Chief Complaint - the reason why the patient came to see the physician. History of Present Illness - explanation of the CC to determine the onset of the illness. Past,family,and social history - summary of personal and family health problems as well as social to include marital status, occupation, use of drugs, etc. Body Processes necessary for life: - Body Temperature, Respiration, Heart Function Vital Signs of body function: - temperature, pulse, respiration, blood pressure Febrile - presence of fever afebrile - absence of fever intermittent fever - fluctuating fever that returns to or below baseline remittent fever - fluctuating fever that remains elevated and does not return to baseline continuous fever - fever that remains constant; does not fluctuate axillary temperature - least accurate; taken under the arm tympanic temperature - useful for children; placed in the ear rectal temperature - per rectum; most effective normal adult pulse range - between 60-100 bpm apical pulse - taken over the apex of the heart by auscultation normal respiration rate - 12-20 per minute (Adults) apnea - temporary complete absence of breathing tachypnea - respiration rate greater than 40 per minute bradypnea - decrease in the numbers of respiration cheyne stokes - regular pattern of irregular breathing rate Downloaded by Denis Munene (munenedenis957@gmail.com) lOMoARcPSD|16310140 orthopnea - decrease in numbers of respiration hypoventilation - reduced amount of air enters the lungs resulting in decreased oxygen level hyperpnea - abnormal increase in the depth and rate of breathing hyperventilation - increased amount of air entering the lungs Systole - the highest amount of pressure exerted during the cardiac cycle Diastole - the lowest amount of pressure exerted during the cardiac cycle Palpation - the sense of touch to determine the characteristics of an organ system Percussion - tapping or striking the body to determine the position, size and density of the underlying organ/tissue Auscultation - listening to sounds produced by internal organs Horizontal Recumbent Position - patient lies on back w/legs extended (used for most physical exams) Dorsal Recumbent Position - patient lies on back with knees flexed and soles of the feet flat on the bed Fowler's Position - semi/sitting position where back of the table is elevated. Dorsal Lithotomy Position - patient lies on back with knees flexed, legs seperated and thighs are acutely flexed. feet are usually in stirrups, Prone position - patients lies on abdomen with head turned to side Sim's position - patient lies on left side with right knee flexed against the abdomen and left knee slightly flexed knee-chest position - patient is on knees with chest resting on the bed and elbows resting on the bed above head OSHA - Occupational Safety and Health Administration external hemorrhage - controlling the bleeding is most effectively accomplished by elevating the affected part above heart level Shock - occurs when there is insufficient return of blood flow to the heart