This document provides an overview of medical terminology used in patient assessments and examinations. It breaks down terminology into components and provides definitions for key terms related to:
- Taking a patient's history and assessing their current health status and past medical history.
- Techniques used in physical examinations like auscultation, inspection, palpation, and percussion.
- Components of a physical examination and patient assessment, including vital signs, focussed history taking, and the initial on-going assessment of patients.
- Types of patients that require priority care and terms related to assessing the safety of a medical scene.
This document provides an overview of medical terminology used in patient assessments and examinations. It breaks down terminology into components and provides definitions for key terms related to:
- Taking a patient's history and assessing their current health status and past medical history.
- Techniques used in physical examinations like auscultation, inspection, palpation, and percussion.
- Components of a physical examination and patient assessment, including vital signs, focussed history taking, and the initial on-going assessment of patients.
- Types of patients that require priority care and terms related to assessing the safety of a medical scene.
This document provides an overview of medical terminology used in patient assessments and examinations. It breaks down terminology into components and provides definitions for key terms related to:
- Taking a patient's history and assessing their current health status and past medical history.
- Techniques used in physical examinations like auscultation, inspection, palpation, and percussion.
- Components of a physical examination and patient assessment, including vital signs, focussed history taking, and the initial on-going assessment of patients.
- Types of patients that require priority care and terms related to assessing the safety of a medical scene.
TERMINOLOGY By Ms R. Maritz (BSc Human Life Sciences, BEMC,MEMC)
“Words are, of course, the most powerful drug used by mankind.”
― Rudyard Kipling TIPS • Break words down into components • Eg. Neuroblastoma • “Neuro”=nerves • “blast”= immature cells • “oma”= tumour • Study common root words, prefixes and suffixes • Make your own list! TERMINOLOGY 1 • Chief Complaint • A patients Primary Complaint • Clinical Reasoning • Using results from questions to consider associated problems & body system changes related to the pt’s complaint • Current health Status • Current status of pt’s health, environment & personal habits • Family History • Illness or disease in a pt’s family or family’s background that may relate to the pt’s current condition. TERMINOLOGY 2 • History Taking • Information gathered during the pt interview • Present Illness • Identification of the chief complaint & a full clear chronological account of the symptoms • SAMPLE • Significant Past Medical History • A pt’s medical background that may offer insight into the pt’s current problem TERMINOLOGY 3 • Auscultation • A technique requiring the use of a stethoscope used to assess body sounds produced by the movement of fluids or gasses in organs or tissues • Inspection • Visual assessment of the patient and surroundings • Palpation • A technique using ones hands and fingers to gather information from a pt via touch TERMINOLOGY 4 • Percussion • A technique used to assess the presence of air or fluid in body tissues using ones hands and fingers • Physical Examination • An assessment of a pt that includes examination/ assessment techniques incl. vital signs, height, weight and the skilful use of examination equipment • Tidal Volume • The volume of gas inhaled and exhaled during normal breath TERMINOLOGY 5 • Focussed History • A component of pt assessment to ascertain the pt’s chief complaint, history of presenting illness, medical history & current health status • General Impression • An immediate assessment of the environment & pt’s chief complaint used to determine whether the pt is injured or ill & the nature of illness or mechanism of injury • Initial Assessment • A component of the pt assessment to recognise and manage all life- threatening conditions TERMINOLOGY 6 • On-going Assessment • A repeat of the initial assessment that is performed throughout the emergency care provider-pt-encounter • Priority Patients • Pts who need immediate medical care and transport • Scene Size-up • An assessment of the scene to ensure the safety of the ambulance crew, pts and bystanders as well as to determine resources required QUESTIONS
Propaedeutics of intеrnаl medicine as аn introduction to the clinic of internal medicine. Questioning and physical examination of the patient. Еthical and deontological aspects