Case Files Emergency Medicine, Third Edition
Applying “book learning” to a specific clinical situation is one of the mostchallenging tasks in medicine. To do so, the clinician must not only retain information, organize facts, and recall large amounts of data, but also apply all of this to the patient. The purpose of this text is to facilitate this process. The first step involves gathering information, also known as establishing the database. This includes taking the history, performing the physical examination, and obtaining selective laboratory examinations, special studies, and/or imaging tests. Sensitivity and respect should always be exercised during the interview of patients. A good clinician also knows how to ask the same question in several different ways, using different terminology. For example, patients may deny having “congestive heart failure” but will answer affirmatively to being treated for “fluid in the lungs.”
The history is usually the single most important tool in obtaining a diagnosis. The art of seeking this information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized.
1. Basic information:
a. Age: Some conditions are more common at certain ages; for instance, chest pain in an elderly patient is more worrisome for coronary artery disease than the same complaint in a teenager.
b. Gender: Some disorders are more common in men such as abdominal aortic aneurysms. In contrast, women more commonly have autoimmune problems such as chronic idiopathic thrombocytopenic purpura or systemic lupus erythematosus. Also, the possibility of pregnancy must be considered in any woman of childbearing age.
c. Ethnicity: Some disease processes are more common in certain ethnic groups (such as type II diabetes mellitus in the Hispanic population).
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