1. Chief Complaint (CC):
- The primary reason a patient seeks help. This is typically captured in response to questions like
"What's wrong?" or "What happened?"
2. History of Present Illness (HPI):
- Provides details about the chief complaint, offering a chronological account of how the patient’s
current illness developed, starting from the first sign or symptom or from the last visit.
3. Vital Signs:
- Temperature, pulse, respiration, and blood pressure are all objective measurements.
4. Normal Oral Temperature:
- Ranges from 97.6°F to 99.6°F.
5. Intermittent Fever:
- A fever that alternates between elevated and normal or subnormal body temperatures.
6. Remittent Fever:
- A fever in which the temperature fluctuates significantly but never returns to normal levels.
7. Continuous Fever:
- A fever that stays consistently above the baseline and does not fluctuate.
8. Normal Pulse Rate:
- Between 60-100 BPM (beats per minute).
9. Respirations:
- The rate, rhythm, and depth are important metrics when measuring breathing.
, 10. Systole:
- The phase of heart contraction.
11. Diastole:
- The phase of heart relaxation.
12. Anthropometric Measurements:
- Includes measurements of height (length for infants), weight, BMI, head circumference in infants,
waist-to-hip ratio, and body fat percentage.
13. Inspection:
- Involves evaluating general appearance, nutritional status, body habits, symmetry, posture and gait,
and speech.
14. Palpation:
- The examination of the body through touch.
15. Percussion:
- A physical examination technique that involves tapping the body to produce sounds and vibrations
to assess size, borders, or fluid content in areas like the chest.
16. Auscultation:
- The process of listening to sounds within the body (like those from the lungs or heart) to aid in
diagnosis and treatment.
17. OSHA (Occupational Safety and Health Administration):
- A government agency under the Department of Labor aimed at ensuring a safe and healthy work
environment.