Physical exam Flashcards
A statement in the patient’s own words that describes the reason for the visit is called:
chief complaint (CC)
When documenting a patient’s allergies in a paper record, they are typically written in ___ ink.
red ink
Which type of communication technique is utilized in order to encourage the patient to respond in more detail?
open-ended
Which instrument is used to examine and view the ears?
otoscope
What term defines a physician listening to the patient’s heart or digestive organs?
auscultation
to measure
mensuration
Which word is an electrical recording or graph of the heart?
electrocardiogram
Which position will the patient be placed in for symptoms of shock?
Trendelenburg
A patient comes in for an examination of external hemorrhoids. Which position should the patient be positioned in for this exam?
Sims
A tuning fork is used to check the patient’s auditory acuity and bone vibration, as well as:
diabetic peripheral neuropathy.
questions that provide a guide to the patient’s general health and help detect conditions
Systems review (SR) or review of systems (ROS)
Record of a patient’s demographic information, along with the history, physical examination, and initial lab findings
Database
Subjective findings
symptoms, they are what the patient feels and can be interpreted only by the patient.
Objective findings
signs, They are the indicators of health or disease that a provider detects when examining a patient.
closed questions
ask for specific information. This form of questioning limits the answer to one or two words—in many cases, yes or no.