Chapter 2

Question 1

SOAP

Answer 1

subjective
objective
assessment
plan

Question 2

subjective

Answer 2

how a patient experiences and personally describes the problem as well as medical history; the patients own words of duration, quality, of other factors

1. main reasons for health visit
2. description of problem
3. timing of problem
4. previous medical problems and surgeries
5. fam health problems
6. current meds and allergies

Question 3

objective

Answer 3

patient’s physical exam, lab findings, and imaging studies performed at the visit

Question 4

assessment

Answer 4

with all the information, the assessment could be diagnosis, id of the problem, list of possibilities for the diasnosis

Question 5

plan

Answer 5

course of action consisted with his or her assessment…could be medicine or procedure

Question 6

subjective color

Answer 6

blue

Question 7

objective color

Answer 7

red

Question 8

assessment color

Answer 8

yellow

Question 9

plan

Answer 9

green

Question 10

assessment and plan together color

Answer 10

light green

Question 11

chief complaint

Answer 11

the main reason for the patients visit

Question 12

history of present illness

Answer 12

story of patient’s problem

Question 13

review of systems

Answer 13

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

Question 14

past medical history

Answer 14

other significant past illnesses like high blood pressure, asthma, diabetes

Question 15

past surgical history

Answer 15

any of the patient’s past surgeries

Question 16

family history

Answer 16

any significant illnesses that run in the patient’s family

Question 17

social history

Answer 17

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

Question 18

abrupt

Answer 18

all of a sudden

Question 19

acute

Answer 19

just started recently or is a sharp, severe symptom

Question 20

afebrile

Answer 20

to not have a fever

Question 21

chronic

Answer 21

it has been going on for awhile now

Question 22

exacerbation

Answer 22

getting worse

Question 23

febrile

Answer 23

to have a fever

Question 24

genetic/hereditary

Answer 24

runs in the family

Question 25

lethargic

Answer 25

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

Question 26

malaise

Answer 26

not feeling well

Question 27

noncontributory

Answer 27

not related to this specific problem

Question 28

progressive

Answer 28

more and more each day

Question 29

symptom

Answer 29

something a patient feels

Question 30

alert

Answer 30

able to answer questions, responsive, interactive

Question 31

auscultation

Answer 31

to listen

Question 32

marked

Answer 32

it really stands out

Question 33

oriented

Answer 33

being aware of who he or she is, where, the current time, patient who is aware is oriented x3

Question 34

palpation

Answer 34

to feel

Question 35

percussion

Answer 35

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

Question 36

unremarkable

Answer 36

another way of saying normal

Question 37

impression

Answer 37

another way of saying assessment

Question 38

diagnosis

Answer 38

what the healthcare professional thinks the patient has

Question 39

differential diagnosis

Answer 39

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

Question 40

benign

Answer 40

safe

Question 41

malignant

Answer 41

dangerous; a serious problem

Question 42

degeneration

Answer 42

to be getting worse

Question 43

etiology

Answer 43

the cause

Question 44

remission

Answer 44

to get better or improve; used when discussing cancer

Question 45

idiopathic

Answer 45

no know specific cause; just happens

Question 46

localized

Answer 46

stays in a certain part of the body

Question 47

systemic/generalized

Answer 47

all over the body (or most of it)

Question 48

morbidity

Answer 48

the risk for being sick

Question 49

mortality

Answer 49

the risk of dying

Question 50

prognosis

Answer 50

the chances for things getting better or worse

Question 51

occult

Answer 51

hidden

Question 52

pathogen

Answer 52

the organism that causes the problem

Question 53

lesion

Answer 53

diseased tissue

Question 54

recurrent

Answer 54

to have again

Question 55

sequelae

Answer 55

a problem resulting from a disease or injury

Question 56

pending

Answer 56

waiting for

Question 57

discharge

Answer 57

literally to unload; has two meanings 1. to send home 2. fluid coming out of a part of the body

Question 58

disposition

Answer 58

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, intensive care unit, or normal hospital bed)

Question 59

observation

Answer 59

watch, keep an eye on

Question 60

palliative

Answer 60

treating the symptoms but not actually getting rid of the cause

Question 61

prophylaxis

Answer 61

preventive treatment

Question 62

sterile

Answer 62

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

Question 63

supportive care

Answer 63

to treat the symptoms and make the patient feel better

Question 64

distal

Answer 64

farther away from the center; distal and distant come from the same word and mean far

Question 65

proximal

Answer 65

closer in the center; proximal and approximate come from the same word and mean close

Question 66

lateral

Answer 66

out to the side

Question 67

medial

Answer 67

toward the middle

Question 68

dorsal/posterior

Answer 68

the back

Question 69

ventral/antral/anterior

Answer 69

the front

Question 70

caudal

Answer 70

toward the bottom

Question 71

cranial

Answer 71

toward the top

Question 72

prone

Answer 72

lying down on belly

Question 73

supine

Answer 73

lying down on back

Question 74

inferior

Answer 74

below

Question 75

superior

Answer 75

above

Question 76

contralateral

Answer 76

opposite side

Question 77

ipsilateral

Answer 77

same side

Question 78

dorsum

Answer 78

top of hand or foot

Question 79

palmar

Answer 79

palm of hand

Question 80

plantar

Answer 80

the sole of foot

Question 81

coronal

Answer 81

divides the body into slices from front to back; divides in half from top of head down (starting at neck and going down to toes; but in back and boobs in front)

Question 82

sagittal

Answer 82

divides the body into slices down right to left..as if someone shot an arrow through

Question 83

traverse

Answer 83

divides the body top and bottom