Clinical definitions, acronyms and abbreviations

• Pathology

  Changes in the normal anatomy and physiology of the body as a result of a disease.
• three other things to take note of when taking a medical history:

  1. for patients with mental conditions, take the history again from a relative or other witness.
  2. Check the patient's outpatient card for previous history
  3. Tell the patient a summary of the history and ask him/he to correct anything wrong
• Sign


  When a clinician finds when a patient is examined clinically, medically, or physically. It is preformed systematically.
• Basic observations


  Helps you decide if the patient is sick or not, identify common diseases, and allows early interventions of treatment and preventions.
• The different types of basic observations include:

  Level of consciousness and signs of meningeal irritation, temperature, pulse rate, respiration rate and type of respiration, blood pressure, weight, dehydration, edema, malnutrition or chronic wasting illness present and even determine color, especially for anemia.
• One area of basic observation on vital signs.
• The importance of vital signs includes:

  1. Monitoring body functions
  2. Reflect changes in function that were overlooked
  3. Not automatic or routine
  4. Is a thoughtful scientific assessment
• Vital signs should be evaluated with reference to the client's present and prior health status and compared to accepted normal standards.
• Temperature range

  36-37 degree Celsius or centigrade
• The normal site for taking the temperature

  Axillary (> 3 minutes)
• Pyrexia

  body temperature increases
• Hyperthermia


  Lay term for fever
• Hyperpyrexia

  Temperature is greater than 41 degree Celsius
• Febrile

  Somebody who has fever
• Hypothermia


  Somebody who has a temperature less than 36 degree Celsius
• Pulse rate

  A wave of blood is created by the contraction of the left ventricle of the heart. In other words, it is the amount of blood that enters the arteries with each ventricular contraction.
• pressure pulse or pulse waves

  Represent stroke volume output.
• Normal pulse

  1. Newborn: 120-140
  2. Child (1-5): 100-120
  3. Child (6-10): 90-100
  4. Adults: 60-80
• Respiration

  The act of breathing, respiratory intake of oxygen, and output of carbon dioxide.
• Hyperventilation

  Fast breathing
• Hypoventilation

  Shallow breathing
• Normal values of respiration:

  1. Infants: 30-40 breaths per minute
  2. Child: 20-30 breaths per minute
  3. Adult: 16-24 breaths per minutes
• Blood pressure is the measure of pressure exerted by blood as it flows through the arteries
• Systolic

  The measure of pressure of blood as a result of contraction of ventricles.
• Diastolic 


  when ventricles are at rest
• Normal blood pressure

  90-130/60-80 mmHg
• Course

  What usually happens to a person who has the disease
• Complication

  Other clinical conditions that can occur on top of the original clinical condition.
• Three reasons for doing tests or investigations:

  1. Help me decide between different possible diagnosis
  2. Confirm a diagnosis
  3. Provide a baseline b which I can judge if the patient is getting better or worse
• Three groups of tests:

  1. Those performed at the health center
  2. Those that require samples for testing in hospital laboratories
  3. Those that require the patient to be physically present for a test at the hospital and not the health center.
• Differential diagnosis

  A short list of all the diseases which could be causing the patient's main symptoms and signs.
• Diagnostic features

  The most typical things about the disease are nearly always present if that disease is present.
• Provisional diagnosis

  Is the disease I think the patient really has. It is usually concluded when elimination is done on the differential diagnosis.
• When you have made a provisional diagnosis, you manage the patient for this.
• The provisional diagnosis is the disease you think the patient has. Usually decided after eliminating all other diseases in the differential diagnosis as they do not fit the patient's symptoms' criteria.
• Management is done for provisional diagnosis
• Four important to consider when managing:

  1. Treat the patient
  2. Notify or advise certain other people
  3. Control the spread of the disease
  4. Prevent other members of the community from getting the disease and the patient from getting it again
• Treatments that include the following nine things:

  1. Decision on outpatient treatment or admission for inpatient treatment
  2. Nursing care of many types
  3. Specific treatments to attempt to cure the disease
  4. Symptomatic treatment, to attempt to relieve the patient's symptoms and make him/her feel better
• What to do when signs and symptoms provide indications

  1. Describe the patient's condition to health officer
  2. transfer
  3. Referral
• Prognosis

  What the likely result of a condition will be