Each medical history should have a sheet of solution of clinical problems as they appear and their disappearance or permanence.
It means clinical problem, the signs and symptoms that the patient requested medical assistance. They are obtained from the anamnesis, physical examination and complementary data.
This type of reflective documentation, promotes training and a student's active attitude, expressed so analytical and synthetic, with possible inclusion of brief bibliographical annotations. The role of the tutor-professor is the process supervisor.
Sequentially, the student must be reflected in problems sheet:
- Clinical problems and the date of detection in the evolution of each of the 6 clinical histories presented.
- The differential diagnosis made on the basis of the diagnostic hypotheses formulated related to the clinical problem.
- The diagnostic methods used with special mention of scans and used non-invasive and invasive monitoring and the degree of participation procedures.
- The solution or not of the clinical problem with date display.
- The type of symptomatic treatment, support or empirically.
MODEL OF CLINICAL PROBLEMS
CLINICAL problem date
SOLVED YES / NO Date