Exploiting Medical History and Past Traumatic Pathology

OUTLINE

The goal of the physical examination is to find the symptoms to make a diagnosis. From there, it is suggested to do more paraclinical tests to supplement the correct diagnosis. In the field of orthopedic trauma, many people think that just taking pictures X-ray of the lesion is sufficient basis for diagnosis. Many doctors, when examining patients, only make a brief visit and ask them to take films or do other imaging methods without taking a thorough history and examining them carefully. Because the personality seems so obvious and decisive in the X-ray film, the clinical examination is often not appreciated and paid attention to. This has led to errors, omissions in diagnosis, and inadequate treatment of the disease. Although today's science and technology is developing more and more sophisticated and modern diagnostic tools, it is still inevitable that it cannot replace medical history and clinical examination.

Exploiting the patient's medical history and medical history is a job that always follows us throughout our lives from being a medical student, starting a career until adulthood is a long-term experienced physician. A detailed history will make the diagnosis easier and more accurate. Every good medical record needs to take the medical history, the medical history must be complete, objective, meticulous, accurate, and keep a close eye on the patient's progress.

DISCOVER HISTORY

Reason for admission

The reason for admission is the most uncomfortable symptom that requires the patient to see a doctor (usually no more than three symptoms, symptoms are separated by commas or hyphens, no plus signs between symptoms) .

For example: pain in the foot after a fall, a lot of pain when walking. If the patient is referred, the diagnosis from the previous referral can be recorded.

When asking the reason for admission to the hospital, it is necessary to suggest very cleverly so that the patient does not mislead the diagnosis. The reason for admission is the first basis to find out the cause of the disease. Considered as the initial "key" for doctors to "open the door" into the world of patients. Also from the reason for admission to the hospital helps to suggest the part of taking history and examination later.

Medical history

Medical history describe disorders that directly affect the patient's life and health. Sometimes it is a collection of symptoms that develop over a short period of time, sometimes years to decades. Therefore, taking the history is very important. The doctor must ask short, clear, easy to understand questions (avoid using overly technical words).

While the patient tells the disease, he must listen patiently, do not interrupt or show discomfort, make the patient embarrassed, afraid not to tell the whole disease, but must know how to suggest and focus on the focus, not letting the story go too far. away or in the wrong direction. The physician must be able to listen, refine, and summarize the important details needed to make a diagnosis.

Depending on the patient's age, occupation, local accent, and level of knowledge, ask appropriate questions. If the patient is comatose or young, it is necessary to rely on the testimony of relatives (quoting the person declaring in the history: the patient's father declares, the patient's wife declares, ...). History ends at the time of examination. There are two medical histories with the time of visit of the patient as follows:

Newly admitted patients: History consists of two stages:

• Stage 1: from symptom onset to examination.
• Stage 2: current condition (only functional symptoms, no physical symptoms).

Patients who have been and are being treated at the hospital: History consists of four stages:

• Stage 1: from symptom onset to hospital admission.
• Stage 2: condition at admission.
• Stage 3: Prophylactic progression: record the main symptoms (both physical and functional) involved during treatment, whether symptoms decrease or increase, or new symptoms appear during treatment. treatment (if the patient lies less than 1 week, the progress should be recorded on a day-to-day basis).
• Stage 4: current status (specify time at examination), describe the patient's subjective functional symptoms when answering the doctor's questions.

+ Symptoms appear in the history section: which symptoms persist, which symptoms disappear, has there been a change in the nature of those symptoms?

+ Are there any new symptoms?

The history can be summarized as follows:

If it is a disease, pay attention to the following characteristics:

+ When did the disease begin (the more specific the better)

What symptoms appear first?

The nature of these symptoms

+ Other accompanying symptoms

+ How was the disease treated, where, and what were the results?

+ Record current patient status.

– If it is a new injury, we should pay attention to the following points:

+ Date and time of the accident location (the more specific the better)

+ Mechanism of injury: a clear description will help us visualize the force of impact, the degree of injury (the same mechanism can have many different injuries)

+ Other symptoms occur. For example, the patient has a headache, vomiting, chest tightness, ... or unconsciousness. These symptoms are important to suggest if there are other lesions involved.

+ First aid from the front line: after the accident, where and how does the patient receive first aid? Careful inquiry and correct description will help us to assess the condition and prognosis of the patient.

+ Record the current condition of the patient when entering the hospital for timely treatment.

METHODS OF DISEASE PRINCIPLES

Personal history

Medical history

• Internal, external, obstetric, pediatric, infectious, etc. diseases previously contracted are related to the current disease or serious diseases affecting the patient's health or quality of life. May have been cured or are in the process of treatment.
• Các bệnh lý nội khoa có thể ảnh hưởng đến gây mê hồi sức (nếu bệnh nhân tiên lượng phẫu thuật) như: tim mạch, tăng huyết áp, hen suyễn, lao phổi, đái tháo đường, sốt rét, viêm gan siêu vi, suy giảm miễn dịch mắc phải,… hay bất kì bệnh lý khác đi kèm. Ghi nhận rõ ràng thuốc đang điều trị, liều lượng, cách dùng.
• Previously treated surgical diseases, duration, length of hospital stay, complications, etc.
• Have you ever had such pain before?

Habit

Habits of smoking, drinking alcohol, drugs.

Allergy

Do you have any allergies to drugs or other foods?

Obstetric history

PARA, in addition, for women, it is necessary to exploit gynecological history such as: menstrual cycle, menstrual characteristics, menstrual disorders if any.

Family history

someone in the family has the same disease as the patient, or has a special genetic disease. If yes, describe who is in the family, how is the manifestation, if so, where is the treatment, etc.

Prepayment for children

easy or difficult birth, full term or premature birth, what is the number of children in the family, are they fully vaccinated, what are the diseases acquired from birth to now, where are they treated, etc. knee joint