2 - CLINICAL CONCEPTS.pdf

MEDICAL ADMINISTRATION LECTURER LANDA BROOKS BASIC CLINICAL CONCEPT PRIMARY PATIENT HISTORY Taking a preliminary primary patient history involves gathering essential information about the patient's current condition, medical history, and other relevant details. Introduction an...

MEDICAL ADMINISTRATION LECTURER LANDA BROOKS BASIC CLINICAL CONCEPT PRIMARY PATIENT HISTORY Taking a preliminary primary patient history involves gathering essential information about the patient's current condition, medical history, and other relevant details. Introduction and Establishing Rapport: Greet the patient warmly. Introduce yourself and your role. Ensure privacy and comfort for the patient. Identifying Data: Confirm the patient's identity (name, age, gender). Note any primary complaints or reasons for the visit. PRIMARY PATIENT HISTORY Present Illness/ chief complaint: Ask questions on the present symptoms or apprehensions. Collect information about onset, duration, severity, progression, and factors that improve or worsen symptoms. Use open-ended questions to allow the patient to describe their symptoms in their own words. Medical History: Ask about previous medical conditions (chronic illnesses, surgeries, hospitalizations). Inquire about current medications (prescription, over-the-counter, supplements) and allergies. Search family medical history (specifically for conditions that might be hereditary). PRIMARY PATIENT HISTORY Social History: Ask questions about lifestyle influences such as diet, exercise, smoking, and alcohol use. Inquire about work-related history and any environmental exposures that might be relevant. Psychosocial History: Assess the patient's emotional well-being and stressors. Question about support systems (family, friends, caregivers). Screen for any history of mental health issues. Review of Systems: Systematically go through different body systems (e.g., cardiovascular, respiratory, gastrointestinal) to identify any additional symptoms. This can help uncover symptoms that the patient may not have mentioned initially. PRIMARY PATIENT HISTORY Closing: Summarize the material collected. Query if there's anything additional information the patient would like to add. Thank the patient for providing information. Documentation: Record the history accurately and comprehensively in the patient's medical record. Ensure clarity and specificity to aid in diagnosis and treatment planning. SUMMARY MAS should recall that taking an effective patient history-taking requires active listening, empathy, and respect for the patient's perspective. It is the basis for all groundwork to establish a trusting patient-provider relationship and guiding appropriate clinical decision-making. MANUAL CHARTING FORMAT Patient Information Section: Demographics: Name, age, sex, date of birth, address, contact information. Insurance Information: Insurance provider, policy number. Chief Complaint: Brief statement summarizing the reason for the patient's visit. History of Present Illness (HPI): Facts about the current symptoms, comprising of onset, duration, severity, aggravating and alleviating factors. Past Medical History: Previous illnesses, surgeries, hospitalizations. Allergies and adverse drug reactions. MANUAL CHARTING FORMAT Medication: Present medicine with dosage and frequency. Family history: Significant medical conditions among immediate family members. Social History: Lifestyle habits (smoking, alcohol, drug use). Occupational and environmental exposure Review of Systems (ROS): Systematic inquiry into symptoms related to each organ system. Physical Examination Findings: Objective findings from the physical examination.. MANUAL CHARTING FORMAT Assessment and Plan: Diagnosis or working diagnosis. Treatment plan, including medications prescribed, referrals made, and follow-up instructions. Progress Notes: Documentation of subsequent visits, changes in condition, responses to treatment ELECTRONIC HEALTH RECORD FORMAT EHRs typically mirror the manual charting format but offer several advantages such as: Structured Templates: Pre-designed forms or templates for documenting varied sections of the patient encounter (HPI, ROS, physical exam, etc.). Integration: Capacity to incorporate laboratory results, imaging reports, and other diagnostic findings directly into the patient's record. Efficiency: rapid documentation and recovery of client's data. Decision Support: Warnings for allergies, drug interactions, and reminders for preventive care. The structure of an EHR generally follows the same sections as manual charting but allows for more efficient data entry and retrieval, as well as improved communication between healthcare providers. Key Principles for Charting (Both Manual and EHR): Accuracy: Make certain that all info recorded is accurate and relevant to the patient's care. Clarity: to enable understanding by other health providers , simplified data using clear and concise language. Relevance: ensure proper documentation the is of specific relevance to the patient present and continuous management. Timeliness: for accuracy and continuity of patient care , record data promptly. Both manual charting and EHRs serve the same fundamental purpose of documenting patient information to support clinical decision-making, continuity of care, and legal and regulatory requirements. VITAL SIGNS Vital signs are neutral indicators of physiological functioning and provide valuable information about a patient's baseline health, response to treatment, and any changes that may indicate illness or distress. The primary vital signs typically monitored include: Temperature Pulse Respiration Blood pressure Oxygen saturation VITAL SINGS TEMPERATURE ANATOMY Hypothalamus: Location: Located at the base of the brain. Function: Acts as the body's thermostat, receiving temperature information from peripheral sensors and initiating responses to regulate body temperature. Peripheral Temperature Sensors: Skin Receptors: Detect external temperature changes and relay information to the central nervous system. Internal Sensors: Receptors within the body (e.g., abdominal organs) provide feedback on internal temperature conditions. VITAL SIGNS Autonomic Nervous System: Sympathetic Nervous System: Triggers reactions to increase body temperature. Parasympathetic Nervous System: Stimulates responses to lessening body temperature. Blood Vessels: Vasoconstriction: Narrowing of blood vessels in the skin to conserve heat and redirect blood flow to vital organs. Vasodilation: Widening of blood vessels in the skin to release heat and cool the body. VITAL SIGNS Normal Temperature Range: Adults: Normally ranges between 97.8–99.1°F (36.5–37.3°C) when taken orally. Children: May have slightly higher normal ranges than adults. Elderly: Normal temperatures may be slightly lower than average for younger adults. Methods of Measurement: Oral Temperature: Placing a thermometer under the tongue and wait for approximately a minute for the results. Rectal Temperature: Inserting a thermometer into the rectum. Tympanic (Ear) Temperature: Using an infrared thermometer to measure the temperature inside the ear canal. Quick and non-invasive, often used in clinical settings. VITAL SIGNS Axillary (Underarm) Temperature: Thermometer is placed under the armpit and wait for results in one minute. Least accurate method, often used when other methods are not feasible. Temporal Artery Temperature: The thermometer scans the forehead over the temporal artery. Fast and non-invasive. VITAL SIGNS Significance of Temperature: Fever (Pyrexia): High body temperature above the normal range. Causes: Typically, due to infection (bacterial or viral), inflammation, or other medical conditions. Clinical Considerations: Fever is the body’s natural response to infections and can help in diagnosing the core cause. Terminologies used : febrile or afebrile Hypothermia: Unusually low body temperature. Causes: Exposure to cold environments, extended exposure to water, certain medical conditions. Clinical Considerations: Severe hypothermia can be life-threatening and requires immediate medical attention. VITAL SIGNS PULSE RATE/ HEART RATE(PR/HR) Pulse rate, also known as heart rate, is an important vital sign that mirrors the number of times the heart beats per minute (bpm). It is an important indicator of cardiovascular health. Additionally, measured by measuring the palpable pulsations of an artery, typically the radial artery in clinical settings. Anatomy of Pulse Rate: Heart: Location: Located in the center of the chest, slightly left of the sternum. Function: Acts as a muscular pump that contracts rhythmically to circulate blood throughout the body. Arteries: Radial Artery: Located on the wrist, just below the thumb. Carotid Artery: Located on either side of the neck. Brachial Artery: Located in the upper arm, commonly used in infants.  PR/HR Physiology of Pulse Rate: Generation of Heartbeat: Sinoatrial (SA) Node: The heart's natural pacemaker located in the right atrium. It initiates electrical impulses that travel through the heart, causing it to contract. Conduction System: Electrical impulses pass through the atria, stimulating atrial contraction, and then through the atrioventricular (AV) node to the ventricles, causing ventricular contraction. Measurement of Pulse: Palpation: Using fingers(FIRST& SECOND) to feel pulsations at arterial sites such as the radial artery. PR/HR Normal Pulse Rate: Adults: between 60-100 beats per minute (bpm) at rest. Children: Generally higher, depending on age. Athletes: May have lower resting heart rates due to cardiovascular conditioning. Approximately 40- 60bpm PR/HR Factors Influencing Pulse Rate: 1.Physical Activity: Exercise increases heart rate to meet increased oxygen demands. 2.Emotional State: Stress, anxiety, or excitement can elevate heart rate. 3.Temperature: Fever or exposure to heat can increase heart rate. 4.Medications: Some medications (e.g., stimulants) can affect heart rate. 5.Age and Fitness Level: Generally, younger individuals and athletes have lower resting heart rates. PR/HR Clinical Significance: Diagnostic Tool: Abnormal pulse rates (bradycardia or tachycardia) can indicate various medical conditions, such as arrhythmias, heart disease, or thyroid dysfunction. Monitoring: Monitoring changes in pulse rate over time helps assess response to treatments, evaluate cardiovascular fitness, and detect abnormalities. Treatment: Depending on the cause, interventions may include medications, lifestyle modifications (e.g., exercise, stress management), or surgical interventions. VITAL SIGNS Respiration rate, refers to the number of breaths an individual takes per minute. It offers important info about lung function, respiratory efficiency, and overall health status. Anatomy of Respiration: Lungs: Location: Positioned within the thoracic cavity. Function: Facilitate the exchange of oxygen and carbon dioxide between the air and the bloodstream. Diaphragm and Intercostal Muscles: Diaphragm: Dome-shaped muscle beneath the lungs that contracts and relaxes to facilitate breathing. Intercostal Muscles: Muscles between the ribs that assist in expanding and contracting the chest cavity during breathing. Physiology of Respiration Rate: Breathing Process: Inhalation (Inspiration): Diaphragm contracts and moves downward, while intercostal muscles contract, expanding the chest cavity and drawing air into the lungs. Exhalation (Expiration): Diaphragm and intercostal muscles relax, reducing the chest cavity size and pushing air out of the lungs. Control of Respiration: Medulla Oblongata: Part of the brainstem that regulates basic involuntary functions, including breathing. Chemoreceptors: Sensors in the blood vessels and brain that detect changes in oxygen and carbon dioxide levels, influencing respiratory rate.  Counting Breaths: Typically measured by counting the number of Measurement breaths (inhalations and exhalations) in one minute. of Observation: Visual observation of chest movements to assess breathing pattern and effort. Respiration Normal Respiration Rate: Rate Adults: Normal range is typically 12-20 breaths per minute at rest. Children: Respiration rates may be higher, varying with age VITAL SIGNS Factors Influencing Respiration Rate: 1.Physical Activity: Increased activity or exercise can elevate respiration rate to meet increased oxygen demands. 2.Emotional State: Stress or anxiety may affect breathing patterns. 3.Temperature: Fever or exposure to heat can increase respiration rate. 4.Medical Conditions: Respiratory diseases, metabolic disorders, or neurological conditions can impact respiratory rate. 5.Bradypnea- slow heart rate 6.Tachypnea- rapid heart rate VITAL SIGNS Clinical Significance: Diagnostic Tool: Abnormal respiratory rates (bradypnea or tachypnea) can indicate respiratory distress, lung disease, metabolic acidosis, or other medical conditions. Monitoring: Regular monitoring of respiratory rate helps assess respiratory function, response to treatments, and progression of illness. Treatment: Interventions may include medications, respiratory therapies, oxygen supplementation, or addressing underlying medical conditions. VITAL SIGNS BLOOD PRESSURE Blood pressure is a vital sign that measures the force exerted by the blood against the walls of arteries as the heart pumps it around the body. It consists of two numbers: systolic pressure (the pressure when the heart beats and pushes blood out ) over diastolic pressure (the pressure when the heart relaxes between beats). Anatomy and Physiology of Blood Pressure: Heart: Location: Located in the thoracic cavity, slightly left of the center. Function: Acts as a muscular pump that contracts (systole) to pump blood into the arteries and relaxes (diastole) to allow the chambers to refill. Arteries and Arterioles: Location: Blood vessels that carry oxygen-rich blood away from the heart to various parts of the body. Function: Arteries expand and contract to accommodate the blood flow generated by each heartbeat. BLOD PRESSURE Blood Volume and Viscosity: Blood Volume: The amount of blood circulating in the body affects blood pressure. Blood Viscosity: Thickness or thinness of blood, predisposed by factors such as hydration and certain medical conditions. Measurement of Blood Pressure: Systolic Pressure: The top number in a blood pressure reading, representing the pressure in the arteries when the heart beats. Diastolic Pressure: The bottom number, representing the pressure in the arteries when the heart is resting between beats. Unit of Measurement: Millimeters of mercury (mmHg). BLOOD PRESSURE/BP Normal Blood Pressure: Normal Range: below 120/80 mmHg. Elevated: 120-129/