Translations:Medicine/9/en: Difference between revisions

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Message definition (Medicine)
The components of the medical interview and encounter are:
* Chief complaint (CC): the reason for the current medical visit. These are the '[[symptom]]s.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'chief concern' or 'presenting complaint'.
* History of present [[illness]] (HPI): the chronological order of events of symptoms and further clarification of each symptom. Distinguishable from history of previous illness, often called past medical history (PMH). [[Medical history]] comprises HPI and PMH.
* Current activity: occupation, hobbies, what the patient actually does.
* [[Medication]]s (Rx): what drugs the patient takes including [[Medical prescription|prescribed]], [[over-the-counter drug|over-the-counter]], and [[Home remedy|home remedies]], as well as alternative and [[Herbalism|herbal medicines or remedies]]. [[Allergy|Allergies]] are also recorded.
* Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past [[infectious disease]]s or [[vaccination]]s, history of known allergies.
* Social history (SH): birthplace, residences, marital history, social and economic status, habits (including [[diet (nutrition)|diet]], medications, [[:en:tobacco smoking|tobacco]], alcohol).
* [[Family history (medicine)|Family history]] (FH): listing of diseases in the family that may impact the patient. A [[Wikipedia:family tree|family tree]] is sometimes used.
* Review of systems (ROS) or ''systems inquiry'': a set of additional questions to ask, which may be missed on HPI: a general enquiry (have you noticed any [[Wikipedia:weight loss|weight loss]], change in sleep quality, fevers, lumps and bumps? etc.), followed by questions on the body's main organ systems ([[human heart|heart]], [[human lung|lungs]], [[digestive tract]], [[Urinary system|urinary tract]], etc.).

The components of the medical interview and encounter are:

  • Chief complaint (CC): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'chief concern' or 'presenting complaint'.
  • History of present illness (HPI): the chronological order of events of symptoms and further clarification of each symptom. Distinguishable from history of previous illness, often called past medical history (PMH). Medical history comprises HPI and PMH.
  • Current activity: occupation, hobbies, what the patient actually does.
  • Medications (Rx): what drugs the patient takes including prescribed, over-the-counter, and home remedies, as well as alternative and herbal medicines or remedies. Allergies are also recorded.
  • Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases or vaccinations, history of known allergies.
  • Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).
  • Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.
  • Review of systems (ROS) or systems inquiry: a set of additional questions to ask, which may be missed on HPI: a general enquiry (have you noticed any weight loss, change in sleep quality, fevers, lumps and bumps? etc.), followed by questions on the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc.).