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It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".
For example, an "OB/GYN" section may be included, including language such as "G3P2, menarche at age 14, LMP 2 weeks ago, regular". family history (FH) "noncontributory" Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase ...
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
The obstetric history of a female who has had four pregnancies, one of which was a miscarriage before 20 weeks, would be noted in the GPA system as G 4 P 3 A 1 and in the GP system as G 4 P 3. The obstetric history of a female who has had one pregnancy of twins with successful outcomes would be noted as G 1 P 1+1. [16]
History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on ...
Finally, a white blood cell count can detect maternal blood in the sample, as fetal white blood cells are primarily leukocytes, while maternal white blood cells are mostly neutrophils. If amniotic fluid infiltrated the sample, then there would be a reduction in the volume of RBCs, white blood cells, and platelets in the sample. [9]
The Ballard Maturational Assessment, Ballard Score, or Ballard Scale, is a commonly used technique of gestational age assessment. It was devised by Dr Jeanne L. Ballard, professor emeritus of Pediatrics, Obstetrics and Gynecology at the University of Cincinnati College of Medicine.