SOAP

2.2 Common Terms in Medicine

Acute

It just started recently or is a sharp, severe symptom

Chronic

It has been going on for a while now

Exacerbation

It is getting worse

Abrupt

All of a sudden

Febrile

To have a fever

Afrebile

To not have a fever

Malaise

Not feeling well

Progressive

More and more each day

Symptom

Something a patient feels

Noncontributory

Not related to this specific problem

Lethargic

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

Genetic/Hereditary

It runs in the family

Alert

Able to answer questions; responsive; interactive

Oriented

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”

Marked

It really stands out

Unremarkable

Another way of saying normal

Auscultation

To listen

Percussion

To hit something and listen to the resulting sound or feel the resulting vibrations; drums are a percussion instrument

Palpation

To feel

Impression

Another way of saying assessment

Diagnosis

What the health professional thinks the patient has

Differential diagnosis

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

Benign

Safe

Malignant

Dangerous; a problem

Degeneration

To be getting worse

Remission

To get better or improve; most often used when discussing cancer; remission does not mean cure

Idiopathic

No known specific cause; it just happens

Localized

Stays in a certain part of the body

Systemic/Generalized

All over the body (or most of it)

Prognosis

The chances of things getting better or worse

Occult

Hidden

Lession

Diseased tissue

Recurrent

To have again

Sequela

A problem resulting from a disease or injury

Pending

Waiting for

Pathogen

The organism that causes the problem

Morbidity

The risk for being sick

Mortality

The risk for dying

Etiology

The cause

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)

Discharge

Literally, to unload; it has to 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)

Palliative

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

Observation

Watch, keep an eye on

Reassurance

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

Supportive care

To treat the symptoms and make the patient feel better

Sterile

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

Prophylaxis

Preventative treatment