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
... [Show More] 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
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 produ [Show Less]