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Medical History
record of past and current health; includes the health of the patient and sometimes, the patient’s family
Chief complaint
the patients description of what they feel is their main health problem
physical signs
pieces of evidence that shows an illness (external)
symptoms
evidence a patient’s disease that they percieve (ache) —> allows the provider to see possible conditions to make a diagnosis
current medical history
Keeps track of what disease/chronic illnesses that are happening now in your current life
past medical history
Keeps track of what happened in your past —> past chronic illness/disease
family history
keeps track of any disease/chronic illness that a family member have because it could be genetic
social history
keeps track of what an idvidual does with themself - if they drink, smoke, workout, etc.
tact
discretion and sensitivty dealing with others (choose words carefully)
demeanor
the way you present yourself towards a patient (smile, cheery will gain people trust)
empathy
the ability to understand and share feelings with another person even if you can’t really relate to them
Heart Rate
the numbers of times a person’s heart beats per minute
vital sign
measurement that indicates the state of a patients essential bodily function
Tool used for heart rate
heart rate monitor, fingers on pulse, fitness tracker
Units for heart rate
beats per minute (bpm)
Normal range for heart rate
60-80 bpm but for older people it is 60-100 bpm
blood pressure
pressure exerted on the walls of the blood vessels (arteries)
Tools used for blood pressure
Bp cuff, sthethoscope, automatic cuff
Units for blood pressure
mmHg
normal range for blood pressure
120/80 mmHg
body temperature
the temperature of a person’s body
tools used for temperature
thermometer
units for body temp
°F or °C
normal range for body temp
98.6°F
respiratory rate
the number of times a person breaths per minute (inahle and exhale count as 1)
tools used for respiratory rate
sthethoscope (disguise it)
units for respiratory rate
breaths per minute
normal range for respiratory rate
12-20 bpm
height
the length of a person from head to toe (not a vital sign)
tools used to measure height
tape measure
units for height
inches (in)
weight
how much a person’s body weighs
tools used for weight
scale
units for weight
pounds (lb) and kilograms (kg)
oxygen saturation
the amount of O2 in the blood: the amount to which hemoglobin is saturated with O2
tools used for oxygen saturation
pulse oximeter
units for oxygen saturation
top (blood saturation) and bottom (pulse)
normal range for oxygen saturation
95%-100% is normal
BMI
ratio of a person’s weight to their height
tools used for BMI
formula or chart
a visual exam of the outside of the eye will be done, opthalmoscope is used to look at the inside of the eye, test pupillary response - penlight (indicates the health of the eye and the nervous system), and testing visual activtity using an eye chart
What happens at an eye exam?
redness, swelling, puss, and discharge can lead to an infection, corneal injury can compromise the safety of the eye and cause pain with blinking, change in color or apperance of the retina can be an indicator of disease
Signs of an eye exam?
do a visual inspection inside: uses an otoscope (light + magnifying glass)
What happens at an ear exam?
pain, dimished hearing, redness, bulging eardrum, fluid behind eardrum: middle ear infection —> occure secondary to something like a cold or flu, impacted cerumen (ear wax) makes it difficult to hear
Signs at an ear exam?
visual inspection outside the nose, otoscope to examine the nasal passages and the throat
What happens at a throat/nose exam?
swollen tonsils area sign of infection, sore throat, painful swalloing, red/infalmmed tonsils/uvula, fever, body aches, swollen lymph nodes, white patches on tonsils: strep, tonsillites: inflamation caused by virus or bacteria - enlarged tonsils, redness, sore throat
Signs at throat/nose exam?
Doctors check to see if the heart has a predicatble beat and rhythm
What happens at heart exams?
classic lub-dub sound with each heartbeat occurs as the two sets of values close in sequence
Normal signs in the heart?
any additional sounds can show a problem with the structure of the heart
Abnormal signs in heart?
doctors/nurses listen to the sounds of lungs to check functioning
What happens during lung exams?
clear inhale/exhale
Normal lung signs?
gurggle, “swoosh” between sounds can be a problem (asthma or allergies)
Abnormal lung signs?
erythrocyte
red blood cells
erythrocyte strcuture
red, biconcave (divets on both sides) discs packed with hemoglobins - no nucleus
erythrocyte function
transport O2 through the body
Elevated red blood cells
indicates possible low O2 and body is making extra red blood cells to deliver more O2
Low red blood cells
anemia (not enough hemoglobin or RBCs to carry O2)
leukocyte
white blood cells
leukocyte structure
varies - has a nucleus
leukocyte function
immune support —> immunity cells
Elevated white blood cells
signs of infection or inflamation
Low white blood cells
body is more vulnerable to infection or disease
thrombocytes
platelets
thrombocytes structure
cell fragments
thrombocytes function
assits in clotting by adhearing to other platelets or ro damages tissue
plasma structure
makes up over 50% of your blood volume; contains mostly water with other solutes; when isolated it turns a pale yellow
plasma function
transport nutrietnts around the body
elevated platelets
blood clots can form when not nescessary; can travel through circulatory system and prevent O2 delivery to tissues
low platelets
prevents effective clotting and can contribute to blood loss
hemoglobin
the protein in RBCs that binds to O2
elevated hemoglobin
usually no symptons but has complications, inclduing blood clots (makes blood red)
low hemoglobin
difficulty with O2 circulation
hematocrit
what % of your total blood is represented by RBCs
elevated hematocrit
RBCs make up more of your total blood volume
low hematocrit
RBCs dont account for enough of your total blood volume
LDL
takes cholestoral out of the body cells that need it
HDL
takes cholesterol from the arteris to the liver for storage
Telehealth
A way to set health services using technology, rather than in person contact
Used on devices - electronic reminders to take medicine and go to appts
How is telehealth used?
people who have busy work schedules, people with disabilities, people with anxiety/depression
Who can benefit from telehealth?
food
How do obtain energy?
carbohydrate
Molecules most avaible source of energy
It enterer the cell through the cell membrane with the help of a glucose transport protein (GTP)
How does glucose enter the cell?
elevated blood glucose
Hyperglycemia - happens when the body has too little insulin or when the body can't use insulin properly