Activity 2.1.1 Building a Medical History

diagnosis

Identification of an injury or disease

Components of a Medical History: Previous History

Includes information about any past health issues, procedures, medications, vaccinations, and previous hospital stays.

Components of a Medical History: Family History

Includes medical information about the patient's close relatives.

physical signs

Pieces of evidence that indicate an illness that can be observed externally, such as a rash, coughing, or elevated temperature.

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.

Pediatrician

A specialist physician who provides medical care to infants, children, and adolescents.

primary care physician

A specialist trained to work in the front line of healthcare system and provide care for any health problems that a patient might have.

Components of a Medical History: 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.

chief complaint

The patient's description of what they feel is their main health problem.

medical assistant

helps physicians examine and treat patients and performs tasks to keep offices running smoothly

Medical Student

person who studies to be a doctor

Patient Liason

works with patients and their families to address needs and concerns. Acts as an intermediary between patients, their families and the hospital administration.

Medical Terminology:Tacts

Discretion and sensitivity in dealing with others. example: A doctor might exhibit tact when they choose their words carefully so as to not upset a patient when they must deliver bad news.

non physician practitioner

Health care provider who practices either in collaboration with or under the supervision of a physician. Some examples include nurse practitioners, clinical nurse specialists, and physician assistants.

Other specialists

Many other specialists provide care at the clinic, including genetic counselors who advise families on their risk for inheriting or passing on certain diseases, and specialist physicians such as psychiatrists and cardiologists.

Medical Terminology: Demeanor:

Outward behavior or bearing. example: 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.

Components of a Medical History: current history

Patient's chief complaint and any other current 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, such as exercise are also part of the patient's current history.

Medical Terminology: Empathy

The ability to understand and share the feelings of another person.

medical technician

Uses sophisticated equipment and has different responsibilities.

Nurse

a person trained to care for the sick or infirm, especially in a hospital.

primary care physician

a specialist trained to work in the front line of a healthcare system and provide care for any health problems that a patient might have.

symptoms

any subjective evidence of disease a patient perceives, such as aches, nausea, or fatigue. It allows the health care provider to narrow down the possible conditions that may be affecting the patient and then run tests to make a diagnosis.