Fall 2020 Introduction to Elements of Physical Assessment

Vocabulary flashcards covering the major terms and definitions from the physical assessment lecture notes.

Chief Concern (CC)

Reason for seeking care; the patient's problem described in the patient’s own words (often in quotes).

History of Present Illness (HPI)

Chronological account of the chief complaint and its context; may use forward or backward chronology; should include location, radiation, quality, severity, timing, setting, associated manifestations, aggravating/relieving factors, and impact.

Past Medical History (PMH)

Medical background including childhood illnesses, immunizations, adult medical illnesses, communicable diseases, surgeries or hospitalizations, medications, allergies, and disabilities when relevant.

Childhood Illnesses

Examples include measles, mumps, chickenpox, pertussis, strep throat, rheumatic fever, scarlet fever, polio, smallpox, diphtheria, and chronic ear infections.

Immunizations

Vaccinations such as MMR, polio, DPT, flu, pneumococcal, varicella, hepatitis B, meningitis, PPD/TB testing; status should be noted.

Adult Medical Illnesses

Common chronic conditions to ask about, e.g., myocardial infarction (MI), cerebrovascular accident (CVA), diabetes mellitus (DM), hypertension (HTN), cancer, peripheral vascular disease (PVD), angina, COPD, asthma, GERD, renal or liver disease, thyroid problems.

Communicable Diseases

Diseases that can be transmitted between people, such as AIDS, STDs, herpes, hepatitis; note symptoms, treatments, and complications when known.

Surgeries/Serious Injuries/Hospitalizations

Record of past surgeries, serious injuries, accidents or hospitalizations, including dates and sequelae.

Medications

All prescription and over-the-counter drugs, and herbals; include dose and frequency.

Allergies

Allergic reactions to medications, foods, environmental factors, or insects; include type of reaction and treatment used.

Disabilities/Handicaps

Type of limitation, required support, and how the patient manages the condition.

Other Health Information

Additional items such as GYN history, blood transfusions, emotional status, or alcoholism as relevant to care.

Family History (FH)

Health status and age of blood relatives; aim to cover two generations and identify hereditary diseases; may be recorded in a pedigree.

Pedigree Diagram

A chart that records family history across generations to visualize hereditary patterns.

Current Health Status (CHS)

Personal and social history including factors such as birthplace, ethnicity, educational level, home environment, marital status, religious practices, and economic status.

Personal Status

Detailed biographical and social attributes: birthplace, ethnicity, education, home environment, marital/relationship status, religion, economic status.

Occupation

Description of work, working conditions, and exposure to hazardous substances.

Habits

Patterns such as caffeine intake and alcohol or drug use.

Activities of Daily Living (ADL)

Daily living patterns including sleep, diet, exercise, and use of remedies or alternative therapies.

Sexual Practices

Sexual activity and practices relevant to health history and risk assessment.

Hobbies/Interests/Leisure

Engagement in hobbies, interests, and leisure activities.

Stress

Sources of stress and methods used to manage it.

Travel History

Recent travel history, especially outside the US, and any military service.

Health Habits and Checkups

Last physical exam and screening tests (PAP, PSA, CXR, eye and dental exams, BSE/TSE, etc.).

Review of Systems (ROS)

Systematic questioning to determine if the chief complaint relates to any major body system; note positive or negative responses.?

Inspection

Observation of the patient using sight (and other senses) as part of the examination; performed throughout history and physical exam.

Palpation

Touch used to gather objective information; light palpation (up to 1 cm) and deep palpation (1–4 cm); areas of pain are assessed last.

Percussion

Striking one object against another to produce vibrations and sounds; common notes include flat, dull, resonance, hyper-resonance, and tympany.

Auscultation

Listening to body sounds, usually with a stethoscope; sounds are often assessed with a Bell (low frequency) and a Diaphragm (high frequency).

Bell (Stethoscope)

A small, concave instrument used to hear soft, low-frequency sounds.

Diaphragm (Stethoscope)

A flat, wide-surfaced part of the stethoscope used to hear high-frequency sounds.