history(redirected from makes history)
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neurologic examinationA 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.
non-cardiac chest painInternal 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.
ClinicalSection/08Chestpain.html, from Dept Navy, Bureau of Med & Surg; Internally Peer Reviewed
to meals and relative nonresponse to nitroglycerine helps distinguish this pain from
past, family and/or social historyMedical 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
historyA 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.
historythe 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
|Facilitation||Actions/postures/words that communicate the interviewer's interest in what the patient is saying|
|Reflection||The interviewer repeats the patient's key words, to encourage the patient to continue speaking|
|Clarification||Requesting more support information and meaning, to ensure that the interviewer's interpretation is the same as the patient's meaning|
|Empathy||Words/actions that communicate that the interviewer recognizes the patient's feelings|
|Ask about the feelings||Direct questions on what the patient felt in terms of pain, discomfort, an event or a symptom|
|Interpretation||Summarization and paraphrasing of what the patient has said during the interview to ensure that there is no misunderstanding|
|Confrontation||Stating something about the patient's responses (feelings/behaviours) which are inconsistent with other symptoms or signs|
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.