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