File Name: clinical history taking and examination .zip
This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables. As a basic textbook for the academic teaching of physical diagnosis, this one has many excellent features and few faults.
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Professional Reference articles are designed for health professionals to use. You may find one of our health articles more useful. NICE has issued rapid update guidelines in relation to many of these.
The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms , in contrast with clinical signs , which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
Taking a history from a patient is a skill necessary for examinations and afterwards as a practicing doctor, no matter which area you specialise in. It tests both your communication skills as well as your knowledge about what to ask. Specific questions vary depending on what type of history you are taking but if you follow the general framework below you should gain good marks in these stations. This is also a good way to present your history. In practice you may sometimes need to gather a collateral history from a relative, friend or carer. This may be with a child or an adult with impaired mental state.
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