medical history and physical examination with complete solutions.
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Course
History and Physical
Institution
History And Physical
legal health record
documentation of healthcare services provided to an individual, in any aspect of healthcare delivery by a healthcare provider organization; contains data that are individually identifiable, stored on any medium and directly used in documenting health care or status
confi...
medical history and physical examination
with complete solutions
legal health record - ANSWER- documentation of healthcare services provided to
an individual, in any aspect of healthcare delivery by a healthcare provider
organization; contains data that are individually identifiable, stored on any
medium and directly used in documenting health care or status
confidentiality - ANSWER- information the patient shares with the physician and
the physician's observations during the course of consultation or treatment are
considered privileged communication
medical history and physical examination reports - ANSWER- document records
baseline information and overall evaluation of the patient's state of health
subjective - ANSWER- symptoms and feelings that the patient describes to the
physician
objective - ANSWER- what the examiner can see, hear, touch
history - ANSWER- first section of medical history and PE; includes CC, PI,
PH,SH, and review of symptoms
CC; Chief Complaint - ANSWER- subjective description of the symptom or
symptoms that caused the patient to seek medical attention; listed in order of
importance; can be described in series of words or a phrase
malaise - ANSWER- vague feeling of bodily discomfort
primary symptoms - ANSWER- directly related to a disease
secondary symptoms - ANSWER- results or consequences of the disease
process
, PI; present illness - ANSWER- includes location, duration, timing, severity,
quality, content, modify factor, and associated signs and symptoms;
PH; Past History - ANSWER- includes any childhood or adult diseases, surgical
procedures, accidents, pregnancies, deliveries, previous illnesses, physical
defects, treatments, medications, and allergies to medications
FH; Family History - ANSWER- include relevant information about family
members; include whether parents are deceased, marital status, history of breast
cancer, heart disease, diabetes
SH; Social History - ANSWER- summarize the patients lifestyle and environment
and determine whether something about the environment may be contributing to
the disease; recent traveling, recreation, drug or alcohol use, occupation, sexual
activity
ROS; Review of Symptoms - ANSWER- exchange between patient and the
physician; physician will ask specific questions and record significant responses
sign - ANSWER- objective, observable, or measurable manifestation of a disease
as noted or observed by the physician or health care practitioner; signs are
accompanied by symptoms
HEENT - ANSWER- Head, Eyes, Ears, Nose, Throat
PE, PX; Physical Examination - ANSWER- usually completed with MH and PE;
objective assessment of the patient
Auscultation - ANSWER- listening for sounds within the body chiefly to determine
the condition of thoracic or abdominal organs; stethoscope
Palpation - ANSWER- feeling with fingers or hands to determine the physical
characteristics of organ or tissues
Percussion - ANSWER- using the fingertips to tap the surface area of the body to
produce sound
Visualization or inception - ANSWER- sight alone
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