Physical Examination and Patient Communication

A comprehensive set of vocabulary flashcards to aid in the study of physical examination concepts and patient communication skills.

Chief Complaint (CC)

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

History of Present Illness (HPI)

A detailed description of the development and progression of the patient's current health issue.

Past History (PH)

A record of the patient's previous medical conditions and treatments.

Vital Signs (VS)

Measurements of bodily functions such as temperature, pulse, respiration, and blood pressure.

Pain Score

A subjective assessment of pain intensity typically measured on a scale from 1 to 10.

Empathy

The ability to understand and share the feelings of another, essential for building therapeutic relationships.

Active Listening Techniques

Methods used to fully engage in a conversation by attentively hearing and interpreting the speaker's message.

Nonverbal Communication

Communication conveyed through body language, facial expressions, gestures, and other visual cues.

Open-Ended Questions

Questions that require more than a yes or no answer, encouraging detailed responses from patients.

Closed-Ended Questions

Questions that limit responses to typically one word or a short phrase, often used for specific information.

Therapeutic Communication

An interactive process that promotes the well-being of patients and facilitates understanding.

Documentation

The process of recording patient information and care in their medical records.

Patient Education

The process of informing patients about their health conditions and treatment options.

Therapeutic Techniques

Methods used to facilitate patient expression and understanding, including summarizing and reflecting.

Standard Precautions

Infection control practices used to protect both healthcare providers and patients.

Fowler Position

A sitting posture in which the patient is at a 45- to 60-degree angle to aid comfort and respiratory function.

Supine Position

A position in which the patient lies flat on their back.

Dorsal Recumbent Position

A position where the patient lies on their back with knees bent.

Lithotomy Position

A position where the patient lies on their back with legs raised and spread apart, commonly used for gynecological examinations.

Sims Position

A position where the patient lies on their side with one leg drawn up, typically used for rectal examinations.

Prone Position

A position where the patient lies flat on their stomach.

Body Mechanics

The study of proper body movement during physical activity to prevent injury.

Inspection

A method in physical examination where the provider observes the patient for signs of illness.

Palpation

An examination technique where the healthcare provider uses their hands to feel the patient's body for abnormalities.

Percussion

A technique in which the provider taps on specific body areas to assess the underlying structures.

Auscultation

The process of listening to internal body sounds, often using a stethoscope.

Patient-Centered Care

An approach to healthcare that respects and responds to individual patient preferences, needs, and values.

HIPAA

Health Insurance Portability and Accountability Act, which protects patient privacy and confidentiality.

Therapeutic Environment

A setting that supports the well-being of patients, promoting comfort and safety.

Patient Interview

A structured interaction aimed at gathering comprehensive information about a patient's health.

Documentation Guidelines

Protocols that govern the proper recording of patient information and care provided.

Patient Coaching

Guiding patients in understanding their health information and health management.

Self-Boundaries

Limits set by healthcare providers to maintain professional relationships with patients.

Diversity in Healthcare

Recognizing and respecting differences in patients, including cultural, racial, and religious factors.

Feedback

The information given back to the patient or provider to enhance understanding and care.

Medical Assistant’s Role

Assisting with patient care, documentation, and preparation for examinations in a healthcare setting.

Consent Forms

Documents signed by patients to grant permission for treatment and sharing of their health information.

EHR (Electronic Health Record)

A digital version of a patient's paper chart that contains medical history and treatment information.

Personal Space

The physical distance individuals maintain while interacting with others, important in patient communication.

Clinical Equipment

Tools and instruments used during a physical examination, such as stethoscopes and ophthalmoscopes.

Patient Rapport

A trusting relationship developed between a healthcare worker and a patient.

Documentation in EHR

Recording patient information in a digital format to ensure efficiency and accessibility.

Therapeutic Relationships

Connections cultivated with patients to provide effective care and support.

Cardinal Symptoms

Symptoms that carry significant diagnostic importance in assessing a patient's condition.

Symptom vs. Sign

Symptoms are subjective findings reported by the patient, while signs are objective findings observed by the provider.

Disinfection Protocols

Procedures for cleaning and sanitizing medical environments to prevent infection.

Pain Intensity Scale

A scale used by patients to self-report the severity of their pain.

Patient Interviews

Structured conversations aiming to gather detailed information about a patient's health history.

Mental Status Examination

An assessment method to determine a patient's cognitive function and emotional state.

Referral Process

The procedure for directing a patient to a specialist for further evaluation or treatment.

Specimen Collection

The process of obtaining biological samples from patients for testing purposes.

Integration of Communication Styles

Adapting communication methods based on the patient’s age, background, and situation.

Visual Inspection

An initial observation technique that assesses the general appearance and conditions visible on the body.

Physical Examination Techniques

Methods used to evaluate a patient’s physical condition and health status.

Comfort Measures

Actions taken to ensure a patient’s comfort during medical examinations.

Documentation of Medical History

The comprehensive recording of a patient's past health experiences and issues.

Crisis Communication

Communication strategies implemented during urgent and high-stress situations in healthcare.

Patient Safety Protocols

Guidelines designed to protect patients during healthcare delivery.

Verbally Explaining Procedures

Describing medical procedures thoroughly to patients to enhance their understanding.

Measuring Body Mass Index (BMI)

A calculation to assess body weight in relation to height, used to categorize nutritional status.

Medical Supplies

Instruments and materials necessary to perform medical examinations.

Documentation of Observation

The record of visual assessments done by healthcare providers during patient interactions.

Charting

The systematic process of recording patient assessments, interventions, and outcomes.

Patient Consent

Approval given by the patient for healthcare treatment and procedures after being informed.

Privacy Considerations

Measures taken to protect patient information and confidentiality in all healthcare interactions.

Interpersonal Skills

Skills required to effectively communicate and interact with patients and colleagues.

Clinical Procedures

Standardized methods followed during patient examinations and treatment.

Health Care Delivery Models

Various structured approaches designed to provide patient care and support.

Professional Boundaries

Guidelines that help maintain a helpful and appropriate relationship between healthcare providers and patients.

Documentation Accuracy

The importance of ensuring all recorded patient information is correct and up-to-date.