Physical exam

Chief Complaint (CC)

The main reason for the patient's visit to a healthcare provider.

Vital Signs (VS)

Measurements of the body's basic functions, including heart rate, temperature, respiratory rate, and blood pressure.

History of Present Illness (HPI)

A description of the patient's current health condition and the reasons for seeking care.

Past Medical History (PMH)

A record of the patient's previous illnesses, surgeries, allergies, and any other relevant health information.

Empathy

The ability to understand and share the feelings of another person, crucial for creating a therapeutic environment.

Active Listening

A communication technique that involves fully concentrating, understanding, responding, and remembering what the patient says.

Palpation

The examination technique that uses touch to assess tenderness, masses, or other physical characteristics.

Auscultation

The act of listening to the internal sounds of a patient’s body, typically using a stethoscope.

Inspection

The visual examination of the patient in order to assess health and identify any abnormalities.

Patient Education

The process of informing patients about their health conditions, treatments, and lifestyle changes to empower them in their healthcare decisions.

HIPAA

The Health Insurance Portability and Accountability Act, which mandates the protection of patient privacy and confidentiality.

Manipulation

A method of examination that tests a patient's range of motion in joints.

Therapeutic Communication

An interaction that aims to improve and promote the well-being of the patient.

Knee-Chest Position

A position where a patient kneels with the chest on the table, used for specific examinations.

Sims Position

A lateral position often used for examinations of the rectum or vagina.