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history

 [his´to-re]
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.

history

(his'tŏr-ē),
1. A record of a patient's symptoms, illnesses, and conditions, alterations in development, and significant related life events.
2. A record of earlier events, usually with some sort of analysis and interpretation.

history

[his′tərē]
Etymology: L, historia, inquiry
1 a record of past events.
2 a systematic account of the medical, emotional, and psychosocial occurrences in a patient's life and of factors in the family, ancestors, and environment that may have a bearing on the patient's condition.

neurologic examination

A battery of clinical tests that evaluates a person's physiologic function and mental status, as well as the presence of any structural–organic lesions that may cause changes in neurologic function. Cf Psychiatric examination.
Neurologic Examination-data obtained
History of the Pt's chief complaint
Mental status Coherency, memory, judgement, comprehension, and other cognitive processes
Cranial nerves
1. Olfactory–1st cranial nerve Ability to identify common odors
.
2. Optic nerve–2nd cranial nerve Visual acuity, visual fields, pupil size and response to light, optic examination
.
3. Ocular muscles–3rd, 4th, 6th cranial nerves
.
4. Trigeminal nerve–5tth cranial nerve
.
5. Facial nerve–7th cranial nerve
.
6. Auditory nerve–Rinne & Weber tests, 8th cranial nerve
.
7. Glossopharyngeal–9th cranial nerve, vagal nerve–10th cranial nerve
.
8. Accessory nerve–11th cranial nerve
.
9. Hypoglossal nerve–12th cranial nerve
Motor function
Upper extremities: Finger-to-nose test, extension-flexion of elbow, power of grip, reflexes–eg biceps, brachioradialis, sensation–eg vibration, pain
Lower extremities: Heel-to-knee test, extension-flexion of knee, reflexes–eg patellar, plantar, sensation–eg vibration, pain  
.

non-cardiac chest pain

Internal medicine Chest pain that simulates cardiac nosologies, but is unrelated to cardiovascular disease; 50% of Pts with NCCP have known reflex and may have postprandial or noctural Sx. See Gastroesophageal reflux disease.
Non-cardiac chest pain shamelessly taken, virtually verbatim from www.vnh.org/GMO/
ClinicalSection/08Chestpain.html, from Dept Navy, Bureau of Med & Surg; Internally Peer Reviewed
Sources of chest pain The heart, great vessels, pericardium; GI tract; lungs & pleura; chest wall
How to minimize YOUR risks of managing Acute chest pain Identification of ischemic chest pain requires a high index of suspicion; when the diagnosis of acute MI is overlooked and Pts are sent home–the mortality during the next 72 hrs is about 25%–how did you spell  that phrase again, “…out-of-court settlement.”–vs ± 6% for Pts with infarction who are hospitalized; being liberal in admissions for evaluation of CAD; incidence of acute MI in Pts hospitalized with acute chest pain is between 25 and 30%; despite conservative admission rates, clinicians misdiagnose ±5-10% of Pts with acute MI–ie, you're in good company if you screw up
History The Hx rules decision making; elements of the Hx important in discriminating cardiac from noncardiac chest pain are quality, severity, duration and frequency; knowledge of exacerbating features and maneuvers that ameliorate the discomfort are helpful; cardiac risk factors should not overly influence clinical thinking; the presence of risk factors simply implies that a person is more likely to develop overt signs of ASHD in the future, but are not exclusionary criteria
Pain character Chest pain due to coronary ischemia is classically a dull heavy pressure–but Pts have been pretty colorful in use of adjectives to describe this pain; they may have classic pain, DON'T expect a classic description of anginal pain; the pain may be confined to the chest or accompanied by aching in one or both arms, more often the left; neck or mandibular pain or aching confined to the shoulder, wrist, elbow, or forearm may manifest solely or with typical chest pressure; small zones of pain are generally not of myocardial origin; radiation of pain to the digits, brief zaplets of pain or discomfort that persists for days are not due to myocardial ischemia; effort or emotional stress commonly provokes angina; angina may occur at rest if perfusion is compromised; pain subsides within 1 to 5 mins if the triggering activity is discontinued; nitroglycerin hastens this relief
EKG The 12-lead ECG has limited value in excluding the presence of CAD; excluding the Dx of angina pectoris or acute MI because of a normal ECG is as great an error as inferring a diagnosis of CAD from the incorrect interpretation of nonspecific electrocardiographic abnormalities
Cocaine Cocaine causes ↓ coronary blood flow due to vasoconstriction; rhabdomyolysis, a complication of cocaine use, provides another mechanism for the chest pain; all chest painers should be questioned about cocaine use and, when appropriate, have a urine drug screen
GI tract Pain from the GI tract, especially the esophagus, may give rise to angina-like chest discomfort; GERD is the most common esophageal cause of noncardiac chest pain; it is described as a burning sensation or squeezing pain located in the retrosternal area between the xyphoid and suprasternal notch; listen for clues about association of Sx with meals, posture, and relief by belching or antacids; medical management involves dietary modifications, smoking cessation, and histamine type 2 (H2) antagonists or antacids; GI referral is warranted when these interventions are unsuccessful in alleviating Sx; the pain of peptic ulcer disease may also occur high in the epigastrium or lower chest; relationship
to meals and relative nonresponse to nitroglycerine helps distinguish this pain from
angina pectoris
Esophagus spasm Diffuse esophageal spasm is a neuromuscular disorder characterized by chest pain and difficulty in swallowing; NOTE Nitroglycerin promptly relieves esophageal spasm causing confusion in the diagnosis; vigorous disordered contractions in the body of the esophagus are induced by ingestion of cold liquids or normal swallowing during a meal; anxiety and stress are also common precipitating factors; there is usually no exertional component but ↑ abdominal pressure from lifting, sit-ups, or running can cause reflux; diagnosis rests on history and verification of esophageal spasm by manometric studies
Pulmonary origin Pain of pulmonary origin characteristically has a distinct pleuritic quality varying with the respiratory cycle; intercostal nerves supply sensory afferents to the costal parietal pleura; inflammation arising from this region is appreciated in the adjacent chest wall; referred pain originating in the diaphragm is appreciated in the ipsilateral shoulder; differentiating features of pulmonic from musculoskeletal pain are the more intense nature of pleuritic pain and the worsening of musculoskeletal pain by extension, abduction, or adduction of the arm and shoulder; pain centered around involved muscle groups may also distinguish musculoskeletal from pleuritic chest pain; (a) Spontaneous pneumothorax tends to occur in young adult males producing sharp pleuritic chest discomfort and dyspnea; (b) Pulmonary embolus may produce pleuritic pain, however, dyspnea, and tachypnea are most frequent. Inciting factors for pulmonary embolus include the post-operative period after long recumbent or inactive periods and following trauma where the same immobility may result in venous stasis and thrombosis.
Chest wall Tietze's syndrome or costochondritis is a self-limiting discomfort. Its quality is sharp or burning and is exacerbated by mechanical activity of the chest wall, specifically respiration; the second or third costal cartilages on either side are the most common area of involvement, but any of the costochondral articulations can be involved; NSAIDs or aspirin may offer temporary relief but reassurance tends to be as useful.
Etc Rarely, no etiology is found on standard evaluation of chest pain from the cardiology or GI consultation; one should then rule out panic disorder, visceral hypersensitivity in irritable bowel syndrome, and other exotica

past, family and/or social history

Medical practice A historical evaluation of a Pt, which consists of a review of 3 areas, which is required for CPT-related documentation of a physician's evaluation and management services
History
Past history The Pt's past experiences with illnesses, operations, injuries, and treatments
Family history A review of medical events in the Pt's family, including disease which may be hereditary, or place the Pt at risk
Social history An age-appropriate review of past and current activities

his·to·ry

(his'tŏr-ē)
In health care, record of a patient's symptoms, illness, and treatment thereof, as well as other life details related to health.

history

A medical history is the record of everything that is relevant to a person's health. A full history includes an account of the previous medical conditions, the social and family record and the details of the present complaint. Taking a good medical history is a fine art.

history

the reported patient's health up to the present day; the history should review the medical and surgical status of all body systems (following CRANGLES protocol), lower limb and foot (following the DeBiFVaN protocol), and also note pharmacological history (both prescribed and over-the-counter medications) and sociological history (noting smoking, alcohol and recreational drug use), occupation and social history, particularly in relation to any proposed treatment regime; see Table 1
Table 1: Principles of data-gathering - factors within the medical history interview
InterventionsComments
FacilitationActions/postures/words that communicate the interviewer's interest in what the patient is saying
ReflectionThe interviewer repeats the patient's key words, to encourage the patient to continue speaking
ClarificationRequesting more support information and meaning, to ensure that the interviewer's interpretation is the same as the patient's meaning
EmpathyWords/actions that communicate that the interviewer recognizes the patient's feelings
Ask about the feelingsDirect questions on what the patient felt in terms of pain, discomfort, an event or a symptom
InterpretationSummarization and paraphrasing of what the patient has said during the interview to ensure that there is no misunderstanding
ConfrontationStating something about the patient's responses (feelings/behaviours) which are inconsistent with other symptoms or signs

history

in a clinical examination, the collection of facts about the clinical signs of the patient, its environment including feeding, vaccination status, exposure to infection, recorded and arranged in chronological order and in relation to each other.

Patient discussion about history

Q. I took my friend to a doctor and he questioned her about her history of alcohol. My friend who is a county level athlete is a superb runner. We were all sure that she would be selected for high level competitions. Two years back she lost one of the track events and did not make any attempt to try again. Her problem started when she lost her mother during a practice session. This has been very hard on her and has led to a trauma so much so that she has lost her confidence and has started drinking. She has never touched alcohol before in her life and has become such a wreck that I feel so sad for her. When I last met her she was in a bad condition and was drinking more heavily than usual. She did recognize me though and I sat and talk to her for a long time. I took her to a doctor and he questioned her about her history of alcohol. I do not know how long all this is going to take as she has no family members alive and is totally alone. Her dreams have perished and she feels helpless. I will help her all I can with information and whatever else I can do for her apart from the treatment she has started on.

A. I am so happy that you have a helping nature. First of all, let her treatment go on for as long as she needs it, as she needs to regain her lost strength before she makes a comeback as an athlete. It`s very difficult to be by her side all the time though she might need a friend at this desperate juncture since she has lost her dreams. You can support her by admitting her in a rehab center or any other organization that helps alcoholics. I hope she will get well soon.

More discussions about history