SOAP Terms 2

acute (ah-KYOOT)

it just started recently or is a sharp, severe symptom

chronic (KRAWN-ik)

it has been going on for a while now

exacerbation (eks-AS-er-BAY-shun)

it is getting worse

abrupt (ah-BRUPT)

all of a sudden

febrile (FEB-ril)

to have a fever

afebrile (uh-FEB-ril)

to not have a fever

malaise (mah-LAYZ)

not feeling well

progressive (proh-GREH-siv)

more and more each day

symptom (SIM-tom)

something a patient feels

noncontributory (NON-kon-TRIH-byoo-TOR-ee)

not related to this specific problem

lethargic (lah-THAR-jik)

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

genetic/hereditary (jen-ET-ik, heh-RED-ih-TER-ee)

it runs in the family

alert (ah-LERT)

able to answer questions; responsive; interactive

oriented (OR-ee-EN-ted)

being aware of who one is, where one is, and the current time; a patient who is aware of all three is “oriented × 3”

marked (MARKT)

it really stands out

unremarkable (un-ree-MAR-kah-bul)

another way of saying normal

auscultation (aw-skul-TAY-shun)

to listen

percussion (per-KUSH-un)

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

palpation (pal-PAY-shun)

to feel

impression (im-PRESH-un)

another way of saying assessment

diagnosis (DAI-ag-NOH-sis)

what the health care professional thinks the patient has

differential diagnosis (DIF-eh-REN-chal DAI-ag-NOH-sis)

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

benign (beh-NAIN)

safe

malignant (mah-LIG-nant)

dangerous; a problem

degeneration (dee-JEN-eh-RAY-shun)

to be getting worse

remission (rih-MISH-un)

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

idiopathic (ID-ee-oh-PATH-ik)

no known specific cause; it just happens

localized (LOH-kal-aizd)

stays in a certain part of the body

systemic/generalized (sis-TEM-ik, JEN-ral-aizd)

all over the body (or most of it)

prognosis (prawg-NOH-sis)

the chances for things getting better or worse

occult (ah-KULT)

hidden

lesion (LEE-zhun)

diseased tissue

recurrent (rih-KUR-ent)

to have again

sequela (seh-KWEL-eh)

a problem resulting from a disease or injury

pending (PEN-ding)

waiting for

pathogen (PATH-oh-jen)

the organism that causes the problem

morbidity (mor-BID-it-ee)

the risk for being sick

mortality (mor-TAL-it-ee)

the risk for dying

etiology (EET-ee-AWL-oh-jee)

the cause

disposition (dis-poh-ZISH-un)

final outcome or location for a patient following a medical evaluation, such as returning home or being admitted to intensive care.

discharge (DIS-charj)

sending a patient home from a healthcare facility, or a fluid released from a body part.

palliative (PAL-ee-AH-tiv)

care focused on managing symptoms rather than curing the underlying condition.

observation (OB-zer-VAY-shun)

monitoring or keeping a close watch on a patient's condition.

reassurance (REE-ah-SHUR-ants)

informing a patient that their condition is not dangerous or grave.

supportive care (suh-POR-tiv kehr)

medical treatment intended to alleviate symptoms and improve patient comfort.

sterile (STER-ul)

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

prophylaxis (proh-fih-LAK-sis)

preventive treatment