Medical Assessment and Diagnosis

Vital Signs

• Definition: Measurements of a patient's basic physiological functions
• Components:
  1. Body Temperature: Normal range: 36.5°C - 37.5°C (97.7°F - 99.5°F)
  2. Pulse: Normal range: 60 - 100 beats per minute (bpm)
  3. Blood Pressure: Normal range: 90 - 120 mmHg systolic, 60 - 80 mmHg diastolic
  4. Respiratory Rate: Normal range: 12 - 20 breaths per minute
  5. Oxygen Saturation: Normal range: 95% - 100%

Physical Examination

• Definition: Systematic evaluation of a patient's body systems through observation, palpation, percussion, and auscultation
• Components:
  • Inspection: Visual examination of the patient's overall appearance and body systems
  • Palpation: Feeling the body with hands to assess texture, temperature, and tenderness
  • Percussion: Tapping on the body to assess organ size and position
  • Auscultation: Listening to sounds within the body using a stethoscope

Diagnostic Tests

• Definition: Procedures used to confirm or rule out a diagnosis
• Types:
  • Laboratory Tests: Blood, urine, and tissue samples analyzed in a laboratory
  • Imaging Studies: X-rays, CT scans, MRI, and ultrasound to visualize internal structures
  • Functional Tests: Assess organ function, such as ECG, spirometry, and stress tests

Medical History

• Definition: Collection of information about a patient's past and present medical conditions
• Components:
  • Chief Complaint: Primary reason for the patient's visit
  • History of Present Illness: Detailed description of the patient's symptoms
  • Past Medical History: Previous illnesses, surgeries, and hospitalizations
  • Family Medical History: Medical conditions in the patient's family members
  • Social History: Lifestyle, occupation, and environmental factors that may impact health