|
I have a question for any students in the audience today. Are you ready? Here it is: what is the most important part of the medical history?
The medical history, by the way, is what physicians document when they meet a patient for the first time. The doctor asks a series of questions and the answers are shaped into a narrative that documents the details of the clinical situation in order to deduce what exactly is wrong with the patient and maybe even correct the problem. The medical history is recorded in this order:
Chief Complaint
History of Present Illness
Allergies
Medicines
Past Medical History
Family History
Social History
Review of Systems
Following the completion of the medical history the physical examination is performed and tests are ordered. Then an assessment of the problems and the most likely diagnoses are listed, along with the treatment plan.
I suppose the most logical answer to my question is that the “History of Present Illness (HPI)” is the most important part of the interview, for the obvious reason that here is where the patient describes his symptoms, and where doctors formulate their diagnoses. It’s hard to treat an illness if one doesn’t have any clue as to what the diagnosis is, not that this would ever occur in our fair nation.
I personally feel that the most important part of the medical history is not the HPI, but another section, traditionally neglected by physicians beginning with the third year of medical school. Can you guess what it is?
Read the rest of this post… | Read the comments on this post…
|