Clinical Practice

"The Doctor" by Sir Luke Fildes, 1891

Clinical practice, assess the patient's personal physician to diagnose, treat and prevent disease, clinical evaluation. Doctor-patient relationship usually starts with a history of interaction with the investigation of patients and medical records, the medical interview and physical examination. The main diagnostic medical devices (eg, stethoscope, tongue depressor) is normally used. After an interview and examination for signs of symptoms, your doctor may order medical tests (eg blood), a biopsy or prescription drugs or other pharmaceutical therapies. Differential diagnostic methods to help develop the conditions, based on the information. At the meeting, properly informed the patient of all relevant facts is an important part of relationships and develop confidence. Medical experience is then documented in the medical record, which is a legal document in many jurisdictions. [17] followups are shorter, but the same general procedure.

Components of the medical interview and the meeting is:

Chief complaint (cc): cause of the current medical visit. These are the "symptoms". These words have been patient and are included with each length. Also called "an appeal."

History of present illness / complaint (HPI): Early symptoms and further clarification of any symptom. Current activity: occupation, hobbies, what the patient actually does. Drugs (Rx): what drugs the patient is also provided for over-the counter and Home and herbal remedies, and alternative / herbal medicines. Allergies are also recorded.

Past medical history (PMH / PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and / or vaccination, history of known allergies.

Social history (SH): birthplace, residences, marital history, social and economic status, habits (including food, drugs, tobacco, alcohol).

Family history (FH): a list of diseases in the family, which may affect the patient. Genealogy is sometimes used.  An overview of systems (ROS) or systems science: a series of additional questions that may be left on HPI: a general review (you've noticed that the weight loss, changes in the quality of sleep, fever, lumps and bumps? Etc..), Followed by questions on the main body systems ( heart, lungs, digestive tract, urinary tract, etc.).

Physical examination of the examination of a patient looking for signs of disease (symptoms' is what the patient volunteers, 'Signs' are what the healthcare provider detects the control). Health care provider uses the senses of sight, hearing, touch, smell and perhaps (taste has been dismissed by the availability of modern lab tests ). Four chief methods: control of palpation (feel), percussion (tap determine resonance characteristics) and Listening (listening), the smell may be useful (eg infection, uremia, diabetic ketoacidosis). Clinical trials include studies of: Vital functions, such as height, weight, body temperature, blood pressure, heart rate, respiration, oxygen-hemoglobin saturation The general impression of the patient and specific indicators of disease (nutritional value, the presence of jaundice, pallor or Clubbing)

Skin

Head, eye, nose and throat (HEENT)

Cardiovascular (heart and blood vessels)

Respiratory (large airways and lungs)

Abdomen and rectum

Genitals (and pregnancy if the patient is or may be pregnant)

Muscles (including the spine and the extremities)

Neurological (consciousness, awareness, brains, vision, cranial nerves, spinal cord and peripheral nerves)

Psychiatric (orientation, mental status, evidence of abnormal perception or thought)

Laboratory and imaging studies results may be obtained, if needed.

Medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (differential diagnosis), with the idea of what to do in order to obtain a definitive diagnosis to explain the problem to the patient.

Treatment may include an additional laboratory tests and studies, starting therapy, seek professional care or follow-up. Follow-up may be recommended.

This process is used by primary care physicians and specialists. There are only a few minutes if the problem is simple and clear. On the other hand, the weeks in one patient recorded a number of bizarre symptoms or problems with the system, are involved in a number of specialists.

For subsequent visits, the process is repeated an abbreviated manner to obtain a new history, symptoms, physical findings and laboratory or imaging results or specialist consultations.