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Chapter 1 Physical Examination and History Taking

Key Terms for this chapter

AB
Objective DataData found during the physical examination
Universal PrecautionsDesigned to prevent transmission of bloodborne pathogens
Tongue DepressorUsed during the physical assessment to evaluate the back of the throat
ThermometerUsed to assess a patient's temperature
OtoscopeUsed to evaluate the ear canal
Personal HistoryDescribes educational level, family of origin, current household, personal interests, and lifestyle
Identifying DataName, Date of Birth, Social Security Number
InspectionFirst step in the assessment process
Chief ComplaintWhat brought the patient to the clinical setting
Focused AssessmentAssesses symptoms restricted to a specific body system
History of Present IllnessAmplifies the chief complaint; describes how each symtom developed
AuscultationThe act of listening to different areas of the body
Standard PrecautionsPrinciple that all blood, body fluids, secretions, exretions may contain transmissible infectious agents
PercussionUse of third fingers on each hand to produce a striking sound; used to assess deep organ placement
Review of SystemsInformation provided by the patient that assesses a specific body system
StethoscopeUsed to listen to different areas of the body
PalpationUse of the pad of the fingertips to assess a patient by applying pressure
Comprehensive AssessmentIncludes all elements of the health history
Subjective DataInformation that is provided by the patient
SphygmomanometerUsed to assess blood pressure


Health Science Technology Instructor
Carl Wunche High School
Spring , TX

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