History
The patient’s history can be the most important tool in developing an accurate diagnosis. The prudent physician is both thorough and organized. The history should not only detail the patient’s current complaint, but also document other elements of the patient’s medical history, which can be of great significance for interpreting the current problem and choosing treatment options.
The history can be separated into several categories:
Patient demographics
Current complaint
Medical history
Allergies and medications
Social history
The time and date of the interview should be clearly documented as the history is taken.
Patient Demographics
Basic information that should be recorded includes the patient’s name, age, sex, occupation, and hand dominance.
Current Complaint
As much detail as possible should be obtained about the patient’s current problem. First, identify the presenting symptoms. It can be helpful to ask about the following complaints:
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