The writing of the reason for consultation and the current disease in a medical record is an essential part of medical practice, the preparation of it can make the difference between a good diagnosis or an uncertain one, so it is necessary to understand and understand its elaboration from undergraduate.
Reason for consultation:
The reason for consultation is, worth the redundancy, the fact that motivated the patient to go to the doctor, it can be only one or it can be several. Often this must be elucidated. It happens in practice that patients can give inaccurate information about their ailment and the reason for consultation go unnoticed or not ranked as such. It is therefore useful when writing the narration of the history to listen to the reason for the consultation but without writing it down, to do so after collecting the complete data of the current disease and thus check whether the reason for the consultation provided by the patient agrees with that of the current disease. An example would be a patient who presents for "abdominal pain", but when taking a complete anamnesis it is detected that in the hours prior to the consultation there was bloody vomiting,
This practice of comparing what the patient reports with what is collected from the current illness is useful since the person often finds excuses for seeking medical attention, either out of embarrassment, or because of downplaying what happened. The doctor must create an environment of trust so that the patient can feel comfortable and relate as much information as possible.
The next thing to discuss is the dilemma that often arises over recording the "doctor's words or the patient's words." If the bibliography on this point is controlled, neither of the two behaviors is wrong, but some considerations are established.
The medical record is constructed for the use of health professionals. It is a fundamental database of medical practice. It is an essential record for a conscious and hierarchical service. The people trained to read and understand the narration of the medical history are the doctors and related personnel. Medical terminology is accurate, and expresses or attempts to accurately express biological reality. It is based on science. The use of colloquial language is only understood when it is intended to be "clearer to the common people" in what is expressed. To use an example, the patient narrates "My leg is falling asleep." This can be interpreted in different ways as causes.
The ordering of the information known as the Problem-Oriented Clinical History, has a section called SOAP, (Subjective, Objective, Analysis and Plan) where you can write verbatim what the patient relates so that in the reading of the narrative any member the health team can make their interpretation and thus draw their own conclusions.
In short, the information that faithfully expresses reality must always be transcribed, and if it is necessary to use the patient's words for this, it can be used.
In the space for the reason for consultation, not all the signs and symptoms that the patient has should be written, but rather the most important and relevant ones, so for example, if the patient comes for hematemesis and has abdominal pain, it can be noted as a reason for consultation: Hematemesis and abdominal pain.
Special care must be taken in choosing the correct words and terminology to make the reason for consultation. "Excess saliva" is not a correct term. It should be written Sialorrhea or Hypersialia.
In the case that the patient attends the consultation with an established diagnosis that does not offer doubts, the reason for the interview must be written. An example of this can be the patient who comes to the consultation for a pre-surgical control. In this case, you can write down "Pre-surgical consultation for umbilical hernia surgery".
It may happen that the reason for consultation is imprecise or not a sign or symptom, such as: Traffic, domestic or work accidents, requests for hospitalization or referral, inter-consultations, exacerbations, etc.
The writing of the current disease space is what requires more dedication. Just as in other sections they should only be completed with objective and precise data, this is where literary skills should be used to achieve the best writing of the current picture of the patient and that it is interpreted by the other members of the health team.
There are different opinions on how to write the chronology of the signs and symptoms of the clinical picture, some choose to write chronologically the facts from the onset of the disease until the arrival of the patient until the current consultation, others, on the contrary, decide to write first place, the symptoms and signs included in the reason for consultation, and this is a valid point, since if the reason for the consultation is hematemesis and the patient has been suffering from different signs and symptoms for three months, you should read the entire current disease until the end where hematemesis would be cited. Taking this into account, it seems logical to start by first writing the reason for the consultation and once finished, continue chronologically from the beginning of the table. For example:
Reason for consultation: Hematemesis
Current disease: 53-year-old male patient who attends the Centenario hospital guard service for a condition characterized by an episode of low intensity hematemesis, two hours prior to the consultation, refers to lunch 3 hours before and that it was preceded by nausea.
This example clearly expresses the above. Hematemesis, which would remain at the beginning, as in a news item, where the reason for consultation would be the headline and then the rest of the information would be developed successively
The successive description without ranking would be:
Reason for consultation: Hematemesis
Current disease: 53-year-old male patient who attends the Centenario hospital guard service for a condition characterized by abdominal pain of increasing intensity over the months, of a burning and oppressive nature in the epigastric region that radiates to the left hypochondrium and back and is relieved with the intake of alkalis or commercial antacids.
This other interrogation model does not rank the dimension of the painting in the narrative.
In the drafting of the current disease there are guidelines that are mandatory and other optional. Among the mandatory guidelines is the order of events, never begin to describe a symptom, and then cite a different sign and then resume the initial symptom. It must be done in order to avoid complicating the interpretation of the painting.
It is optional to use a separate paragraph to describe a certain sign and / or symptom, so that each of them is well defined and the understanding of the current disease is improved.
Signs, objectifiable to the patient, must be specified with all their characteristics and if there were any witnesses.
For example: - "I had a fever of 39º C!"
If we write in the clinical history "Patient refers fever of 39º C", we would be ensuring that the patient had a fever, which can be true or false, that is why it is specified in a more precise way by asking the patient if the patient was really taken temperature with a thermometer or you just thought. Also ask if someone took your temperature and where, etc.
Different would be the case in which the patient states: - "I thought I had a fever" or - "I took my temperature and it gave me that it was 37.8ºC"
"(...) The patient refers to a febrile episode of 38.7º C axillary, verified by a thermometer by a pharmacist friend, at 3:00 p.m. the day before the consultation (...)"
"(...) subjective fever not verified by thermometer (...) "
" (...) The patient manifests recurrent episodes of fever of more than 38ºC in several shots verified by thermometer (...) "
" (...) patient denies febrile episodes without verification by thermometer (...) "
It is in good order not to write findings of the physical examination, for that there is a special section in the medical history dedicated to it. With the same principle, no antecedent or habit of the patient will be specified in the current disease space, contemplating the following situations:
If there is a history or important fact in the rest of the medical history that could change the way the patient sees the picture, it should be recorded.
In the previous example, the alcoholism habit of the patient stands out since this condition can be caused by alcoholic liver disease and hematemesis due to esophageal varices, for which it is appropriate to mention it in the current disease.
Another similar case would be a patient who has a respiratory disease, being an active smoker or working with solvents, sand, asbestos, etc.
If the patient has an ulcer in the lower limb that does not heal and manifests being diabetic, it must be specified as a hierarchical antecedent since it approximates the diagnosis to a peripheral vascular disease due to diabetes. If you have a picture of pain in the right fossa and you already have an appendectomy, in the same way before a possible liver picture and a history of cholecystectomy surgery.
Due to the aforementioned, the patient's antecedents (positive) that are considered necessary and that modify the diagnostic behavior must be established, but on certain occasions it may also be written if they are not present (negative antecedents). As in the case of a patient who manifests an ulcer in the lower limb and refers NOT to be diabetic, since it would change the diagnostic behavior or a respiratory condition and he does not have a smoking habit.
It is also useful to ask the patient for other symptoms related to the current disease, in the previous example if a digestive picture is suspected, it can be investigated for signs and symptoms that the patient has not repaired and that may be related to the digestive system, for example : dysphagia, odynophagia, diarrhea, constipation, etc. being these negatives, they are specified giving more information for the differential diagnosis.
For the writing of the medical history, a level of knowledge of medical language as well as synonyms is necessary in order to avoid unnecessary repetition of objects or ideas. To unify the language, something similar to a template can be used as a memory aid for the student, such as the following:
"Patient (sex) of (age) who (attends the consultation / is brought to the consultation / is referred from the service of / enters the ward) for (a painting / for presenting a painting / referring) etc.
Here are some examples of current disease headings:
> "A 59-year-old male patient who attends the consultation with a condition characterized by dyspnea of (...)"
> "An 81-year-old female patient who is brought to the Centenario Hospital guard service for a characterized condition due to an abrupt loss of consciousness lasting two hours (...) "
> " A 49-year-old female patient referred from the Cardiology service of the Centenario Hospital for postoperative cardiac angioplasty (...) "
> " A 26-year-old male patient with age attending the preoperative consultation for scheduled gallbladder surgery (...) "
There are different connectors to relate paragraphs, signs and symptoms to each other, such as:
"(...) The patient refers (...)", "(...) The patient manifests (...)", "(...) The patient adds (...)", "( ...) Added to box (...) "," (...) Added to box (...) ".
An example in a medical record would be:
A 28-year-old male patient who attends the Centenario Hospital guard service due to a condition characterized by rusty sputum of 6 hours of evolution preceded by cough.
The patient also refers to dyspnea on moderate exertions a few days after the start, which increased with the passing of the days.
A febrile episode of 38ºC was added to the table, verified by a thermometer by the pharmacist three days before the consultation.
The patient manifests a feeling of weakness and fatigue after performing regular domestic activities.
As an important antecedent, the patient refers to being a senior smoker, consuming one to two bundles of cigarettes per day, from the age of 15 years and hospitalization for a spontaneous pneumothorax in the past year.
There are cases where the writing of the reason for consultation or the current illness is complicated, for example in injured patients, unconscious, certain deficiencies, referrals, etc.
In each case, you should ask about specific situations that would not be asked in a conventional medical history.
Reason for consultation: Traffic accident
Current illness: 30-year-old male patient who attends the consultation for a traffic accident on public roads at the intersection of Santa Fe and Av. Francia in the city of Rosario at 7:30 p.m. today, driving a low-displacement motorcycle.
Reason for consultation: Fall from height
Current illness: 42-year-old male patient who was brought to the guard service of the centennial hospital due to a fall from height of approximately 8 meters.
Reason for consultation: Preoperative Surgery
Current illness: 61-year-old female patient who attends the hospital for preoperative admission for programmed surgery for umbilical hernia.
Reason for consultation: Traffic accident
Current illness: Female patient of approximately 20-25 years of age who is brought to the guard service by police mobile due to a traffic accident on the Rosario-Córdoba highway at kilometer 123.