Unit 2.1 Flashcards
(85 cards)
1
Q
Medical History
A
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.
2
Q
Chief Complaint
A
The patient’s description of what they feel is their main health problem.
3
Q
Physical Signs
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Pieces of evidence that indicate an illness that can be observed externally, such as a rash, coughing, or elevated temperature.
4
Q
Symptoms
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Any subjective evidence of diseases a patient perceives, such as aches, nausea, or fatigue. Symptoms allow the healthcare provider to narrow down the possible conditions that may be affecting the patient and then run tests to make a diagnosis
5
Q
Diagnosis
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The process of determining which disease or condition explains a person’s symptoms and signs.
6
Q
Demeanor
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Outward behavior or bearing; a doctor might have a cheerful, peaceful, or friendly demeanor and put the patient at ease; doctors with an arrogant or dismissive demeanor might lose a patient’s trust.
7
Q
Tact
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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.
8
Q
Empathy
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The ability to understand and share the feelings of another person.
9
Q
Medical Assistant
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An unlicensed caregiver who works primarily in doctor’s offices and clinics. They assist their medical director through a wide variety of duties.
10
Q
Nurse
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A licensed healthcare professional who is skilled in promoting and maintaining health.
11
Q
Medical Technician
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Uses sophisticated equipment and has different responsibilities. Some work directly with patients (a phlebotomist draws blood) while others work in a lab (a histotechnician analyzes tissues).
12
Q
Patient Liaison
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Works with patients and their families to address needs and concerns; acts as an intermediary between patients, their families, and the hospital administration.
13
Q
Medical Student
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A student enrolled at a medical school who is training to become a physician.
14
Q
Non-Physician Practitioner
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A healthcare 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.
15
Q
Primary Care Physician
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A specialist physician trained to work in the front line of a healthcare system and provide care for any health problems that a patient might have.
16
Q
Pediatrician
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A specialist physician who provides medical care to infants, children, and adolescents.
17
Q
Vital Signs
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Measurements (specifically pulse rate, temperature, respiration rate, and blood pressure) that indicate the state of a patient’s essential body functions.
18
Q
Homeostasis
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The maintenance of stable internal physiological conditions (like body temperature or the pH of blood), which enables the optimal functioning of an organism.
19
Q
Pulse
A
The rhythmic expansion and recoil of arteries resulting from heart contraction.
20
Q
Respiratory Rate
A
The number of breaths an organism takes per minute.
21
Q
Blood Pressure
A
The pressure that blood exerts upon the walls of blood vessels, especially arteries, usually measured with a sphygmomanometer; expressed in mm of mercury.
22
Q
Triage
A
The sorting and prioritization of patients based on the urgency of their need for care
23
Q
Oxygen Saturation
A
The amount of oxygen in the blood. It is measured as a percentage using pulse oximeters.
24
Q
BMI (Body Mass Index)
A
A measure of body fat that is the ratio of the weight of the body to its height. It is calculated using the formula: weight(lb)/height (inches) square X 703.
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Lung-Breath Sounds
The sound and clarity of breaths. Measured qualitatively as a description of the sound (clear, wheezing, crackles) using a stethoscope.
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Palpate
Examine (a part of the body) by touch, especially for medical purposes.
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Ophthalmoscope
An instrument for inspecting the retina and other parts of the eye.
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Otoscope
An instrument designed for visual examination of the eardrum and the passage of the outer ear, typically having a light and a set of lenses.
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Visual Acuity
Sharpness of vision, measured by the ability to discern letters or numbers at a given distance according to a fixed standard.
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Cyanosis
A bluish color of the skin and the mucous membranes due to insufficient oxygen in the blood.
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Rosacea
A condition in which certain facial blood vessels enlarge, giving the cheeks and nose a flushed appearance.
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Phlebotomist
A medical professional trained to draw blood from patients who require testing as well as blood donors.
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Risk Factors
A behavioral, environmental, genetic, psychological, or demographic attribute that increases risk or susceptibility.
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CBC (Complete Blood Count)
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.
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Hematocrit (HCT)
The proportion of red blood cells to plasma, the fluid component in blood.
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Hemoglobin (HB/Hgb)
The oxygen-carrying protein in red blood cells.
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Leukocyte (White Blood Cell)
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.
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Erythrocyte (Red Blood Cell)
Hemoglobin-rich, red blood cells that transport oxygen through a body. Erythrocytes give the red color to vertebrate blood and do not have nuclei.
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Thrombocyte (Platelet)
A minute, colorless, anucleate disk-like body of mammalian blood that assists in blood clotting by adhering to other platelets and damaged epithelium.
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Blood 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.
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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.
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LDL (Low-Density Lipoprotein)
The “bad” cholesterol that can build up in the arteries and help form plaques, which can cause coronary artery disease; a type of lipoprotein responsible for transporting cholesterol to the cells.
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HDL (High-Density Lipoprotein)
The “good” cholesterol that helps remove the less beneficial forms of cholesterol from blood; type of lipoprotein responsible for removing excess cholesterol from the bloodstream and transporting it to the liver.
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Basic Metabolic Panel
A basic metabolic panel is a blood test that measures your sugar (glucose) level, electrolyte and fluid balance, and kidney function.
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Hormones
A signaling molecule produced by glands; induces a specific effect on the activity of cells.
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Electrolytes
Minerals found in your blood, urine, and other tissues; sodium, calcium, potassium, and chloride help keep a water balance in the body and move nutrients into cells and wastes out, and make sure that your nerves, brain, muscles, and heart function properly.
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Blood Urea Nitrogen (BUN) and Creatinine
BUN and creatinine are waste products filtered out of the blood by the kidneys; give an indication of how well the kidneys are functioning.
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Telehealth
A way for individuals to remotely access health-related services using technology, rather than in-person contact to make it easier for a patient to connect with a healthcare provider.
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Biomolecules
Large molecules, or macromolecules, produced by living organisms such as nucleic acids (DNA and RNA), carbohydrates, proteins, and lipids.
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Chemical Reactions
Processes where atoms and/or molecules are rearranged to transform matter.
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Adenosine Tri-Phosphate (ATP)
A compound composed of adenosine and three phosphate groups that supplies energy for many biochemical cellular processes
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Carbohydrates
The primary source of energy for cells; examples are sugar, starch, and cellulose which are found in foods and tissues.
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Lipids
One of a family of compounds including fats, phospholipids, and steroids that are insoluble in water; they are a secondary source of energy for our cells.
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Protein
A biomolecule made of building blocks called amino acids; a protein’s form and function are determined by a cell’s nucleic acid sequence and are a “last resort source of energy for our cells.
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Nucleic Acids
Biomolecules that carry the instructions for producing proteins; DNA and RNA are examples of nucleic acids and are not a source of energy for our cells.
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Metabolism
The chemical reaction processes of breaking down molecules for energy and using simple building blocks to build up more complex molecules needed for growth and repair.
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Insulin
A protein hormone secreted by the pancreas essential for the metabolism of carbohydrates and the regulation of glucose levels in the blood; it lowers blood glucose levels by allowing cells to increase glucose uptake.
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Glucagon
A hormone secreted by pancreatic endocrine cells that raises blood glucose levels; an antagonistic hormone to insulin.
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Type 1 Diabetes
A form of diabetes that usually develops during childhood or adolescence; it is characterized by a severe deficiency of insulin, leading to high blood glucose levels.
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Type 2 Diabetes
A form of diabetes that develops especially in adults, most often obese individuals; characterized by high blood glucose resulting from impaired insulin use coupled with the body’s inability to compensate with increased insulin production.
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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.
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Previous History
Includes information about any past health issues, procedures, medications, vaccinations, and previous hospital stays.
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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.
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Family History
Includes medical information about the patient’s close relatives.
For example, a patient may have inherited a health condition that could place them at a higher risk of having many disorders—such as heart disease, high blood pressure, stroke, certain cancers, or diabetes.
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Temperature
Body temperature is a measure of how warm your body is. Body temperature can vary slightly based on factors such as age, stress, physical activity, food or fluid consumption, time of day, and the method by which it was measured.Body temperature can be measured in a variety of ways including orally, by ear, under the armpit, or rectally. Many people cite 98.6 °F as a normal body temperature, but in healthy adults, it generally ranges from about 97.8 to 99 °F
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Pulse
Your heart rate is the number of times your heart beats in one minute. With each heartbeat, a pressure wave (pulse) passes along an artery as its walls bulge and then relaxes to accommodate the surge of blood. The range of normal heart rates for adults is 60–100 beats per minute (bpm).
Radial Artery (in wrist)
Carotid Artery (in throat)
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Respiration Rate
Respiratory rate is the measure of the number of breaths you take in a minute. One breath includes both an inhalation and an exhalation. You can see and feel this as your chest rises (inhale) and falls (exhale). With each breath, your body takes in oxygen and expels carbon dioxide waste. The normal respiration rate for an adult at rest is 12–20 breaths per minute.
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Oxygen Saturation
Pulse oximetry is a measure of the amount of oxygen found in the blood, also known as oxygen saturation. Oxygen saturation is measured using a device called a pulse oximeter. The measurement taken by a pulse oximeter is called SpO2 or peripheral oxygen saturation. The word peripheral refers to the location. SpO2 measures the oxygen levels at an appendage (finger, toe) that is farther from the heart, or on the periphery (outline) of the body. A normal range for SpO2 is between 95–99%. Mild respiratory illnesses such as colds, flu, or bronchitis may cause the SpO2 rate to fall between 90–94%. Anything below 90% is a signal of a problem that needs urgent treatment.
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Blood Pressure
Blood pressure is caused by the movement of blood through the vessels—the arteries and veins—in your body. With each heartbeat, the blood moves through the vessels as a pulse. It presses against the walls of the vessel when the heart contracts or pushes the blood and then relaxes. When you measure blood pressure, you’re measuring the force applied to the walls of the arteries as the heart pumps blood. The pressure is determined by the amount of force and the quantity of blood being pumped. The basic instrument used to take a blood pressure reading is called a sphygmomanometer. This device consists of an inflatable cuff with an attached pressure gauge. The cuff is placed on the upper arm and is inflated to cut off blood flow. Pressure in the vessel is measured as the cuff is released and blood flow returns to the artery.
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Look
A routine visit includes visual inspection of the body, particularly the eyes, ears, nose, throat, and skin. Doctors look for any abnormalities, injuries, or signs of infection or disease. They may also look for changes in the body that link to symptoms a patient has reported in the initial conversation.
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Eyes
Medical professionals examine the external anatomy of the eye and also use a handheld device called an ophthalmoscope to examine the interior. Testing the response of the pupils to light and the patient’s ability to track a moving object with the eyes can tell a doctor about the health of the eye as well as the nervous system. A patient may also be asked to read the eye chart to measure their visual acuity and determine whether they need corrective lens or glasses.
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Ears
The ear is a complex organ responsible for hearing and balance. External, middle, and inner ear structures conduct sound waves through the ear and to the brain via nerves.
Doctors use a device called an otoscope, a tool with a light and magnifying glass, to look inside the ear.
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Skin
Another component of the routine exam is checking the skin for abnormalities. Changes such as growths, level of dryness, or even skin discoloration can provide clues to other health conditions.
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Nose and Throat
Medical professionals use the otoscope to examine the nasal passages. They also make the patient open and say “Ahh” to observe the anatomy of the throat. Your tonsils, a pair of small masses at the back of the throat, are part of the lymphatic system and help you fight infection. Swollen tonsils are often a sign that your body is fighting an infection. Lymphatic tissues, such as the spleen, tonsils, and thymus, contain high concentrations of white blood cells and are able to identify and destroy toxins in lymph fluid.
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ABCDE Acronym
A - Asymmetry - One half of the mole doesn't match the shape of the other half
B - Border - The edges of the mole are irregular or jagged
C - Color - The mole is not one uniform color, but shows different colors or shades throughout
D - Diameter - The diameter of the mole is larger than a pencil eraser
E - Evolving - The mole appears to be changing (shape, color, size) over time.
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Listen
The next part of the exam involves listening to sounds the body makes, particularly the stomach, heart, and lungs. Changes to predictable, rhythmic sounds may signal changes in structure and function and can alert medical professionals to the need for further tests.
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Heart
A heart that is functioning normally has a predictable beat and rhythm. The classic lub-dub sound with each heartbeat occurs as the two sets of valves close in sequence.
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Lung
As you inhale and exhale, your lungs make sounds you can hear. Using a stethoscope amplifies these sounds. Normal breathing sounds like a clear movement of air in and out of the lungs. Hearing other noises such as crackles or wheezing can indicate the presence of some condition, such as asthma, respiratory illness, allergies, or emphysema (damage to the air sacs in the lungs)
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Lung Sounds
Clear - A clear woos of air with each inhalation and exhalation.
Wheezing - A high-pitched whistling sound caused by narrowed airways; can sometimes be heard without a stethoscope
Crackles (rales) - Short and intermittent clicking, rattling, or popping sounds are heard during inhalation when air is forced through an airway narrowed by fluid.
Stridor - Harsh, shrill sound, similar to wheezing, usually heard closest to the back of the neck, as it is caused by a partially obstructed windpipe.
Rhonchi - A snore-like sound heard when airways are partially obstructed.
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Common Blood Draw Areas
For adults, the most frequently used vein is the median cubital vein, commonly referred to as the antecubital, found on the inside of the elbow.
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What a CBC Includes
CBC - Complete Blood Count; It Includes:
WBC - White Blood Cells - The five types of cells that the body uses to fight infection and injury and maintain our health.
RBC - Red Blood Cells - The cells that transport oxygen around the body
HB/Hgb - Hemoglobin - The oxygen-carrying protein in red blood cells
HCT - Hematocrit - The proportion of red blood cells to plasma, the fluid component, in blood
Platelets - The cell fragments that assist with clotting
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Cholesterol
A waxy substance that is naturally produced in the liver and is also absorbed from food as it passes through the intestines. Regardless of where cholesterol originates, it must be transported to all the cells in the body. Cholesterol is a key component in the structure of cell membranes and is also used to make essential molecules such as hormones and vitamins. As with most substances transported through the body, it is carried by the bloodstream.
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Cholesterol Level
Less than 200 mg/dL - Optimal
200-239 mg/dL - Borderline High
240 mg/dL and above - High
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LDL Cholesterol Level
Less than 100 mg/dL - Optimal
100-129 mg/dL - Near Optimal/Above Optimal
130-159 mg/dL - Borderline High
160-189 mg/dL - High
190 mg/dL and above - Very High
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HDL Cholesterol Level
60 mg/dL or higher - Considered protective against heart disease
40-59 mg/dL - Protection increases as HDL increases
Less than 40 mg/dL - A major risk factor for heart disease
