SEMANA DE OUTGOINGS: DIA 4

¿CÓMO ELABORAR
UNA HISTORIA
CLÍNICA?
EN INGLÉS
ELABORADO POR: Ximena G. Aguado Rodríguez

Local Exchange Officer (General) de AECSA y

Coordinadora de Zona 1 del Equipo Nacional
de SCOPE AMMEF A.C.
 ICEBREAKE
R
● Nombre y CL al que perteneces.
● ¿Estás en curso clínico?
● ¿Cuándo te irás de intercambio?
● ¿A dónde te irás de intercambio?
● En caso de que ya hayas recibido CA… ¿En
qué especialidad fuiste seleccionado/a?
La historia clínica…
● Constituye el registro de varios
hechos de la vida de un ser
humano.
● Intenta encuadrar el problema
del paciente.
● Orienta el tratamiento.
● Posee un contenido científico de
investigación.
● Tiene implicaciones
médico-legales.

Obligatorio, irremplazable, privado

 Importance of Effective History Taking

● Accurate diagnosis
● Personalized treatment
● Improved outcomes
● Enhanced patient-provider
relationship
 01

KEY COMPONENTS
OF HISTORY TAKING
 IDENTIFYING DATA
Name, gender, age, place of origin, date of birth, marital status, current occupation,
religion, schooling, complete current address, responsible relative. Type of interrogation
that can be direct or indirect, date of elaboration of the medical history.
 MAIN COMPLAINT
The reason for consultation or hospitalization is the medical cover page of the medical
history and its purpose should be to provide, in a few words, an orientation towards the
affected system or apparatus and the evolution of the condition. Signs and
symptoms and their chronology should be recorded.
 PERSONAL HISTORY
PERSONAL ANDROLOGICAL AND NON-PATHOLOGICAL
PATHOLOGICAL HISTORY GYNECO-OBSTETRICAL HISTORY PERSONAL HISTORY
 ASSESSING SOCIAL AND
FAMILY HISTORY
Family Health History Social Determinants of Health
 CONDUCTING A
REVIEW OF SYSTEMS
General Cardiovascular Respiratory Gastrointestinal

PHYSICAL EXAMINATION?
LAB TESTS, DIAGNOSTIC PROCEDURES
AND INVESTIGATIONS
● Chest X-Ray
● Ultrasonogram
● Electrocardiography
● CT, MR
● Lab tests (Hb, WBC, RBC, etc.)
DIAGNOSIS AND MANAGEMENT
 DIAGNOSIS AND MANAGEMENT

To conclude the history taking process, it is important to summarize the key findings, explain the next steps
in the patient's care plan, and address any remaining questions or concerns the patient may have. This
helps ensure the patient feels informed, empowered, and ready to move forward with their treatment.
 02

SUPPORT TOOLS
for Outgoings
https://www.med.unc.edu/medclerk/education/grading/history-and-physical-examination-h-p-examples/