medical history


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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.

medical history

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.

medical 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 history

Clinical 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 history

information given by patient (and/or patient's partner/carer/parent/referring practitioner), detailing the patient's current and past health status (Table 1)
Table 1: The medical history
History elementAdditional information
Introductory informationDemographics (age, sex, race, place of birth, marital status, occupation, religion, next of kin)
Main presenting complaintThe problem that has prompted the patient to request the consultation (and/or additional information supplied by referrer)
Past history
MedicalGeneral state of health, childhood illnesses, adult illnesses, psychiatric illnesses, accidents and injuries, operations and hospitalizations (list surgical procedures in chronological order)
PodiatricPrevious foot/limb problems and treatments received
Current health statusCurrent GP or hospital clinics attended
Current allied health professional clinics attended
Alternative therapists attended
Drugs/medications historyCurrent and previous prescription-only medicine regimes
Current and recent over-the-counter regimes
Allergies and hypersensitivity history
Family historyHealth and age of siblings/parents/children
Ages and causes of death of parents/grandparents
Social historySmoking/alcohol/recreational drug consumption
Hobbies and recreational activities
General systems review: CRANGLESC = 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 reviewVascular review (arteries, veins, lymphatics)
Neurological review (sensory, motor, autonomic)
Biomechanical review
Dermatological review
Overall impression of status of tissues of the foot and lower limb
References in periodicals archive ?
To complete the medical history, the investigator must examine the date and circumstances of the infant's last doctor's visit; determine if the child ever received emergency room attention and, if so, under what circumstances; and ascertain if the baby ever required a hospital stay or surgery.
Of the group-three participants who received a medical history of somatic complaints, 80% would order more tests for the patient with a headache, with 21% believing a subarachnoid hemmorhage was possible.
Unfortunately, the medical history is disintegrating.
Taking a family medical history involves asking the patient a number of questions about the health history of his/her family.
A medical history and physical examination may be the only diagnostic tests needed before the doctor suggests treatment.
When a paramedic, or other health professional, gets to the scene it's vital they know as much as possible about the patient - medical history, allergies, crucial details which can save time and ultimately a life.
Very strongly recommended, Beyond The Hippocratic Oath is a highly encouraged read among students of medicine, ethics, and medical history, as well as non-specialist general readers with an interest in any of the above.
From key events which sparked changes and people involved in them to how inflections diseases have been stopped, Plagues And Poxes provides both a case history and a social analysis, written by a medical doctor who has been a member of many prestigious medical history societies.
While the history of childbirth in Canada has been discussed under the rubric of other, related issues, such as maternal and infant welfare, the eclipse of midwifery and the concomitant professionalization and specialization campaigns in medicine, Wendy Mitchinson's study is the first in-depth, monograph-length examination of a topic that sits at the critical juncture of women's, family, and medical history.
The Pentagon has acknowledged past problems with tracking troops' medical history, but Pentagon officials said their recordkeeping in the current conflicts in Afghanistan and Iraq has greatly improved.
A 50-year-old woman with a medical history of hypertension and depression was admitted to the hospital for exacerbation of her chronic obstructive pulmonary disease.

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