side

Question 63

Unilateral

Answer 63

One side

Question 64

Bilateral

Answer 64

Both sides

Question 65

Dorsum

Answer 65

The top of the hand or foot

Question 66

Plantar

Answer 66

The sole of the foot

Question 67

Palmar

Answer 67

The palm of the hand

Question 68

Sagittal

Answer 68

Divides the body along a hypothetical plane from right to left

Question 69

Coronal

Answer 69

Divides the body along a hypothetical plane from front to back

Question 70

Transverse

Answer 70

Divides the body from top to bottom

Question 71

Chief complaint

Answer 71

The main reason for the patient’s visit

Question 72

History of present illness

Answer 72

The story of the patient’s problem

Question 73

Review of systems

Answer 73

Description of individual body systems in order to discover any symptoms not directly related to the main problem

Question 74

Past medical history

Answer 74

Other significant past illnesses, like high blood pressure, asthma, or diabetes

Question 75

Past surgical history

Answer 75

Any of the patients pass surgeries

Question 76

Family history

Answer 76

Any significant illnesses that run in the patient’s family

Question 77

Social history

Answer 77

A record of habits like smoking, drinking, drug abuse and sexual practices that can impact health

Question 78

Clinic note

Answer 78

Documents a visit

Question 79

Consult note

Answer 79

Provides an expert opinion on a more challenging problem

Question 80

Emergency department note

Answer 80

Documents an emergency department visit

Question 81

Admission summary

Answer 81

Documents the admission of a patient to the hospital

Question 82

Discharge summary

Answer 82

Describes when and why the patient was admitted, documents a longer stay

Question 83

Operative report

Answer 83

Documents a surgery in detail

Question 84

Daily hospital note/progress note

Answer 84

Documents daily hospital visit

Question 85

Radiology report

Answer 85

Explains reason for image, how image was performed, what was seen on image, radiologist’s assessment

Question 86

Pathology report

Answer 86

Provides reasons for test, what was seen on the test, and an assessment

Question 87

Prescription

Answer 87

Provides directions for a medication