NSE 13A/B Chapter Notes - Chapter 5: Bleeding On Probing, Hemoptysis, Hemorrhoid
Document Summary
Patient"s name, address, phone number, age, birthdate, birthplace, gender, marital status, ethnocultural background, and usual and current occupation. Record who provides the information: usually the patient him/herself, a parent, a relative, or friend. Judge how reliable the informant seems and how willing he or she is to communicate: a relatable patient always gives the same answers, even when questions are rephrased or are repeated later in the interview. Note any special circumstances: e. g. use of interpreter. Reason for seeking care (previously called chief complaint) Brief, spontaneous statement in the patient"s own words that describes the reason for the visit. Symptom: subjective sensation that the patient feels from the disorder. Sign: objective abnormality that the examiner could detect on physical examination or in laboratory reports. For the well patient: short statement about the general state of health. For the ill patient: chronological record of the reason for seeking care , from the time the symptom first started until now.
