SOAP Terms

Acute

It 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.

Afebrile

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; usually an indication that a patient is really sick.

Genetic/Hereditary

It runs in the family.

Alert

Able to answer questions; responsive.

Oriented

Being aware of who he or she is.

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 for the resulting vibration.

Palpitation

To feel.

Impression

Another way of saying assessment.

Diagnosis

What the healthcare professional thinks the patient has.

Differential Diagnosis

A list of conditions the patient may have based on the symptoms they have 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; 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 for things getting better or worse.

Occult

Hidden.

Lesion

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.

Discharge

Literally, to unload; (1) to send home; (2) fluid coming out of a part of the body.

Palliative

Treating the symptoms, but not 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.

Prophylaxis

Preventative treatment.