Hello fellow SteemSocial members, this is my first post in your community, I hope to be able to share with you my knowledge about medicine and to be able to provide you with publications of great interest.
Today I want to talk about a topic that for us health personnel is fundamental and it is none other than the medical history, a legal medical document that we all use to narrate everything about the patient. I am sure that everyone will have something to say about this.
Because undoubtedly every time we go to a hospital or a clinic, there are many questions we are asked and it is precisely to fill in the necessary information of our patients.
A medical history is made up of many parts, and both the medical and nursing staffs handle one of them. First of all, I can mention the patronymic record, where we put part of the patient's data: name, last name, age, address, emergency telephone numbers, religion, because as you know, there are religions that do not allow blood transfusions, so it is relevant.
The blood type, marital status, as you can see this first step is to talk about the patient's personal data and it is usually much faster than it seems.
Then we move on to the reason for the consultation, which is nothing more than stating why the patient came to the hospital or clinic, for example, if he/she came for fever and vomiting, we put that in that part of the history. Usually these are the symptoms or signs that the patient refers.
The next step is to talk about the current disease, which is nothing more than the chronological narration of the symptoms and signs that the patient presented. Here we must make a lot of emphasis, because many times only with this small step, we can decipher the real diagnosis.
Here we should ask the patient about specific times and dates, the key moment when it all started, the exact description of the symptoms, if it was a fever for how long, if it subsided or not with medication, what was the maximum temperature reached, every detail counts. If there was any intake of other medications, in short, the complete evolution of the disease or in this more specific case of signs and symptoms.
At the end of the current disease comes the time to place the diagnosis, but usually first we go to the history and physical examination, and at the end we place a possible diagnosis or simply the definitive diagnosis if we are completely sure, but usually laboratory or imaging tests are usually indicated.
Here we ask about allergies, surgical, personal, family, epidemiological, pathological, pathological and gynecological antecedents if necessary (in women).
And we must also take into account the psychobiological and socioeconomic background. This is important because many times by the area where the person lives we can make a possible diagnosis or by his or her habits in general.
After the history, which is not at all pleasant for patients because there are certainly many questions. We go to the interrogation by apparatus and systems, here we make more emphasis on those symptoms and signs that the patient presented. More details, frequencies, quantities, everything much more specific.
And last but not least, we have the physical examination, here we will implement the 4 steps of the physical examination, the inspection where we detail every part of the patient's body, so we can identify any abnormality, any difference, the facies, gait, posture, speech, in short, every detail that is in sight.
Then we move on to palpation, although it is not always the order, it depends on the doctor, some prefer to start with auscultation and then move on to the rest. In the palpation we will apply certain maneuvers to rule out some pathologies. Many times just by performing these techniques we can finally reach the final diagnosis.
Then we have the percussion, where through small blows we can know the state of some organs or spaces of the body, for example, at the level of the abdomen, where we can demonstrate if there is tympanism or if on the contrary there is dullness. This can guide us towards certain diseases.
And finally we have the auscultation, where we use our best companion, "the stethoscope" and auscultate in many parts of the body, especially at the thoracic and abdominal level. There, in case of respiratory symptoms, we can rule out certain pathologies or, on the contrary, confirm our diagnosis.
Of course, we can not forget the diagnosis, some doctors place a presumptive diagnosis while performing other studies, and then we go to the treatment, which usually meets the nursing staff, it is important to have and be part of a great team.
As we can see it is quite an extensive and very important topic, that is why it is necessary that patients know the magnitude of everything we do because many times they do not want to collaborate in the process, we do not do it to bother them or because we do not want to attend them, but because this document is very important for us.
It is here where we capture everything relevant to the case and where we will always have a history of each of the patients served. In addition, it is a legal document, because everything that was done remains and can be used in case of any problem or misunderstanding.
So, if you are a patient remember that all this is for the common good, to be able to have a much clearer picture and for your peace of mind. I hope this topic has been to your liking and has brought you value.
See you soon, if you have any quality comments or any experience you can share it with me in the comments.
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