| SOAP note words |
abdominal |
pertaining to the abdomen (belly) |
| SOAP note words |
abrupt |
sudden |
| SOAP note words |
acute |
occuring suddenly (cf. chronic) |
| SOAP note words |
afebrile |
without fever |
| SOAP note words |
alert |
in a state of vigilance |
| general |
anatomical |
pertaining to anatomy |
| general |
anatomy |
body structure |
| directional term |
anterior |
toward the front (in humans, same as ventral) |
| general |
antrum |
body cavity |
| SOAP note words |
auscultation |
the act of listening through a stethoscope |
| SOAP note words |
benign |
not harmful |
| directional term |
bilateral |
on two sides (cf. unilateral) |
| SOAP note words |
cardiovascular |
pertaining to the heart and blood vessels |
| directional terms |
caudal |
towards the tail (buttocks) |
| SOAP note words |
chronic |
occurring over a long time (cf. acute) |
| directional term |
contralateral |
on the opposite side |
| planes of section |
coronal |
anatomical plane that divides the body into front and back (same as frontal) |
| directional term |
cranial |
toward or pertaining to the head |
| SOAP note words |
degeneration |
the process of falling apart |
| SOAP note words |
diagnosis |
the recognition of a disease from its signs and symptoms |
| SOAP note words |
differential |
separating one thing from another |
| SOAP note words |
discharge |
releasing from the hospital |
| SOAP note words |
disease |
condition of being unwell (literally, "without ease") |
| SOAP note words |
disposition |
frame of mind; outcome |
| directional term |
distal |
further away from the point of attachment (generally used only for extremities; cf. proximal) |
| directional term |
dorsal |
pertaining to the back |
| directional term |
dorsum |
the back |
| SOAP note words |
dyslipidemia |
condition of abnormal fats in the blood |
| SOAP note words |
endocrinology |
study of internal secretions (i.e. hormones) |
| abdominal regions |
epigastric |
on top of the stomach |
| SOAP note words |
etiology |
study of the origins of an illness |
| SOAP note words |
exacerbation |
the process of getting worse |
| SOAP note words |
febrile |
with a fever |
| planes of section |
frontal |
anatomical plane that divides the body into front and back (same as coronal) |
| general |
genetic |
pertaining to birth; a condition you are born with |
| general |
hereditary |
passed down through the genes |
| general |
homeostasis |
balance in body systems (literally, "keeping things the same") |
| planes of section |
horizontal |
anatomical plane that divides the body into top and bottom (same as transverse) |
| SOAP note words |
hypertension |
abnormal condition of blood pressure that is too high |
| abdominal regions |
hypochondriac |
below the rib cartilage |
| abdominal regions |
hypogastric |
below the stomach |
| SOAP note words |
hypotension |
abnormal condition of blood pressure that is too low |
| SOAP note words |
hypoxia |
abnormal condition of oxygen concentration in the blood that is too low |
| SOAP note words |
idiopathic |
without obvious cause; a disease that seems to come out of nowhere |
| abdominal regions |
iliac |
pertaining to the flank |
| SOAP note words |
impression |
initial observations made by a clinician |
| directional term |
inferior |
toward the bottom |
| abdominal regions |
inguinal |
pertaining to the groin |
| directional term |
ipsilateral |
on the same side |
| directional term |
lateral |
toward the side (away from the midline, cf. medial) |
| SOAP note words |
lesion |
damage or injury |
| SOAP note words |
lethargic |
appearing to be drowsy |
| SOAP note words |
localized |
in one place, not widespread |
| abdominal regions |
lumbar |
pertaining to the back |
| SOAP note words |
malaise |
disease, sickness |
| SOAP note words |
malignant |
harmful |
| SOAP note words |
marked |
especially noticeable (pronounced "mark-ud") |
| directional term |
medial |
toward the midline (away from the side, cf. lateral) |
| general |
microscope |
device for seeing small things |
| SOAP note words |
morbidity |
pertaining to disease |
| SOAP note words |
mortality |
pertaining to death |
| SOAP note words |
noncontributory |
not relevant to the patient's illness |
| SOAP note words |
observation |
watching the patient to assess further development of signs or symptoms |
| SOAP note words |
occult |
hidden; in an unexpected place |
| SOAP note words |
oriented |
a patient knows where, when, and who they are |
| SOAP note words |
palliative |
care not designed to cure, but to make the patient more comfortable |
| directional term |
palmar |
towards or pertaining to the palm |
| SOAP note words |
palpation |
examining by touching |
| SOAP note words |
pathogen |
an organism that gives rise to disease |
| SOAP note words |
pathology |
the study of disease |
| general |
pathophysiology |
the study of body dysfunction in disease |
| SOAP note words |
pending |
waiting for results |
| SOAP note words |
percussion |
examining by tapping |
| general |
physiology |
the study of body function |
| directional term |
plantar |
towards or pertaining to the underside of the foot |
| directional term |
posterior |
toward the back (in humans, same as dorsal) |
| SOAP note words |
prognosis |
predicting the future of a disease |
| SOAP note words |
progressive |
getting worse over time |
| directional term |
prone |
face down (cf. supine) |
| SOAP note words |
prophylaxis |
treatment to prevent or discourage disease |
| directional term |
proximal |
closer to the point of attachment (generally used only for extremities; cf. distal) |
| SOAP note words |
radiographic |
making an image using X-rays or other radiation |
| SOAP note words |
reassurance |
to give encouragement to help a patient's progress |
| SOAP note words |
recurrent |
happening over and over again |
| SOAP note words |
remission |
process of a disease going away |
| SOAP note words |
reproductive |
to bring into existence again; pertaining to the process of creating children |
| directional term |
rostral |
toward the nose |
| planes of section |
sagittal |
anatomical plane that divides the body into left and right |
| SOAP note words |
sequelae |
things that come out one after another; result of an illness (pronounced "sequel-ay") |
| SOAP note words |
skeletal |
pertaining to the bones of the body |
| SOAP note words |
sterile |
unable to reproduce (of individuals or of micro-organisms) |
| directional term |
superior |
toward the top |
| directional term |
supine |
face up (cf. prone) |
| SOAP note words |
supportive |
lifting up |
| SOAP note words |
symptom |
abnormal feelings reported by the patient (cf. signs, which are the result of objective clinical tests) |
| SOAP note words |
syndrome |
symptoms which occur together |
| SOAP note words |
systemic |
pertaining to an entire organ system or the entire body |
| planes of section |
transverse |
anatomical plane that divides the body into top and bottom (same as horizontal) |
| abdominal regions |
umbilical |
pertaining to the navel ("belly-button") |
| directional term |
unilateral |
on one side (cf. bilateral) |
| SOAP note words |
unremarkable |
not prominent; not important |
| SOAP note words |
vasodilation |
increase in the diameter of a blood vessel |
| directional term |
ventral |
pertaining to the abdomen (belly) |
