Medical History and Pain Assessment

History Taking

• History taking is a crucial part of medical practice.
• Key components include medical history, case history, and anamnesis.
• Further steps include examining symptoms, clinical signs, differential diagnosis, and history and physical.
• Introduction of the medical professional is essential.
• Patient identification is a key aspect (date of birth, sex, ethnicity).
• The presenting complaint is vital for diagnosis. (Patient example: James Taylor, age 55, height 5'8", weight 170lbs.)
• The patient's chief complaints were biliary colic pain, sweating, and yellow skin.

Pain Assessment

• The "SOCRATES" rule is used assessment of pain. (Site, Onset, Character, Radiating, Associated Symptoms, Timing, Exacerbating/Relieving Factors, Severity).
• A pain assessment model is used to guide professionals to precisely understand the nature of the pain. Components of the model are described (Site, Onset, etc).

Pain Assessment Tools

• A Universal Pain Assessment Tool is a method to assess pain. The tool enables professionals to describe the patient's pain via scale (0-10).
• Different methods exist to describe the nature and severity of pain using various scales/methods.

Medical History

• Past medical history is relevant for a complete medical image.
• Past surgical history needs to be included.
• Additional aspects to include are symptoms, allergies, medications, pertinent medical history, last meal, event leading up to the injury or illness

Medication List

• A medication list should be compiled accurately for patient care.

Review of Systems (ROS)

• A review of body systems (ROS) is critical for comprehensive patient care. Information is given regarding specific areas (brain, upper body, chest, lungs, etc.).

Family Information

• Family information is relevant in patient care.
• A family history diagram, called Family Tree, aids data collection.

Social History

• Social history includes factors such as smoking (pack-years = (packs smoked per day) x (years as a smoker)) and alcohol consumption.
• Understanding of alcohol consumption and classification is important. Examples of how to classify drinking are given.

Summary of History

• This section summarizes the key points of the patient's case history, including demographic information, chief complaints, pain scale, body temperature, allergies, medications, past medical history, family history, drug use, and occupation.

Patient Feedback

• Patient feedback is essential in medical practice.

Inhibitive Factors

• Inhibiting factors are potential obstacles. (This section includes an image referencing obstacles in treatment).