Chapter 2 Sections Of A Health Record And Terms Flashcards
The main reason for the patient’s visit
Chief complaint
The story of the patient’s problem
History of present illness
Description of individual body systems in order to discover any symptoms not directly related to the main problem
Review of systems
Other significant past illnesses, like high blood pressure, asthma, or diabetes
Past medical history
Any of the patient’s past surgeries
Past surgical history
Any significant illnesses that run in the patient’s family
Family history
Hey record of habits like smoking, drinking, drug abuse, and sexual practices that can impact help
Social history
It just started recently or is a sharp, severe symptom
Acute
It has been going on for a while now
Chronic
It is getting worse
Exacerbation
All of a sudden
Abrupt
To have a fever
Febrile
To not have a fever
Afebrile
More and more each day
Progressive
Not feeling well
Malaise
Something a patient feels
Symptom
Not related to the specific problem
Noncontributory
A decrease in level of consciousness’s; in a medical record, this is generally an indication that the patient is really sick
Lethargic
It runs in the family
Genetic, hereditary
Able to answer questions; responsive; interactive
Alert
Being aware of who he or she is, where he or she is, and the current time
Oriented