MA Chapter 32, 34 & 35 Flashcards
Family History
FH
Includes a health inventory of the patient’s immediate blood relatives.
Chief Complaint
CC
The main reason the patient has come to see the Dr. Assess by asking,” what brings you to see the Dr. Today?”
Gait Belt
Device used to transfer people from one position to another.
Hemiplegia
Partial paralysis of one side of the body.
History of Present Illness
HPI
Present Illness
PI
On going medical problems. Reasons for visit. Tx rec’d. How effective? Medication used, allergies?
Metastasis
Process of malignant tumor invading or spreading to other tissues in the body.
Objective
Concrete and factual
Occupational History
OH
Jobs a patient has or has had.
Past Medical History
Past History
PH
Summary of a patient’s past medical history.
Radiate
To spread out from
Review of Systems
ROS
An inventory of body systems obtained through a series of questions seeking to identify signs and symptoms that the patient may be experiencing.
Sign
Something that can be measured, an objective finding.
Social History
SH
Overview of a patient’s lifestyle including smoking, education, exercise and occupation.
Symptom
Something that a patient can describe but that cannot be measured or seen. Subjective data.
Subjective
Information provided by patient that cannot be proven.
d/c
c/o
Discharge, discontinue
Complains of
DOB
Date of Birth
Dx
Tx
Rx
Diagnosis
Treatment
Prescription
NKA
N&V
SOB
S/S
No Known Allergies
Nausea & Vomiting
Shortness of Breath
Signs & Symptoms
Inspection
Visual observation
Palpatation
Tactile, feeling
Percussion
Tapping with instruments or fingers and listening to the sound.
Auscultation
Listening with sthethoscope.
Mensuration
Measurements
Bruit
Blowing sound heard heard in narrowing arteries.
Manipulation
ROM, Range of Motion passive movement.
Rales
Crackling sounds heard on inspiration.
Rhonchi
Wheezes heard on inspiration.
Urinalysis
Analysis of urine.
Blood Chemistry
Chemicals, electrolytes, in blood serum
Spirometry,
Type of test that measures lung volume capacity over time.
Differential Diagnoses
Determination of nature of disease that pt has. This is done by interviewing, exam and process of elimination.
Cytology
Study of cells
Speculum
Instrument used to open up vagina for exams, or other body cavities.
Myopia
Near sightedness.
Hyperopia
Farsightedness
Occluded
Blocks one eye.
Presbyopia
Difficulty with near vision due to aging .
Cerumen
Ear wax
Audiometer
Istrument that measures hearing. Loudness measured in dB, decibels- different pitches, tones and volumes.
Obturator
Smooth round end that can be removed.
Occult Blood
Means hidden blood
Guaiac
Developer for the test for hidden blood
Endoscope
Instrument put into body cavity to view internal structure
Decibel
Measurement of loud or soft sounds
Dysplasia
Abnormal development of tumor.
Hernia
Protrusion on an organ through a weakness in a muscle.
Menopause
Permanent cessation of the menstrual cycle.
Post-menopausal
After menopause
Quadrant
Clinical division of the abdominal area into 4 parts.
Refraction
Bending of light rays as they pass wfrom one medium to another.
CBC ECG EKG ENT LMP
Complete Blood Count Electrocardiogram Electrocardiogram Ears, Nose, and Throat Last Menstrual Period
HEENT
PEERLA
ROM
R/O
Head, Eyes, Ears, Nose and Throat
Pupils Equal, Round, Reactive to Light & Accomodation (normal)
Range of Motion
Rule Out
OD
OS
OU
UA
Right Eye
Left Eye
Both Eyes
Urinalysis
