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Medical history
A record of information about a patient’s past and current health. includes information about the patient’s habits, lifestyles, and even the health of their family
Chief complaint
The patient description of what they feel is their main health problem
Physical signs
Pieces of evidence that indicate an illness that can be observed externally, such as a rash, coughing or elevated temperature
Symptoms
Any subjective evidence of disease a patient perceives such as aches, nausea, or fatigue symptoms allow the healthcare provider to narrow down the possible conditions that may be affecting the patient and then run test to make a diagnosis
Diagnosis
The process of determining which disease or condition explains a person symptoms and signs
current history
Patient’s main complaint in any other current health issues symptoms in any treatments or test the patient has recently had or scheduled to have nutrition, allergies, medication, and health habits, such as exercise
Previous history
Include information about any past health issues, procedures, medication, vaccinations, and previous hospital stays
Social history
Addresses aspects of the patient’s life such as living situation, occupation, school, travel, and other activities that could have a direct impact on health
Family history
Include medical information about the patient’s close relative
Empathy
The ability to understand and share the feelings of another person
Cognitive empathy
To see someone’s perspective from their eyes
Emotional empathy
To literally feel the emotions of others
Compassionate empathy
To understand someone else else’s pain and experiences, but to follow those feelings with action
Sympathy
Feeling of pity or sorrow for someone else’s misfortune