medical history(redirected from Clinical history)
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Related to Clinical history: Heteroanamnesis
a systematic account of events.
case history see case history.
health history a holistic assessment of all factors affecting a patient's health status, including information about social, cultural, familial, and economic aspects of the patient's life as well as any other component of the patient's life style that affects health and well-being. The health history is designed to assess the effects of health care deviations on the patient and the family, to evaluate teaching needs, and to serve as the basis of an individualized plan for addressing wellness.
medical history information obtained from the patient to aid in establishing a medical diagnosis and developing a treatment plan.
nursing history a written record providing data for assessing the nursing care needs of a patient.
a narrative or record of past events and circumstances that are or may be relevant to a patient's current state of health. Informally, an account of past diseases, injuries, treatments, and other strictly medical facts. More formally, a comprehensive statement of facts pertaining to past and present health gathered, ideally from the patient, by directed questioning and organized under the following heads. Chief Complaint (CC): a brief statement of the complaint or incident that prompted medical consultation. History of Present Illness (HPI): a detailed chronologic narrative, as much as possible in the patient's own words, of the development of the current health problem from its onset to the present. Past Medical History (PMH): prior illnesses, their treatments and sequelae. Social History (SH): marital status, past and present occupations, travel, hobbies, stresses, diet, habits, and use of tobacco, alcohol, or drugs. Family History (FH); present health or cause of death of parents, brothers, sisters, with particular attention to hereditary disorders. Review of Systems (ROS): an exhaustive survey of symptoms or diseases, organized by body system, not covered in previous parts of the history.
See health history.
medical history(1) History of medicine, see there.
(2) The part of a patient's life history that is important in determining the risk factors for, diagnosing, and treating a disorder, as in a history of exposure, symptoms, occupational, exposure to causative agents linked to a particular condition, physical trauma, infection or cancer.
medical historyClinical medicine The part of a Pt's life Hx important for determining the risk factors for, diagnosing, and treating a disorder–eg, history of exposure, Sx, occupational, exposure to causative agents linked to a particular condition, infection or cancer Vox populi → medtalk Anamnesis
medical historyinformation given by patient (and/or patient's partner/carer/parent/referring practitioner), detailing the patient's current and past health status (Table 1)
|History element||Additional information|
|Introductory information||Demographics (age, sex, race, place of birth, marital status, occupation, religion, next of kin)|
|Main presenting complaint||The problem that has prompted the patient to request the consultation (and/or additional information supplied by referrer)|
|Medical||General state of health, childhood illnesses, adult illnesses, psychiatric illnesses, accidents and injuries, operations and hospitalizations (list surgical procedures in chronological order)|
|Podiatric||Previous foot/limb problems and treatments received|
|Current health status||Current GP or hospital clinics attended|
Current allied health professional clinics attended
Alternative therapists attended
|Drugs/medications history||Current and previous prescription-only medicine regimes|
Current and recent over-the-counter regimes
Allergies and hypersensitivity history
|Family history||Health and age of siblings/parents/children|
Ages and causes of death of parents/grandparents
|Social history||Smoking/alcohol/recreational drug consumption|
Hobbies and recreational activities
|General systems review: CRANGLES||C = cardiovascular system (e.g. history of heart problems, high blood pressure, previous rheumatic fever, heart murmurs, arrhythmias/palpitation, chest pain/angina, blood dyscrasias, peripheral arterial disease [intermittent claudication, leg cramps, rest pain], venous incompetence, lymphatic dysfunction)|
R = respiratory system (e.g. history of asthma, bronchitis, emphysema, tuberculosis)
A = alimentary system (e.g. history of weight change, indigestion, gastric/duodenal ulcer, liver or gallbladder problems, irritable bowel, constipation)
N = central and peripheral nervous system (e.g. history of stroke, nerve injury, any psychiatric problems, fatigue and sleep alteration)
G = genitourinary system (e.g. polyuria, nocturia, pain on urination)
L = locomotor (musculoskeletal) system (e.g. joint or muscle pain, morning stiffness, arthritis, gout, lower-back pain)
E = endocrine system
S = skin (rashes, lumps, sores, itching, dryness, colour changes, changes in hair/nails/sweat pattern)
|Foot and lower-limb systems review||Vascular review (arteries, veins, lymphatics)|
Neurological review (sensory, motor, autonomic)
Overall impression of status of tissues of the foot and lower limb