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  • Essay / Analysis of the clinical methods used to establish a clinical history

    Being a doctor means, above all, being able to observe carefully and listen well. There must be a very good interpersonal relationship between the doctor and the patient. A doctor must therefore be able to assess the signs, look for symptoms and make a diagnosis in a fairly methodical manner. This is where history comes in handy. It is the beginning of patient care and healing, devoid of any social, cultural or ethnic variation. This helps the clinician understand the patient's state of mind and analyze the signs. First, there should be a friendly greeting between both parties. The clinician should quickly assess a few important things like mannerisms, hearing, gait, mood, speech, posture, and any obvious abnormalities in the patient during the first few minutes of the meeting. Then we can move on to the story. Say no to plagiarism. Get a tailor-made essay on “Why Violent Video Games Should Not Be Banned”? Get an Original Essay Maintaining good eye contact is crucial. After explaining to the patient that we would follow a prescription by asking a few questions, we can conceal the collection of general data which includes date of birth, age, employment history, social status, medical history, family history , smoking habits and alcohol consumption. . Tracking history over a period of time provides a descriptive picture of the patient's current condition. This first part of the story is very important because it lays the foundation for an effective diagnosis. After the basic rituals, the patient must be encouraged to explain why he came to the consultation, at his own pace, without any interruption on our part or that of the accompanying person. Because even if he is interrupted a little, the patient will not be able to express his thoughts effectively and completely. Patients who present in a well-structured manner are in the minority. The clinician must therefore encourage the person by asking questions at the right time without offending them. The clinician should also not miss important clinical cues that the patient may show during the conversation. And we should converse using terms that are easy for the patient to understand, rather than complex clinical terms. The clinician's open-ended questions lead patients to unconsciously approve of the clinician and want to talk enthusiastically about their problems, which can help us identify what is important to the patient. On the other hand, direct questions will shut them down, preventing them from properly sharing their situation. This approach is “disease-centered.” The physician must moderate his need to arrive at the diagnosis and the patient's experiences and feelings. The clinician must be able to relate the severity of symptoms to the patient's personal life. What may seem critical to one person may not be so serious to another. Additionally, the degree of pain perceived by each individual is different. Pain scale assessment is helpful in managing the condition. The patient may be asked to rate the sensation of pain on a scale of 10 and be rated accordingly. Most women rate the pain of childbirth at 10. And although the patient may not be able to put things in order, the clinician should note the details, even if they are unexpected, and deal with it later. Each clinician may have their own personalized plan for taking history in different situations. However, it follows a common pattern as follows: - Name, age, occupation, place of birth, any other form of identity, presenting problem,medical history, specific medical history, history of main presenting problem, family history, employment history. , smoking, alcohol, allergies, drug and treatment history and direct questions about discovered body systems. Typically, illnesses are caused by dysfunction of multiple body systems. Thus, a comprehensive assessment should focus on all body systems rather than just the body systems concerned with the patient's perception as the problem area. Different systems can be analyzed by asking relevant questions on the following aspects: Cardiorespiratory: chest pain, palpitations, ankle swelling, orthopnea, nocturnal dyspnea, shortness of breath, etc. GIT: Abdominal pain, dysphagia, weight loss or gain, nausea, jaundice, bowel, rectal bleeding, etc. Genitourinary: hematuria, nocturia, dysuria, etc. Musculoskeletal: joint pain, changes in mobility, etc. Neurological: seizures, fainting, vision, hearing, emaciation, spasms, headaches, etc. Analyzing the patient's words in the back of the mind without rejecting them to their face is elementary in the study of history. Some areas require careful clarification. Pain is one of these areas. This usually confuses clinicians. Thus, the site, irradiation, character, severity, evolution over time, factors aggravating pain, factors relieving it and associated symptoms can be interrogated to precisely identify the problem linked to the complaint. Asking patients directly about the medications they have taken is not as effective. Instead, encouraging them to realize and remember everything they have taken by constantly and carefully asking them about certain medications that may have interfered is beneficial for medication history. Likewise, taking a family history can also be tricky. It may be helpful to find out about any illnesses that exist in their family, their family tree, and whether the same problem has occurred previously with other family members. A person's occupation also affects their current condition, especially with regard to non-organic problems induced by exposure to various environmental elements. Alcohol poses major health risks. It is therefore best to measure the amount of alcohol consumed in units of alcohol per week. The CAGE assessment is a smart approach to recording details of the patient's drinking habits. C - cut; A - Angry; G - Guilty; E - Revealer. It is also important to take medical history into account without completely giving in to what the patient expresses, so that any misinterpretation of the patient's past medical illness or misdiagnosis from a previous clinician does not affect our current diagnosis . Each patient is unique; the same goes for taking the history of different patients, although we most often follow a common routine. Talkative, angry, or knowledgeable patients or patient companions can pose challenges to the clinician. Talkative patients talk too much giving very less important details and should be treated with a well-balanced set of direct and indirect questions. In angry patients, anger may be part of the symptomatology or due to circumstances or expressed in response to diagnosis or treatment. If this attitude is as detrimental as the breakdown of contact between the two parties, then it is better to offer the patient a change of doctor. Today, doctors must provide as much detail as possible about the patient's condition in order to be able to choose wisely.