RCP 101 Vocab chapter 1

Vocabulary terms, medical abbreviations, symptoms, and clinical assessment concepts for RCP 101.

Diagnosis

The process of identifying the nature & cause of illness.

Differential diagnosis

The term used when signs and symptoms are shared by many diseases & the exact cause is unclear.

Comorbidities

Medical conditions that coexist alongside a primary diagnosis and affect health, including treatment and outlook. Common examples among hospitalized people include hypertension, diabetes, and chronic lung disease.

Signs

Objective findings that can be seen or observed, such as color, retractions, and nasal flaring.

Symptoms

Subjective experiences reported by the patient, such as pain, double vision, or difficulty breathing.

Leading question

A question formatted to prompt a specific answer (e.g., "Does your chest hurt on the left?") rather than an open-ended inquiry (e.g., "Tell me about your pain.").

Dyspnea

A subjective feeling or sensation of breathing discomfort.

Breathlessness

Sensation of an unpleasant urge to breathe, which can be caused by conditions such as hypercapnia.

Hypercapnia

High levels of $\text{CO}_2$ in the blood.

Acidosis

A state in which the pH of the blood is in the acidic range.

Hypoxemia

Low levels of oxygen ($\text{O}_2$) in the blood.

Orthopnea

Dyspnea that is triggered when the patient is in the reclining position (e.g., "2 pillow orthopnea").

WOB

Work of Breathing.

CHF

Congestive Heart Failure.

SOB

Shortness of Breath.

CC

Chief Complaint.

PMI

Past Medical History (noted as Past Medica History in source notes).

ADL

Activities of Daily Living.

NPO

Nothing by Mouth.

HOH

Hard of Hearing.

DNR

Do Not Resuscitate. Note that this does not mean do not treat anything else.

Characteristics of a cough

Descriptive qualities of a cough including dry/loose, morning/night, productive/nonproductive, and acute/chronic.

FB

Foreign Body.

Sputum

Mucus from lower airways expectorated through the mouth.

Purulent

Sputum containing pus cells.

Fetid

Foul smelling sputum.

Hemoptysis

Coughing up blood.

Hematemesis

Vomiting blood.

Pleuritic Chest pain

Chest pain located laterally or posteriorly, presenting as sharp pain with deep breathing; associated with lung issues.

Non pleuritic Chest pain

Chest pain located in the center of the chest, which may radiate to the shoulder/arm and is not affected by breathing; associated with heart or gallbladder disease.

Pedal edema

Swelling of the lower extremities, which could be pitting, most often due to heart failure.

HPI

History of Present Illness.

PMH

Past Medical History.

Pack Years

Formula for measuring smoking history: $\text{Pack(s) smoked per day} \times \text{number of years smoked}$.

Physical Exam

Examination consisting of INSPECTION, PALPATION, PERCUSSION, and AUSCULTATION.

LOC

Level of consciousness or sensorium, evaluated by orienting to time, place, person, and situation.

VS

Vital signs, including Temp, HR or pulse, RR (respiratory rate), BP (blood pressure), and $\text{SpO}_2$ (oxygen saturation).

Living Will

Written instructions regarding the patient's wishes if the patient cannot communicate.

Health Care Proxy

An arrangement where the patient has designated a decision maker.

MOLST form

Medical orders for seriously ill patients regarding treatment preference and actionable items in the healthcare setting (more specific).

Tachycardia

HR greater than 100 bpm

Bradycardia

HR less than 60 bpm

Tachypnea

Respiratory rate greater than 20 breathes/min

Bradypnea

Respiratory rate less than 10 breaths/min

Pulse pressure

Different between systolic and diastolic (30-40mg Hg is normal)

Hypertension

Elevated blood pressure, can be staged

Hypotension

Low blood pressure

Supine

Laying on back

Prone

Laying on stomach