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[citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]
He designed a set of standardized protocols to triage patients via the telephone and thus improve the emergency response system. Protocols were first alphabetized by chief complaint that included key questions to ask the caller, pre-arrival instructions, and dispatch priorities. After many revisions, these simple cards have evolved into MPDS.
In this brief vision test specialized cameras detect each eye's light reflexes, which the equipment's software or a test administrator then interprets. If photoscreening indicates the presence of risk factors, an ophthalmologist can then diagnose the condition after a complete eye exam, including dilating the pupils and measuring the focusing ...
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
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).
Central serous chorioretinopathy (CSC or CSCR), also known as central serous retinopathy (CSR), is an eye disease that causes visual impairment, often temporary, usually in one eye. [ 1 ] [ 2 ] When the disorder is active it is characterized by leakage of fluid under the retina that has a propensity to accumulate under the central macula.
When investigating amaurosis fugax, an ophthalmologic consultation is absolutely warranted if available. Several concomitant laboratory tests should also be ordered to investigate some of the more common, systemic causes listed above, including a complete blood count, erythrocyte sedimentation rate, lipid panel, and blood glucose level.
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]