Term | Definition |
Inspection (1/6) | visually examining the exterior surface of the body |
Palpation (2/6) | using hands to feel the skin, underlying organs, and tissues |
Percussion (3/6) | using the fingertips to tap the body lightly but sharply to gain information about the position and size of underlying body parts. |
Auscultation (4/6) | -listening to the sounds within the body
-sounds by heart, lungs, stomach, and bowel are assessed for strength and rhythm. |
Mensuration (5/6) | use of special tools to measure the body or specific body parts (calipers to measure body fat) |
diagnose | determine the cause and nature of a disease or injury |
clinical diagnosis | -aka working diagnosis
-preliminary presumptive diagnosis made by the physician based on health history and physical exam. |
differential diagnosis | the process of determining which, of multiple possibilities, is the cause of the problem. |
prognosis | predicting the course of the condition and determining the recovery rate. |
supine position | -aka horizontal recumbent
-patient lies flat on back with hands at their sides |
dorsal recumbent position | patient lies flat on back with knees bent and feet flat on the table |
lithotomy position | Similar to dorsal recumbent position, but pt's feet are in stirrups (when the Physician is in room and ready) |
Fowler's position | Patient sits on exam table with head of table raised to a 90 degree angle |
Semi-Fowler's position | Patient sits on exam table with head of table raised to a 45 degree angle |
prone position | Patient lies face down on table, flat on stomach, with head turned to the side |
Sim's position | -aka lateral recumbent position
-patient is placed on their left side with the right leg bent sharply upward |
knee-chest position | Patient is placed in the prone position and then asked to pull their knees up to a kneeling position with their thighs at a 90 degree angle to the table |
Trendelenburg position | -Only used in the case of shock or low blood pressure
-Foot of bed is raised above the level of the patient's head |
Proctologic position | -aka jack-knife position
-Pt. lies face-down with hips at hinge of table |
Sitting position | -used to examine the head and chest (anterior and posterior)
-patient sits on table with legs hanging off side |
ROS | Review of Symptoms |
Manipulation (6/6) | passively assessing the range of motion of a joint |
Chief Complaint | -CC
-presenting problem |
signs | -objective and measurable |
symptoms | -subjective
-stated by patient and quoted in chart |
present illness | -PI
-provides a more complete, expansive description of the CC. |
family medical history | record of the health problems of the patient's BLOOD relatives |
social history | -Lifestyle patterns that could affect the health status of the patient
-smoking, drinking, drug-use, occupation, marital status, and sexual preference. |
ophthalmascope | equipment used to examine the interior of the eye |
otoscope | equipment used to examine the ears |
reflex hammer | -aka percussion hammer
-equipment used for testing reflexes |
tuning fork | equipment used to test for hearing loss |
laryngeal mirror | -aka dentist's mirror
-equipment used to visualize the larynx and throat |