Confección de una historia clínica

Confección de una Historia Clínica

THE HISTORY
A complete history is composed of the following parts, which will be discussed in some detail:

(1) General Information
Name of Patient
Address (home and business address and telephone)
Age, Sex, Marital status (S,M,W,D)
Race
Occupation (at the time of examination or hospital admission)Date of examination or admission to the hospital
Name and address of family physician, if relevant
2) Chief Complaint (C.C.)
3) Present Illness (P.I.)
4) Systemic Questionnaire
2) Past History Family history
Previous illnesses, operations and injuries; results of prior examinations when useful
Menstrual and obstetrical history Habits
Birthplace and former areas of residenceOccupational history and, where pertinent, military history Educational history, when significant
(6) Social History
Family, business and personal matters Marital history
(7) Psychiatric History
This need not be repeated if it is integrated into other parts of the history, such as the Present Illness. Otherwise, when the patient and his problem suggest the need, the features of anypsychiatric disturbance should be included here.

A psychiatric history should be included only if the patient exhibits a psychiatric disturbance.
GENERAL INFORMATION

The exact way a history is obtained is determined by many circumstances. Always introduce yourself to the patient if he does not already know you. Be friendly but not "breezy" or familiar; make him comfortable. Do not addressa patient on a first name basis unless he is a personal friend. To do so cheapens you and the patient. It is helpful, when you first see the patient, to open the conversation with the exchange of a few pleasantries—things that you think might be good "ice breakers" with this particular person, unless he is well known to you. In time you will learn to appraise a new patient quickly, and this earlyimpression will be an excellent initial guide as to how you should proceed. As you obtain the history, do not exhibit over concern, apprehension or surprise. Many patients are very alert to your reactions.
When talking with a patient maintain frequent eye contact and observe how he replies. Speak in a clear, soft tone of voice and use inflections of your voice and appropriate gestures. Don'tfall into a sing-song, monotonous pattern of questioning. Don't let your voice trail upward or downward at the end of every sentence. Make obvious your concern for the patient and his problem, and make your conversation with him friendly and interesting. Never act like an inquisitor.
A history should be taken in private. Assure privacy on the wards as best you can. The presence of a third personusually inhibits free discussion by the patient, and too often results in the insertion of many erroneous or distorted opinions of the third party. Sometimes the observations of a third person are of great value, especially if the patient is impaired mentally or may have had attacks (such as epileptic seizures) of which he has no memory. When first seen, your patient may be unconscious, or may bea child. Here you are entirely dependent upon another person for vital information.
Many minor illnesses, such as colds, sore throats, simple injuries and acute gastroenteritis, are usually clear-cut and self-limited. It is not necessary to obtain a full scale, long form history about them; you need only enough information to clearly define the problem. This does not mean that your defensesshould be down so that you fail to recognize that this "simple" complaint is the initial symptom of a more sinister condition. All other patients, particularly those whose trouble is not readily explained, and not excluding those who may have only one complaint (headache, unexplained weight loss or a recent change in bowel habit, for example), deserve a careful review of their whole history. Time...