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Final Exam mda111
|gathering info to determine the pts problem or reason for seeking medical care.
|CC (Chief Complaint)
|main reason for the visit to the medical office.
|relating to the statistical characteristics of populations.
|referring to a disorder that tends to occur more often in a family than would be anticipated soley by chance.
|referring to traits or disorders that are transmitted from parent to offspring.
|(Health Insurance Portability & Accountability Act) federal law, originally passed as the Kassebaum Kennedy Act, that requires all health care settings to ensure privacy & security of pt info. Also requires health insurance to be accessible for working
|small doses of agents that cause similar symptoms in healthy individuals& are given to a person who is ill to help cure the disease causing the symptom.
|Medical History (M Hx)
|record containing info about a pts past & present health status.
|Over the Counter (OTC)
|are available without prescriptions.
|Objective indications of disease or bodily dysfunction as observed or measured by the health care professional.
|objective info that can be observed or perceived by someone other than the pt.
|Subjective indications of disease or bodily dysfunction as sensed by pt. (What it feels Subjective)
|Review of symptoms (ROS)
|review of each body symptom. Specific symptoms.
|Past History (P Hx)
|existing illness & meds, allergies, immunizations.
|Family History (F Hx)
|health status of parents, siblings, grandparents. Familial & Hereditary diseases.
|Social History (S Hx)
|Lifestyle, occupation, edu., marital status, Diet alcohol/tobaccos use, sexual hx.
|allow pt to answer w/ more than one or two words.
|only one or two words.
|(No Fever) body temp not elevated above normal.
|pertaining to measurement of the human body. (include Height & Weight)
|measurements taken at the first visit are recorded as...
|marked in units of measurements, as a thermometer calibrated in Celsius .
|period from the beginning of one heartbeat to the beginning of the next; includes systole & diastole.
|the amount of blood ejected from either ventricle per minute, either to the pulmonary or to the systemic circulation.
|usually, vital signs; signifies their importance in assessment.
|relaxation phase of the cardiac cycle.
|(Fever) having an above-normal body temp.
|abnormally deep; gasping breaths.
|dangerously high temp. , 105 degrees- 106 degrees F.
|morbidly high BP.
|a respiratory rate that greatly exceeds the body's oxygen demands.
|occurring at intervals.
|inability to breathe lying down; the pt usually has to sit upright to breathe.
|technique in which the examiner feels the texture, size, consistency, & location of parts of the body with the hands.
|sudden drop in BP upon standing.
|body temp of 102 degrees F or higher rectally or 101 degrees F or higher orally.
|fever that returns after extended periods of being w/in normal limits.
|device used to measure BP.
|fever that is constant or not fluctuating.
|Contraction phase of the cardiac cycle.
|only sounds heard during phase I (first sound) & phase V(last sound) are recorded as BP. (classified into 5 phases )
|the # of heartbeats in 1 min. In adults average pulse rate is 60 to 100 bpm.
|the interval between each heartbeat or the pattern of beats.
|the strength or force of the heartbeat, can be described as soft, pounding, weak, thread, strong, or full.
|Most often used to determine pulse rate.
|contract diaphragm, breathe oxygen in.
|relax diaphragm, breathe carbon dioxide out.
|the exchange of gases between the atmosphere & the blood in the body. (14-20 in adults per min)
|the volume of air being inhaled & exhaled.
|pumping of blood causes expansion & contraction of arteries- heartbeat.
|lack or absence of symmetry; inequality of size or shape on opposite sides of the body.
|act of listening for sounds w/in the body, usually w/ the stethoscope, such as to elevate the heart, lungs, intestines, or fetal heart tones.
|reflex exhibited normally by infants. (stroking the sole of the foot to flex the big toe & fan the other toes )
|Using both hands.
|abnormal sound or murmur in the blood vessels during auscultation.
|yellowish or brownish wax-like secretion in the external ear canal; Earwax.
|a diagnosis based only on the pts clinical symptoms.
|identification of a disease or condition by evaluating physical signs & symptoms, health hx, & lab tests; a disease or condition identified in a person.
|a diagnosis made by comparing the pts symptoms to two or more diseases that have similar symptoms.
|outside the eye, as in extraocular eye movement.
|manner or style of walking.
|protrusion of an organ through the muscle wall of the cavity that normally surrounds it.
|Pertaining to the regions of the groin.
|agent that reduces friction.
|skillful use of the hands in diagnostic procedures.
|wall or partition dividing the nostrils.
|smooth, rounded, removable inner portion of a hollow tube, such as an anoscope, that allows for easier insertion.
|blood hidden or concealed from observation.
|is touching or moving body areas w/ the fingers or hands
|Papanicolaou (Pap) Smear or Test
|smear of tissue cells examined for abnormalities including cancer, especially of the cervix.
|striking w/ the hands to elevate the size, borders, consistency & presence of fluid or air.
|side vision while looking straight ahead.
|Pupils, Equal, Round, Reactive to Light, & Accommodation.
|ROM (Range of Motion)
|in degrees of angle through which a joint can be extended & flexed.
|pertaining to the rectum & vagina.
|white fibrous tissue that cover the eye.
|instrument that enlarges & separates the opening of a cavity to expose its interior for exam.
|equality in size or shape or position of parts on opposite sides of the body.
|thin, semitransparent membrane in the middle ear that transmits sound vibrations; the Eardrum.