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Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient. History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information.
The patient history is documented through a personal interview with the client and/or the client's family. If there is an urgent need for a focused assessment, the most obvious or troubling complaint will be addressed first. This is especially important in the case of extreme pain.
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
The medical history and physical examination were supremely important to diagnosis before advanced health technology was developed, and even today, despite advances in medical imaging and molecular medical tests, the history and physical remain indispensable steps in evaluating any patient. Before the 19th century, the history and physical ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".
A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [ 1 ] [ 2 ] [ 3 ] Essential parts of a case presentation include:
In the field of medicine a patient history is an account of the significant events in the patient's life that have a relevance to the issue being addressed. The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details. Much of the history is obtained by asking questions.