Building a Medical History Flashcards
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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 illness that can be observed externally, such as rash, coughing, or elevated temperature.
Symptoms
Any subjective evidence of disease a patient perceives, such as aches, nausea, or 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 diagnosis.
Diagnosis
The process of determining which disease or condition explains a person’s symptoms and signs.
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
Vital Signs
Measurements-specifically pulse rate, temperature, respiration rate, and blood pressure-that indicate the state of a patient’s essential body functions.
Homeostasis
The maintenance of stable internal physiological conditions (like body temperature or the pH of blood), which enables the optimal functioning of an organism.
Pulse
The rhythmic expansion and recoil of arteries resulting from heart contraction.
Respiratory Rate
The number of breaths an organism takes per minute.
Blood Pressure
The pressure that blood exerts upon the walls of blood vessels, especially arteries, usually measured with a sphygmomanometer and expressed in millimeter of mercury.
Triage
The sorting and prioritization of patients based on the urgency of their need for care.
Erythrocyte
Hemoglobin-rich, red blood cells that transport oxygen through a body. Erythrocytes give the red color to vertebrate blood and do not have nuclei.
Leukocyte
One of the many cells in the blood that lack hemoglobin but have a nucleus and are active in the immune response. Lymphocytes, monocytes, neutrophils, eosinophils, and basophils are leukocytes.
Thrombocyte
A minute, colorless, anucleate disk-like body of mammalian blood that assists in blood clotting by adhering to other platlets and damaged epithelium
Plasma
The pale yellow, liquid portion of blood that consists of water and dissolved substances, including sugars, lipids, metabolic waste products, amino acids, hormones, and vitamins.
Complete Blood Count (CBC)
A blood test that is run as part of a routine exam or if there are signs or symptoms that may indicate a potential condition impacting blood cells.
Hemoglobin (HB/Hgb)
The oxygen-carrying protein in red blood cells.
Hematocrit (HCT)
The proportion of red blood cells in the blood.
Platelets
The cell fragments that assist with clotting.
Cholesterol
A lipid that is an essential component of animal cell membranes and acts as a precursor molecule for the synthesis of other biologically important steroids.
Risk Factor
A behavioral, environmental, genetic, physiological, or demographic attribute that increases risk or susceptibility.
Low Density Lipoprotein
Type of lipoprotein responsible for transporting cholesterol to the cells.
High Density Lipoprotein
Type of lipoprotein responsible for removing excess cholesterol from the blood stream and transporting it to the liver.
Metabolism
The chemical reaction process of breaking down molecules for energy and of using simple building blocks to build up more complex molecules needed for growth and repair.
Hormones
A signaling molecule produced by glands, A hormone induces a specific effect on the activity of cells.
Glucose
Glucose is a simple sugar that the body uses for energy, High levels of glucose in the blood may indicate risk for diabetes.
Electrolytes
Minerals found in your blood, urine, and other tissues. Electrolytes such as sodium, calcium, potassium, and chloride help keep a water balance in the body, move nutrients into cells and wastes out, and make sure that your nerves brain, muscles, and heart function properly.
Referrals
Written order from a primary care doctor for a patient to see a specialist or to get a particular medical service, such as physical therapy after an injury,
Telemedicine
A new frontier in health care translating to “healing at a distance.”
Telehealth
A way for individuals to remotely access health-related services using technology, rather than in-person contact.
Type 1 Diabetes
A form of diabetes that usually develops during childhood or adolescence. Type 1 is characterized by a severe deficiency of insulin, leading to high blood glucose levels.
Biomolecule
A large molecule, or macro molecule, produced by living organisms. Examples include: nucleic acids (DNA and RNA), carbohydrates, proteins, and lipids.
Chemical Reactions
A process where atoms and/or molecules are rearranged to transform matter.
Adenosine tri-phosphate (ATP)
A compound composed of adenosine and three phosphate groups that supplies energy for many biochemical cellular processes.
Carbohydrates
A compound, such as sugar, starch and cellulose, found in foods and living tissues that can be broken down and used for energy.
Insulin
A protein hormone secreted by the pancreas; essential for the metabolism of carbohydrates and the regulation of glucose levels in the blood.
Hyperglycemia
High blood glucose level.
Type 2 Diabetes
A form of diabetes that develops especially in adults, most often obese individuals. Type 2 is characterized by high blood glucose resulting from impaired insulin use coupled with the body’s inability to compensate with increased insulin production.
Negative Feedback
A mechanism of homeostasis in which a change in physiological variable triggers a reduction in another variable.
Positive Feedback
A mechanism of homeostasis in which a change in a physiological variable triggers an increase in another variable.
