CLPA Definitions Part 1

Subjective data

Information reported by the patient or caregivers (e.g., symptoms, history).

Sources: Patient interview, medical records, family members.

Objective data

Measurable and verifiable findings (e.g., physical exam, lab tests, imaging).

Sources: Vital signs, lab reports, diagnostic tests.

SOAP

Subjective, objective, assessment, plan

Chief complaint (CC)

History of present illness (HPI)

Past medical history (PMH)

Past surgical history (PSH)

Family history (FH)

Social history (SH)

Review of systems (ROS)

Supine

Prone

Latera recumbent

Fowler’s positon

Sagittal plane

Coronal (frontal) plane

Transverse (horizontal) plane

Front vs back

Anterior (ventral) vs posterior (dorsal)

Above vs below

superior (cranial) vs inferior (caudal)

Medial vs lateral

toward the midline vs away from the midline

Proximal vs distal

closer to vs farther from the trunk

Inspection

Visual examination for abnormalities (e.g., skin lesions, posture).

Auscultation

Listening to internal sounds (e.g., heart, lungs, bowel).

Palpation

Using hands to assess texture, temperature, tenderness (e.g., lymph nodes, abdomen)

Percussion

Tapping body parts to assess density (e.g., dullness over liver, tympany over stomach)

Rectal temperature (measurement)

closest to core temperature, most accurate

Digital Thermometers

Reliable for oral, rectal, and axillary use.

Infrared Tympanic Thermometers

Accurate when placed correctly in the ear

Mercury Thermometers

Historically accurate but less commonly used due to safety concerns.

Temporal Artery Thermometers

Convenient but may be less precise in some conditions.

Manual (Sphygmomanometers)

Mercury or aneroid types, require skill.

Digital (Sphygmomanometers)

Automatic, convenient but may require calibration.

Ambulatory BP Monitors

Used for continuous monitoring over 24 hours.

Orthostatic hypotension

 A drop in systolic BP (≥20 mmHg) or diastolic BP (≥10 mmHg) upon standing.

Radial artery

Most commonly used, at the wrist.

Carotid artery

Neck, for quick assessment.

Brachial artery

Inside of the elbow, often for infants.

Femoral artery

Groin, used in critical patients.

Dorsalis pedis

__ & posterior tibial arteries: Foot, for assessing circulation

Pulse obliteration pressure

The pressure at which the radial pulse disappears when inflating the cuff.

This prevents overinflation and ensures accuracy.

Auscultatory gap

A phenomenon where Korotkoff sounds temporarily disappear after their first occurrence and reappear later.

This can lead to an underestimation of systolic BP.