CONTENTS; 1 OUTLINE OF THE CLINICAL HISTORY; Definition and Scope of the Clinical History; Detailed Outline of the Clinical History; 2 BASIC DEFINITIONS: DISEASE, SYMPTOMS, SIGNS, SYNDROMES, AND DIAGNOSIS; I. What is Disease?; II. Manifestation of Disease by Symptoms and Signs; III. Diagnosis and Differential Diagnosis of Disease; IV. Summary; 3 THE IMPORTANCE OF THE CLINICAL HISTORY; I. Why the Clinical History is the Most Important Event in the Practice of Medicine; II. The Clinical History as a Mutual Process of Knowing between the Physician and the Patient; III. The History is the Only Way to Diagnose the Many Diseases that Produce Only Symptoms but no Signs; IV. How the History Focuses the Physical Examination; V. Why No Physical or Laboratory Finding Has Meaning Until Integrated with the Patient’s Full Clinical History; VI. How the History Provides the Basis for Public Health Policy; VII. Summary; 4 HOW THE PHYSICIAN’S ETHICS AND GOALS DETERMINE THE CONTENT AND TECHNIQUES OF THE CLINICAL HISTORY; I. The Ethical and Operational Components of the Medical Model for the Patient-Physician Relationship; II. Origin of the Ethical Code for the Practice of Medicine; III. How Each Ethic of the Medical Model Shapes the History; IV. Replacing Social Responses with Professional Responses; V. The Atcual Operational Steps of the Medical Model for the Practice of Medicine; VII. Beyond the Consulting Room; VIII. Summary; 5 PRIVACY: THE SETTING AND THE APPAREL FOR AN OPTIMUM CLINICAL HISTORY; I. Privacy and the Private Interview; II. The Room Design for the Medical Interview; III. Personal Attributes of the Physician; IV. Use of the Telephone and Telemedicine; V. Summary; 6 THE PATIENT’S CHIEF CONCERN AND PRESENT ILLNESS; I. The Initial Contact and the Face Sheet; II. Format for the Clinical History; III. Technique for Meeting the Patient; IV. THe Patient’s Chief or Presenting Concern; V. Listening: The Essential Technique of the Clinical History; VI. Technique for Eliciting the PResenting Concern and Current Illness; VII. Historical Analysis of Recurrent Attacks that are Similar; VIII. Current Medications and Management; IX. Closing the Present Illness History in Preparation for the Past Clinical History; X. Summary; 7 THE PAST CLINICAL HISTORY AND THE REVIEW OF SYSTEMS; I. Eliciting the Past Clinical History; II. The Review of Systems (ROS); III. Visualize the Head and the Nervous System; IV. Next Visualize the Motor (Muscular) System; V. Next Visualize the Skeletal System; VI. Next Visualize the Bone Marrow; VII. Next Visualize the Chest and Its Contents and Start with the Respiratory System; VIII. Next Visualize the Cardiovascular System; IX. Next Visualize the Gastrointestinal System; X. Next Visualize the Renal System; XI. Next Visualize the Reproductive System; XII. Next Visualize the Endocrine System; XIII. Next Visualize the Immune and Lymphatic System; XIV. Finally Visualize the Skin; XV. Environmental/Toxic Exposure History; XVI. Supplementing the Standard History and Review of Systems with Inventories, Rating Scales, and Structured Interviews; XVII. Efficiency in the Review of Systems: The Long and Short of It; XVIII. Summary; 8 THE FAMILY HISTORY; I. Transition to the Family History; II. Diagramming the Pedigree; III. Special Problems in the Family History of Pediatric Patients; IV. Summary; 9 THE PSYCHOSOCIAL HISTORY AND MENTAL STATUS HISTORY; I Introduction to the Mental Status Examination; II. Quick (but effective) Overall Screening of the Patient for Mental Illness; III. Detailed Inquiries into the Patient’s Mental Status; IV. The Sensorium or Sensorium Commune: Common Sense and Its Testing; V. An Ethics, Values, and Spiritual History; VI. Special Features of the History in Suspected Dementia; VII. A Historical Tutorial with Rufus of Epheseus; VIII. Summary; 10 THE PREGNANCY AND DEVELOPMENTAL HISTORY (FOR PEDIATRIC PATIENTS); I. Introduction to the Developmental History; II. Reproductive History; III. Labor and Delivery History; IV. Neonatal History; V. Classification of Infant Behaviors for Judging the Neurodevelopmental History and the Neurodevelopmental Examination; VI. Attending to the Mother’s COncerns about her Infant’s Development; VII. The Developmental History for Infants from Birth to Two Years of Age; VIII. The Developmental History for Children More than Two Years of Age; IX. Discussing Developmental Retardation with Parents; X. Summary; 11 THE PREVENTIVE HISTORY AND WELLNESS; I. Importance of the Preventive History; II. Preventive History and Preventive Programs for Infants and Children; III. Preventive History and Preventive Programs for Teens and Adults; IV. Preventive History and Preventive Programs for Adults; V. The Positive Promotion of Wellness; VI. Summary; 12 SUCCEEDING WITH THE DIFFICULT HISTORY; I. The Good and the Poor Historian; II. Causes for Difficult Histories and their Differential Diagnosis; III. Keeping the Difficult Patient on Track During the History; . IV. Emotional Interactions Between Patient and Physician that Results in a Diffcult History; . V. When It’s a Question of Honesty or Accuracy of the History; . VI. When It’s a Question of Irreconcilable Differences Between the Patient and the Physician; VII. Summary; 13 ENDING THE CLINICAL HISTORY, RECORDING IT, AND INTEGRATING IT WITH THE PHYSICAL EXAMINATION; I. Three Questions to Close the History, Prior to the Physical Examination; II. Acquiring Additional History; III. Recording the Physical History; IV. Integrating the History and Physical Examination to Complete the Initial Medical Record; V. Integrating the History and Physical Examination, Illustrated by Analyzing the Commonest Sympton of All: Headaches; VI. Summary; 14 THE HISTORY, APPROPRIATE MANAGEMENT, INFORMED CONSENT, AND PATIENT AUTONOMY; I. How the Same Techniques for the Clinical History Evaluate Patient Autonomy and Informed Consent; II. Interrelations of Appropriate Management, Informed Consent, and Patient Autonomy; III. Extending the History when the Patient Declines Appropriate Management; IV. How Promotion of Elective Cosmetic Surgery of Normal Tissues Biases the History; V. The Clinical History, Physician-Assisted Suicide, and Euthanasia; VI. The Clinical History, the Living Will, and Planning for Terminal Care; VII. An Example of How a Knowing Medical History Guided the Care of a Terminally Ill Patient; VIII. Best Examples of the Medical Model; IX. Summary; X. Epilogue: A Personal View; 15 THE CLINICAL HISTORY OF THE MEDICAL MODEL COMPARED TO ALTERNATIVE MODELS; I. THe Science-based Clinical History; II. Definition of Alternative Medicine; III. Accomplishments of Physicians who Adhere to the Medical Model; IV. Epilogue; 16 FOSTERING EMPATHY AND COMPASSION; I. Discovering the Patient’s Personhood; II. Experiences in Compassion; III. Suggestions for Additional Sessions; IV. Feeling an Affinity for the Past of our Profession; V. Selected References for Comparison
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