Term | Definition |
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. |