History Taking
The patient’s own words describing the reason for the visit
What is the chief complaint?
Information reported directly by the patient
What is subjective data?
Using touch to assess texture, tenderness, and temperature
What is palpation?
Height and weight used to estimate body fat
What is body mass index (BMI)?
A list of possible diagnoses ranked by likelihood
What is a differential diagnosis?
A chronological description of symptom onset, course, and characteristics
What is the history of present illness (HPI)?
Problem list is documented in this section
What is the assessment?
Findings expected in a healthy patient
What are normal findings?
Rate, rhythm, depth, and effort of breathing
What is respiratory assessment?
Interpreting findings to explain the patient’s problem
What is clinical reasoning?
A systematic head-to-toe symptom inquiry
What is the review of systems (ROS)?
This type of note includes admission diagnosis and date, summary of hospital course, procedures, etc.
What is the discharge Summary?
Body system with sequence of inspection, palpation, range of motion
What is musculoskeletal system?
Overall impression of the patient’s appearance and behavior
What is the general survey?
A pattern of clues or clinical characteristics that trigger a memory response to a clinician's previously learned information
What is an illness script?
Topic in sexual history assessment related to trauma/violence
What is Plus from 5 P's?
Legal record of patient care
What is the medical record?
Exam maneuvers directed by diagnostic hypotheses
What is a focused physical examination?
Awareness of self and environment
What is level of consciousness?
Using data to confirm or refute working diagnoses
What is hypothesis testing?
The organ system that has the following ROS: dizziness, fainting, numbness or loss of sensation
What is neurologic system?
Used to describe medical services and procedures for billing, insurance processing, and medical record-keeping
What is current procedural terminology (CPT) codes?
Body system includes the technique of having patient press hands to waist and then raise over head while inspecting body system
What is breast and axillae?
A silent interval that may be present between the systolic and diastolic pressures
What is the auscultatory Gap?
A clinical cognitive error that seeks supportive evidence for a diagnosis at the exclusion of more persuasive info refuting it
What is confirmation bias?