Comprehensive Clinical History Overview
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ScribdTranslationsComprehensive Clinical History Overview
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ScribdTranslationsClinical History
It is a record of the data derived from the various examinations conducted on the patient.
It contains from the anamnesis, that is, the systematic questioning carried out with the patient from
that their attendance began, until the reports of the complementary explorations performed
by the psychologist or by the more sophisticated services of the hospital." For Vallejo Ruiloba, the history
the clinic consists of: anamnesis, physical examination, psychopathological and complementary
diagnostic orientation, prognostic orientation, treatment, evolution and comments, and epicrisis.
2. Anamnesis
conversation between the doctor and the patient, during which the doctor asks questions about the
medical history, lifestyle habits, and family background of the patient with the aim of
establish a diagnosis.
3. Reason for Consultation
The reason for consultation is the patient's expression for which they request healthcare attention.
There may be one or several reasons for the consultation in the same meeting between patient and
Specialist, and all should be expressed at the beginning of the clinical interview to facilitate their
posterior approach. In the case of stating more than one, they can be prioritized based on
various parameters (urgency, severity, resolutivity, etc).
4. Non-Pathological Personal Background
This section investigates the patient's data related to their environment (housing, surroundings)
familiar) as well as their habits (nutrition, food intolerance, hygiene, appetite, catharsis
intestinal
sexual, physical activity) in order to obtain the probable factors of what
triggers the current pathology.
5. Personal Pathological Background
They investigate the diseases the patient has suffered from childhood to the present day and
preferably that they have some possible relation to the current condition.
6. Family Medical History
Record of the relationships between family members along with their medical history.
This encompasses current and past diseases. In family history, sometimes there are...
observe the distribution of certain diseases in a family. It is also called medical history
familiar.
7. Diagnosis
process of recognition, analysis, and evaluation of a thing or situation to determine its
trends, to solve a problem or remedy a wrong. The word comes from Greek.
diagnostic
8. Symptoms
Physical or mental problem that a person presents, which may indicate an illness or
affection. The symptoms cannot be observed and do not manifest in medical examinations. Some
Examples of symptoms are headache, chronic fatigue, nausea, and pain.
9. Signs
Clinical signs are the different objective or visible manifestations resulting from a
disease or alteration in the individual's health status. The signs allow the professional
to make a diagnosis, and thus apply the appropriate treatment.
10. Clinical Evaluation
The clinical assessment aims to make a diagnosis and establish a treatment.
Assessment and evaluation of a patient's physical or psychological state, based on the information
obtained from the interview, the patient's medical history, and the anamnesis, from examinations
physical, laboratory test results, and psychological test results.
11. Biochemical evaluation
they are the biochemical indicators that are evaluated in blood, urine, and fecal samples, and
they provide us with information about plasma concentrations: it is observed there
glucose concentrations, urea, creatinine, uric acid, cholesterol, triglycerides, electrolytes and
many more. Excretion of nutrients or metabolites in urine or feces, Functional tests,
Nutrient reserves
12. Anthropometric Evaluation
Anthropometric data and information allow for diagnosing the morphological state and
control the changes produced by a physical activity program, training or a
nutritional intervention. They are also used to assess growing children, levels of
obesity, the effects of exercise on muscle circumferences, the reduction of folds
of subcutaneous fat. They can also be related to other data from an evaluation such as
body weight and oxygen consumption or other functional variables.
Dietary Assessment
Nutritional status is the result of the balance between food intake and needs.
nutritional of individuals, is the consequence of different sets of interactions of a type
biological, psychological, and social.
14. Diagnosis
it is that which, in the field of medicine, is related to diagnosis. This term, in turn,
refers to diagnosing: gathering data to analyze and interpret it, which allows
evaluate a certain condition.
References
FAO glossary(n.d.). Retrieved from [Link]