Overview
This lecture covers essential components of medical history, key definitions, and vital sign measurement for medical assistants.
Medical History Components
- Medical history includes chief complaint, history of present illness (HPI), past, family and social history (PFSH), and review of systems (ROS).
- The chief complaint is what brings the patient to see the physician.
- HPI is an explanation of the chief complaint, including illness onset, associated symptoms, and attempted treatments.
- Past medical history details all health problems, major illnesses, surgeries, current medications with reasons, and allergies.
- Family history summarizes health problems of siblings, parents, and other blood relatives.
- Social history includes marital status, occupation, education, hobbies, substance use, and lifestyle factors.
- Review of systems is a systematic check of each organ and body system by questioning.
Vital Signs
- Three vital signs necessary for life: temperature, respiration, and heart function (blood pressure).
- Four vital signs of body function: temperature, pulse, respiration, and blood pressure.
- Normal body temperature range is 96.6-100.6°F.
- Body temperature is the balance between heat production and heat loss.
- The hypothalamus regulates body temperature.
- The rectum is the most accurate site for measuring body temperature.
- The axillary region (armpit) is the least accurate site for body temperature.
- Types of fever include intermittent, remittent, and continuous.
Key Terms & Definitions
- Chief Complaint — The main reason the patient seeks medical attention.
- History of Present Illness (HPI) — Details about the onset, symptoms, and self-treatment of the current problem.
- Past Medical History — Record of previous health issues, surgeries, medications, and allergies.
- Family History — Health information of immediate and other blood relatives.
- Social History — Patient’s marital status, occupation, education, lifestyle, and substance use.
- Review of Systems (ROS) — Systematic review of each body system through questions.
- Vital Signs — Measurements indicating the state of essential body functions.
Action Items / Next Steps
- Review and memorize the definitions and order of medical history components.
- Study normal vital sign ranges and understand measurement sites.
- Practice identifying components of history and performing a review of systems.