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Disclaimer: This post is for medical students and teachers.
Everyone is welcomed to comment.
Two questions from a medical student.
Question 1:
I'm just quite confused about how to write history of presenting illness.
If a patient comes with few diseases, which particular disease should I write in that category.
Answer to Question 1:
History of presenting complaint should focus on the chronological development of the presenting complaint.
For example, if the patient presents with chest pain, in the history of the presenting complaint you can detail when the symptom started, the location of the pain, its characteristics (nature -sharp/dull, radiation, severity etc).
If the same patient has a known history of let's say ischaemic heart disease and hypertension, that should be mentioned in the opening sentence as it is very important.
Example: this 52 year old man 'with a known background of ischaemic heart disease' presents with chest pain which is severe, central and crushing in nature, etc.
The reason for this is because the presenting complaint is most likely related to the previous diagnosis.
Having said that, if the patient presents with a complaint that is unlikely to be related to the other medical conditions/previous medical history, then there is an option to mention the unrelated conditions after the presenting complaint and history of presenting complaint.
For example in the patient above: this 52 year old man 'with a known background of ischaemic heart disease' presents with chest pain which is severe, central and crushing in nature, etc. In the past medical history, 'the patient has a history of psoriasis for which he attends dermatology clinic in hospital X'.
Question 2:
Let's say a patient was admitted to hosp 2 days ago with disease X and currently taking medication H, do I put medication H under drug history also?
Answer to Question 2:
Yes, it should be mentioned in the history and the drug history would be an appropriate place to mention this.
Or else you could mention the fact that it was prescribed two days ago in the history of the presenting complaint, depending on the presenting complaint of course. Then mention it again with the dose etc in the drug history.
Extra's:
I just want to add that the outline of the history is flexible and is best used as a guide when you are a student.
With time and experience you will be able to tailor it according the case that you see.
Don't be too concerned where the information goes, but focus more on whether your story makes sense to the listener.
Hope this helps.
Disclaimer: This post is for medical students and teachers.
Everyone is welcomed to comment.
Two questions from a medical student.
Question 1:
I'm just quite confused about how to write history of presenting illness.
If a patient comes with few diseases, which particular disease should I write in that category.
Answer to Question 1:
History of presenting complaint should focus on the chronological development of the presenting complaint.
For example, if the patient presents with chest pain, in the history of the presenting complaint you can detail when the symptom started, the location of the pain, its characteristics (nature -sharp/dull, radiation, severity etc).
If the same patient has a known history of let's say ischaemic heart disease and hypertension, that should be mentioned in the opening sentence as it is very important.
Example: this 52 year old man 'with a known background of ischaemic heart disease' presents with chest pain which is severe, central and crushing in nature, etc.
The reason for this is because the presenting complaint is most likely related to the previous diagnosis.
Having said that, if the patient presents with a complaint that is unlikely to be related to the other medical conditions/previous medical history, then there is an option to mention the unrelated conditions after the presenting complaint and history of presenting complaint.
For example in the patient above: this 52 year old man 'with a known background of ischaemic heart disease' presents with chest pain which is severe, central and crushing in nature, etc. In the past medical history, 'the patient has a history of psoriasis for which he attends dermatology clinic in hospital X'.
Question 2:
Let's say a patient was admitted to hosp 2 days ago with disease X and currently taking medication H, do I put medication H under drug history also?
Answer to Question 2:
Yes, it should be mentioned in the history and the drug history would be an appropriate place to mention this.
Or else you could mention the fact that it was prescribed two days ago in the history of the presenting complaint, depending on the presenting complaint of course. Then mention it again with the dose etc in the drug history.
Extra's:
I just want to add that the outline of the history is flexible and is best used as a guide when you are a student.
With time and experience you will be able to tailor it according the case that you see.
Don't be too concerned where the information goes, but focus more on whether your story makes sense to the listener.
Hope this helps.
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