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
