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13 Cards in this Set
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(acronym) SOAP 1. S - subjective 2. O - objective 3. A - assessment 4. P - plan |
1. Subjective - a description of the problem in the patients own words 2. Objective - data collected to assist in understanding the nature of the problem 3. Assessment - a diagnosis an identification of a problem, or a list of possibilities for the diagnosis, which is known as differential diagnosis 4. Plan - treatment with medicine or a procedure also collect more data to arrive at a more accurate diagnosis |
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Subjective terms 1. Acute 2. Chronic 3.Exacerbation 4. Abrupt 5. Febrile 6. Afebrile |
Definition 1. symptoms recently began 2. symptoms have been going on for present for a while 3. Symptoms getting worse 4. all of a sudden 5. to have a fever 6. to not have a fever |
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Subjective terms 7. Malaise 8. Progressive 9. System 10. Noncontributory 11. Lethargic 12. Genetic / Hereditary |
Definition 7. not feeling well 8. more and more each day 9. something a patient feels 10. not related to the specific problem 11. a decrease in level of consciousness 12. It runs in the family |
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Objective terms 1. Alert 2. Oriented 3. Marked 4. Unremarkable 5. Auscultation 6. Percussion 7. Palpitation |
Definition 1. Able to answer questions, be responsive and interactive. 2. Who he or she is , where and current time. 3. It really stands out. 4. Another way of saying normal. 5. To listen. 6. To hit something and listen to the sound or feel for the vibrations. 7. To feel. |
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Assessment terms 1. Impression 2. Diagnosis 3. Differential diagnosis 4. Benign 5. Malignant. 6. Degeneration 7. Remission 8. Idiopathic |
Definition 1. another way of saying assessment. 2. What the health care professional thinks the patient has. 3. A list of conditions the patient may have based on the symptoms exhibited and the results of the exam. 4. Safe. 5. Dangerous; a problem. 6. To be getting worse. 7. To get better or improve most often used when discussing cancer does not mean cure. 8. No known specific cause, it just happens. |
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Assessment terms 9. Localized 10. Systemic / generalized 11. Prognosis 12. Occult 13. Lesion 14. Recurrent 15. Sequela 16. Pending |
Definition 9. Stays in a certain part of the body. 10. All over the body or most of it. 11. The chance for things getting better or worse. 12. Hidden. 13. Diseased tissue. 14. To have again. 15. A problem resulting from a disease or injury. 16. Waiting for. |
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Common terms in medicine 1. Pathogen. 2. Morbidity 3. Mortality 4. Etiology |
Definition 1. The organism that causes the problem. 2. The risk for being sick. 3. The risk for dying. 4. The cause. |
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Plan terms 1. Disposition 2. Discharge 3. Palliative 4. Observation 5. Reassurance 6. Supportive care 7. Sterile 8. Prophylaxis |
Definition 1. What happens to the patient at the end of the visit. 2. Literally to unload. - send home - fluid coming out of a body part. 3. Treating the symptoms, but not actually getting rid of the cost. 4. To watch keep, and an eye on. 5. To tell the patient that the problem is not serious or dangerous. 6. To treat the symptoms and make the patient feel better. 7. Extremely clean, germ-free conditions, especially important during medical procedures and surgery. 8. Preventative treatment. |
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Body planes and Orientation Anatomic position - this position is a person standing, facing forward, arms at the side with palms forward. 1. Proximal 2. Distal |
Back (Definition) |
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Opposites |
Back (Definition) |
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Opposites |
Back (Definition) |
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Opposites |
Back (Definition) |
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Body planes |
Back (Definition) |
