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Medicine is the science and practice of establishing the diagnosis, prognosis, treatment, and prevention of disease. Medicine encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Contemporary medicine applies biomedical sciences, biomedical research, genetics, and medical technology to diagnose, treat, and prevent injury and disease, typically through pharmaceuticals or surgery, but also through therapies as diverse as psychotherapy, external splints and traction, medical devices, biologics, and ionizing radiation, amongst others.
An emergency department (ED), also known as an accident & emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center.
Shortness of breath (SOB), also known as dyspnea, is the feeling that one cannot breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity", and recommends evaluating dyspnea by assessing the intensity of the distinct sensations, the degree of distress involved, and its burden or impact on activities of daily living. Distinct sensations include effort/work, chest tightness, and air hunger.
Palliative care refers to an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex illness. Within the published literature, many definitions of palliative care exist; most notably, the World Health Organization describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”
Pain management, pain medicine, pain control or algiatry, is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with chronic pain. The typical pain management team includes medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, physician assistants, nurses. The team may also include other mental health specialists and massage therapists. Pain sometimes resolves promptly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as analgesics and (occasionally) anxiolytics. Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the pain management team. Effective pain management does not mean total eradication of all pain.
A psychiatric history is the result of a medical process where a clinician working in the field of mental health systematically records the content of an interview with a patient. This is then combined with the mental status examination to produce a "psychiatric formulation" of the person being examined.
The medical history, case history, or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
Step 2 Clinical Skills of the United States Medical Licensing Examination (USMLE) is an exam administered to medical students/graduates who wish to become licensed physicians in the U.S. It is similar to the COMLEX-USA Level 2-PE exam, taken by osteopathic medical students/graduates who seek licensure as physicians in the U.S. For US medical students, the exam fee is $1,285. For medical students at foreign medical schools, the tests cost is higher—currently $1,535. These fees do not include costs associated with travel and lodging to take the test. Historically, US students have taken Step 2 CS late in their senior year, prior to graduation. However, now that more residency programs require students to record a passing score, many US medical schools recommend students take Step 2 CS in the fall of their senior year.
The SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place to be used at specific facilities and in specific circumstances.
The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting. The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. In some instances, the nature of a patient's chief complaint may determine if services are covered by medical or vision insurance.
OPQRST is a mnemonic used by medical professionals to accurately discern reasons for a patient's symptoms and history in the event of an acute illness. It is specifically adapted to elicit symptoms of a possible heart attack. Each letter stands for an important line of questioning for the patient assessment. This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of a SOAP note, for later reference.
The medical home, also known as the patient-centered medical home (PCMH), is a team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal health outcomes. It is described in the "Joint Principles" as "an approach to providing comprehensive primary care for children, youth and adults."
An admission note is part of a medical record that documents the patient's status, reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
Nausea is an unpleasant, diffuse sensation of unease and discomfort, often perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged, and has been described as placing discomfort on the chest, upper abdomen, or back of the throat.
Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders. These include various maladaptations related to mood, behaviour, cognition, and perceptions. See glossary of psychiatry.
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient. Along with the physical examination, it can be particularly useful in identifying conditions that do not have precise diagnostic tests.
In a medical encounter, a past medical history, is the total sum of a patient's health status prior to the presenting problem.
Francis Miller Fesmire was an American emergency physician and a nationally recognized expert in myocardial infarction. He authored numerous academic articles and assisted in the development of clinical guidelines on the standard of care in treating patients with suspected myocardial infarction by the American College of Emergency Physicians and the American Heart Association/American College of Cardiology. He performed numerous research investigations in chest pain patients, reporting the usefulness of continuous 12-lead ECG monitoring, two-hour delta cardiac marker testing, and nuclear cardiac stress testing in the emergency department. The culmination of his studies was The Erlanger Chest Pain Evaluation Protocol published in the Annals of Emergency Medicine in 2002. In 2011 he published a novel Nashville Skyline that received a 5 star review by ForeWord Reviews. His most recent research involved the risk stratification of chest pain patients in the emergency department.
Chronic fatigue syndrome (CFS), also referred to as myalgic encephalomyelitis (ME), is a medical condition characterized by long-term fatigue and other persistent symptoms that limit a person's ability to carry out ordinary daily activities. Other symptoms may include difficulty with thinking or memory, difficulty with sitting or standing, muscle pain, headache, tender lymph nodes in the neck or armpits, recurring sore throat, digestive issues, night sweats, or sensitivities to foods, chemicals, or noise. Symptoms may develop gradually or suddenly, and are often worsened by normal physical or mental activity.
References
- ↑ Adler HM (1997). "The history of the present illness as treatment: who's listening, and why does it matter?". J Am Board Fam Pract. 10 (1): 28–35. PMID 9018660.
- ↑ Evaluation and Management Coding and Electronic Health Records
- ↑ http://www.usc.edu/health/uscp/compliance/tm6.html#6 Archived 2001-05-03 at the Wayback Machine
- ↑ "Medical Assessment". Archived from the original on 2007-02-25. Retrieved 2006-09-26.
- ↑ Learning To Perform a Medical Assessment – Part 1: Quick Medical Assessment
- ↑ "WEMSI – Assessment by PQRST". Archived from the original on 1998-12-06. Retrieved 2006-09-26.
- ↑ Department of Medicine Home Page
- ↑ Dartmouth Medicine Magazine :: Student Notebook
- ↑ "HPI (history of present illness)". Archived from the original on 2006-10-04. Retrieved 2006-09-26.
- ↑ Buring SM, Kirby J, Conrad WF (February 2007). "A structured approach for teaching students to counsel self-care patients". Am J Pharm Educ. 71 (1): 8. doi:10.5688/aj710108. PMC 1847542 . PMID 17429508.
- ↑ "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original (PDF) on 2012-04-11. Retrieved 2011-02-27.