SOAP Notes and Medical Terminology Review

Comprehensive flashcards covering the ED/Clinical SOAP note workflow, anatomy, common medical abbreviations, roots, diagnoses, and treatments based on lecture transcripts.

SOAP Note

A method of documentation for providers (Physicians, Nurse Practitioners, and Physician Assistants) to record a patient encounter within an Electronic Medical Record (EMR/EHR).

Triage

The process where a nurse evaluates the patient's condition to determine if they need immediate treatment or should wait in the waiting room, based on a level of acuity from $1$ (most critical) to $5$ (non-urgent).

Subjective Component

Information provided by the patient or their family, including the story of the problem, symptoms, and medical factors pertinent to why the patient is seeking care.

Objective Component

Information provided by the provider that can be measured, seen, heard, touched, or smelled, including vital signs, diagnostic results, and physical exam findings.

Medical Decision Making (MDM)

The section of the chart where the provider documents considered diagnoses, necessary medical interventions, and how the patient responded to those interventions.

HPI (History of Present Illness)

A detailed narrative in the subjective section documented from the patient's perspective, explaining the symptoms, onset, duration, and severity of the condition.

COLD CARS

A mnemonic used to remember the elements of an HPI: Context, Onset, Location/Radiation, Duration, Character, Alleviating/Aggravating Factors, Related Symptoms, and Severity.

Review of Systems (ROS)

A 'catch-all' organized by functional organ systems that records the presence or absence of symptoms through yes/no questions, documented as positive or negative.

Anatomical Position

A standard description of the human body standing with feet together and palms facing forward; the palms are anterior and the back of the hands are posterior.

Coronal Plane

An anatomical plane that divides the body into front (anterior) and back (posterior) sections.

Sagittal Plane

An anatomical plane that divides the body into left and right halves.

Transverse Plane

An anatomical plane that divides the body into top (superior) and bottom (inferior) sections.

Proximal vs. Distal

Proximal describes structures closer to the core of the body, while distal describes structures farther away (e.g., the knee is proximal to the ankle).

Medial vs. Lateral

Medial describes structures closer to the midline of the body, while lateral describes structures farther away from the midline.

Cervical Spine

The first $7$ vertebrae of the spine, followed by $12$ thoracic and $5$ lumbar vertebrae.

Epiglottis

A flap of tissue that covers the trachea while swallowing to prevent food from entering the lungs.

Coronary Arteries

Arteries located on the exterior of the heart that supply the heart muscles with blood; blockage in these leads to a heart attack.

Disposition

Indicates where the patient will go after leaving the Emergency Department, typically categorized as Discharge, Admit, or Transfer.

Scribe Attestation

A legal statement at the end of a chart identifying the scribe who transcribed the note and confirming the provider's responsibility for the documented medical information.

STEMI

ST Elevation Myocardial Infarction; a type of heart attack characterized by an elevation of the ST wave on an EKG.

Atelectasis

A respiratory diagnosis referring to the partial or total collapse of the lung.

Cholelithiasis

A gastrointestinal condition characterized by the presence of gall stones.

Rhabdomyolysis

A musculoskeletal condition involving the breakdown of muscle tissue.

Troponin

A laboratory test that measures an enzyme released from damaged cardiac tissue during a heart attack; levels increase when cardiac muscles are damaged.

tPA (tissue plasminogen activator)

A medication used for the systemic breakdown of blood clots in stroke patients that must be administered within $3$ hours of symptom onset.

Anisocoria

Specifically refers to the unequal size of the pupils.

Dysphagia

Medical term for painful or difficult swallowing.

Orthopnea

Difficulty breathing when lying down.

Melena

A gastrointestinal symptom characterized by black, tarry stool.

Crepitus

A crackling or grating sound usually heard in the joints.

Paresthesia

An abnormal tactile sensation such as numbness, tingling, or burning.

Bradycardia vs. Tachycardia

Bradycardia is an unusually slow heart rate, while tachycardia is an unusually fast heart rate (typically more than $100$ bpm).

-itis

A medical root meaning inflammation (e.g., Dermatitis, Appendicitis).

-algia

A medical root meaning relating to pain (e.g., Myalgia, Arthralgia).

A&Ox4

An abbreviation for Alert and Oriented to person, place, time, and situation.

AAA

Abbreviation for Abdominal Aortic Aneurysm, which is the enlargement and rupture of the lower part of the aorta.

CBC

Complete Blood Count; a lab test that determines general health and screens for disorders such as anemia or infections.

B-hCG

A lab test typically performed to confirm and monitor pregnancy.

BMP vs. CMP

Basic Metabolic Panel (BMP) is a group of $7-8$ tests for screening diabetes and kidney disease; Complete Metabolic Panel (CMP) is a group of $14$ tests adding liver and protein information.

Rhino Rocket

An absorbent nasal tampon used for compression in cases of epistaxis (nose bleed).

Wood's Lamp

A UV (black) light used in eye exams along with fluorescein drops to check for corneal abrasions.

Angioplasty

A surgical procedure used to open up a coronary artery.

Lumbar Puncture

The withdrawal of cerebrospinal fluid through a needle inserted between the $L4$ and $L5$ vertebrae, also known as a spinal tap.

Paracentesis

Perforation of a body cavity or cyst to remove extraneous fluid or gas.

Hematemesis

The presence of blood in vomit.

Nystagmus

Involuntary, rapid, or irregular movements of the eyes.

Cerumen

The medical term for ear wax.

Tinnitus

The sensation of ringing in the ears.

Diaphoresis

Medical terminology for excessive sweating.

Supple

Describes a flexible neck that can easily move during a physical exam.