Medical Assisting: Patient Interview, History, Vital Signs, and Measurements

Essential vocabulary and diagnostic concepts covering patient interviewing skills, medical records charting, vital signs assessment, and body measurements.

Mirroring

An interviewing technique in which the interviewer restates exactly what the patient says to confirm and maintain focus.

Verbalizing

An interviewing skill that involves stating what is understood from the patient's remarks.

Clarification

The process of seeking increased understanding of a patient's problem or statement during an interview.

Reflection

An interviewing response based on an opinion or conclusion formed after deeper thought.

Six Cs of Charting

The core criteria required for accurate documentation: Client's words, Clarity, Completeness, Conciseness, Chronological order, and Confidentiality.

Source-Oriented Medical Records (SOMR)

A method of charting and organizing patient records according to the department or professional source providing the information.

Problem-Oriented Medical Records (POMR)

A documentation approach structured systematically around a specific, numbered list of the patient's health problems.

SOAP

A standard progress note charting method organized into Subjective data, Objective data, Assessment, and Plan of action.

PQRST

A systematic interview mnemonic used to evaluate patient symptoms: Provoke or palliative, Quality or quantity, Region or radiation, Severity scale, and Timing.

Polypharmacy

The simultaneous use of multiple medications by a single patient, which must be tracked during medical history intake.

Health History Form

A foundational medical intake document containing personal data, chief complaint, history of present illness, past medical history, family history, social and occupational history, and a review of systems.

Review of Systems (ROS)

A systematic, head-to-toe inventory of symptoms related to each body system obtained during the comprehensive medical history.

Febrile

A clinical state characterized by an elevated body temperature; having a fever.

Afebrile

The condition of having a normal body temperature; being without a fever.

Hyperpyrexia

An exceptionally high and dangerous elevation of body temperature.

Tachycardia

An abnormally fast resting heart rate or pulse rate.

Bradycardia

An abnormally slow resting heart rate or pulse rate.

Pulse Oximetry

A noninvasive monitoring method used to measure arterial blood oxygen saturation and identify conditions such as hypoxia and sleep apnea.

Dyspnea

Difficult, painful, or labored breathing.

Apnea

The temporary cessation or complete absence of respiration.

Tachypnea

An abnormally rapid rate of respiration.

Hyperpnea

Abnormally deep or rapid breathing.

Rales

Abnormal, adventitious crackling or rattling breath sounds heard during lung auscultation.

Rhonchi

Whistling, snoring, or coarse rattling sounds heard in the chest caused by secretions in the bronchial airways.

Aneroid Sphygmomanometer

A mechanical device with a circular dial gauge calibrated in $\text{mmHg}$ used alongside an inflatable cuff to measure blood pressure.

Apex of the Heart

The lower, pointed anatomical tip of the heart where apical pulse auscultation is performed.

Brachial Artery

The major artery located at the antecubital space where the stethoscope diaphragm is positioned to auscultate systolic and diastolic Korotkoff sounds during blood pressure measurement.

Orthostatic Hypotension

A form of low blood pressure that occurs when a patient experiences a significant drop in blood pressure upon shifting from lying down to sitting or standing.

Positive Tilt Test

A clinical test result where positional changes induce significant changes in blood pressure and heart rate, confirming postural hypotension or autonomic dysfunction.

Body Mass Index (BMI)

A calculated measure correlating height and weight to assess weight status, defining categories such as healthy weight ($18.5$ to $24.9$), overweight ($25$ to $29.9$), and obese ($\ge 30$).

Radial Artery

The artery at the wrist compressed against the radius to determine a patient's pulse count for $1\,\text{minute}$.

Hypertension

A condition characterized by chronically elevated arterial blood pressure above established physiological thresholds.

Hypotension

A condition defined by abnormally low arterial blood pressure.