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Final Exam mda111

MDA 111

Assessment 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.
Demographic relating to the statistical characteristics of populations.
Familial referring to a disorder that tends to occur more often in a family than would be anticipated soley by chance.
Hereditary referring to traits or disorders that are transmitted from parent to offspring.
HIPAA (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
Homeopathic Medication 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.
Signs Objective indications of disease or bodily dysfunction as observed or measured by the health care professional.
signs2 objective info that can be observed or perceived by someone other than the pt.
Symptoms 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.
Open-ended allow pt to answer w/ more than one or two words.
Closed-ended only one or two words.
Afebrile (No Fever) body temp not elevated above normal.
anthropometric measurements pertaining to measurement of the human body. (include Height & Weight)
Apnea not breathing
baseline data measurements taken at the first visit are recorded as...
Calibrated marked in units of measurements, as a thermometer calibrated in Celsius .
Cardiac Cycle period from the beginning of one heartbeat to the beginning of the next; includes systole & diastole.
Cardiac Output the amount of blood ejected from either ventricle per minute, either to the pulmonary or to the systemic circulation.
Cardinal Signs usually, vital signs; signifies their importance in assessment.
Diaphoresis profuse sweating.
Diastole relaxation phase of the cardiac cycle.
Dyspnea difficulty breathing.
Febrile (Fever) having an above-normal body temp.
Hyperpnea abnormally deep; gasping breaths.
Hyperpyrexia dangerously high temp. , 105 degrees- 106 degrees F.
Hypertension morbidly high BP.
Hyperventilation a respiratory rate that greatly exceeds the body's oxygen demands.
Hypopnea Shallow respirations.
Intermittent Fever occurring at intervals.
Orthopnea inability to breathe lying down; the pt usually has to sit upright to breathe.
Palpation technique in which the examiner feels the texture, size, consistency, & location of parts of the body with the hands.
Postural Hypotension sudden drop in BP upon standing.
Pyrexia body temp of 102 degrees F or higher rectally or 101 degrees F or higher orally.
Relapsing Fever fever that returns after extended periods of being w/in normal limits.
Remittent Fever fluctuating.
Sphygmomanometer device used to measure BP.
Sustained Fever fever that is constant or not fluctuating.
Systole Contraction phase of the cardiac cycle.
Tympanic eardrum.
Korotkoff Sounds only sounds heard during phase I (first sound) & phase V(last sound) are recorded as BP. (classified into 5 phases )
Rate the # of heartbeats in 1 min. In adults average pulse rate is 60 to 100 bpm.
Rhythm the interval between each heartbeat or the pattern of beats.
Volume the strength or force of the heartbeat, can be described as soft, pounding, weak, thread, strong, or full.
Radial Artery Most often used to determine pulse rate.
Inspiration contract diaphragm, breathe oxygen in.
Expiration relax diaphragm, breathe carbon dioxide out.
Respiration the exchange of gases between the atmosphere & the blood in the body. (14-20 in adults per min)
Depth the volume of air being inhaled & exhaled.
Pulse pumping of blood causes expansion & contraction of arteries- heartbeat.
Asymmetry lack or absence of symmetry; inequality of size or shape on opposite sides of the body.
Auscultation 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.
Babinski Reflex reflex exhibited normally by infants. (stroking the sole of the foot to flex the big toe & fan the other toes )
Bimanual Using both hands.
Bruit abnormal sound or murmur in the blood vessels during auscultation.
Cerumen yellowish or brownish wax-like secretion in the external ear canal; Earwax.
Clinical Diagnosis a diagnosis based only on the pts clinical symptoms.
Diagnosis identification of a disease or condition by evaluating physical signs & symptoms, health hx, & lab tests; a disease or condition identified in a person.
Differential Diagnosis a diagnosis made by comparing the pts symptoms to two or more diseases that have similar symptoms.
Extraocular outside the eye, as in extraocular eye movement.
Gait manner or style of walking.
Hernia protrusion of an organ through the muscle wall of the cavity that normally surrounds it.
Inguinal Pertaining to the regions of the groin.
Inspection Visual exam
Lubricant agent that reduces friction.
Manipulation skillful use of the hands in diagnostic procedures.
Nasal Septum wall or partition dividing the nostrils.
Obturator smooth, rounded, removable inner portion of a hollow tube, such as an anoscope, that allows for easier insertion.
Occult Blood blood hidden or concealed from observation.
Palpation 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.
Percussion striking w/ the hands to elevate the size, borders, consistency & presence of fluid or air.
Peripheral Vision side vision while looking straight ahead.
PERRLA Pupils, Equal, Round, Reactive to Light, & Accommodation.
ROM (Range of Motion) in degrees of angle through which a joint can be extended & flexed.
Rectovaginal pertaining to the rectum & vagina.
Sclera white fibrous tissue that cover the eye.
Speculum instrument that enlarges & separates the opening of a cavity to expose its interior for exam.
Symmetry equality in size or shape or position of parts on opposite sides of the body.
Tympanic Membrane thin, semitransparent membrane in the middle ear that transmits sound vibrations; the Eardrum.
Created by: April27
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