lab

• PC meaning

  Presenting Complaint
• HPC meaning

  History of Presenting Complaint
• PMH meaning

  Past Medical History
• DH meaning

  Drug History
• FH meaning

  Family History
• SH meaning

  Social History
• ROS meaning

  Review of Systems
• ICE meaning

  Ideas, Concerns, Expectations
• In medical history taking, this is what the patient tells you is wrong.

  Presenting Complaint
• SOCRATES meaning

  Site

  Onset

  Character

  Radiation

  Associations

  Time course

  Exacerbating/relieving factors

  Severity
• In medical history taking, gather information about a patient’s other medical problems (if any).

  Past Medical History
• In medical history taking, find out what medications the patient is taking, including dosage and how often they are taking them.

  Drug History
• In medical history taking, gather some information about the patient’s family history.

  Family History
• In medical history taking, this is where you ask about smoking and alcohol.

  Social History
• In medical history taking, find out who lives with the patient.

  Social History
• In medical history taking, gather a short amount of information regarding the other systems in the body that are not covered in your HPC.

  Review of Systems
• These are the main systems that should be covered in medical history taking.

  CVS

  Respiratory

  Gastrointestinal

  Neurology

  Genitourinary/renal

  Musculoskeletal

  Psychiatry
• In medical history taking, this is where you complete your history by reviewing what the patient has told you.

  Summary of History
• Medical history taking procedure

  1: Introduce yourself

  2: Presenting Complaint

  3: History of Presenting Complaint

  4: Past Medical History

  5: Drug History

  6: Family History

  7: Social History

  8: Review of Systems

  9: Summary of History

  10: Patient's Feedback/Questions
• SOCRATES: Where exactly is the pain?

  Site
• SOCRATES: When did it start, was it constant/intermittent, gradual/ sudden?

  Onset
• SOCRATES: What is the pain like e.g. sharp, burning, tight?

  Character
• SOCRATES: Does it radiate/move anywhere?

  Radiation
• SOCRATES: Is there anything else associated with the pain, e.g. sweating, vomiting.

  Associations
• SOCRATES: Does it follow any time pattern, how long did it last?

  Time course
• SOCRATES: Does anything make it better or worse?

  Exacerbating/relieving factors
• SOCRATES: How severe is the pain, consider using the 1-10 scale?

  Severity
• In laboratory techniques, describes architectural tissue changes.

  Histopathology
• In laboratory techniques, assesses cells and smaller cell clusters.

  Cytopathology
• In laboratory techniques, removal of a cone-shaped core of tissue.

  Punch biopsy
• In laboratory techniques, suspicious tissue areas are biopsied or excised surgically.

  Intraoperative tissue samples
• In laboratory techniques, this a procedure in which a thin, hollow needle is used to collect a sample of cells from a lump or mass for analysis.

  Fine-needle aspiration cytology
• In laboratory techniques, this is processing and preservation of cells and tissues (embedding and cutting procedures).

  Fixation
• In laboratory techniques, this is routine and special stains.

  Staining Methods
• Processing of every specimens includes

  * Measuring and weighing

  * Photography
• Clinical application: e.g., investigation of palpable breast lumps (breast cancer), suspicious findings during prostate palpation (prostate biopsy), space-occupying lesion in liver, kidney, or skin (skin biopsy)

  Punch biopsy
• Clinical application: e.g., assessment of hysterectomy specimens or prostatectomy specimens (prostate cancer)

  Intraoperative tissue samples
• Clinical application: evaluation of gastric antrum and pylorus specimens (atrophic gastritis), biopsy specimens of the small intestine (gluten-sensitive enteropathy), colon polyps, biopsy specimens of the rectal mucosa in cases of amyloidosis

  Endoscopic removal or puncture
• Example: for differential diagnosis of pleural effusion

  Effusion cytology
• Example: if pneumonia or tuberculosis is suspected.

  Sputum cytology