2.1.1 Building a Medical History Flashcards
Medical History
A record of information about a patient’s past and current health. Includes information about the patient’s habits, lifestyle, and even the health of their family.
Chief Complaint
The patient’s description of what they feel is their main health problem.
Physical Signs
Pieces of evidence that indicate an illness that can be observed externally, such as a rash, coughing, or elevated temperature.
Symptoms
Any subjective evidence of a disease a patient perceives such as aches, nausea, and fatigue. Symptoms allow the health care provider to narrow down the possible conditions that may be affecting the patient and then run tests to make a diagnosis.
Current History
Patient’s chief complaint and other health issues, symptoms, and any treatments or tests the patient has recently had or is scheduled to have related to these conditions. Nutrition, allergies, medication, and health habits are also part of current history.
Previous History
Includes information about any past health issues, procedures, medications, vaccinations, and previous hospital stays.
Social History
Addresses aspects of the patient’s life, such as living situation, occupation, school, travel, and other activities that could have a direct or indirect impact on health.
Family History
Includes medical information about the patient’s close relatives.
Demeanor
Outward behavior or bearing. A doctor might have a cheerful, peaceful, or friendly demeanor and put the patient at ease. A doctor with an arrogant or dismissive demeanor might lose a patient’s trust.
Tact
Discretion and sensitivity in dealing with others. A doctor might exhibit tact when they choose their words carefully so as to not upset a patient when they must deliver bad news.
Empathy
The ability to understand and share the feelings of another person.
