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The most important part of the doctor patient interaction is the medical history. |
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I have been taking medical histories for almost thirty years. If the patient and the doctor can get a precise timeline, accurate descriptions of all the important events then the interaction was a success. I was the first physician in Illinois to diagnose a case of confirmed Lymes
disease. Why did 8 other dedicated physicians miss the diagnosis? Because the medical history did not make sense and the timeline of her illness was not accurate. Please briefly review my suggestions below to see if we can make our interaction better for both of us.
"The trust forged in the initial doctor-patient relationship is often the key to a patient's willingness to participate in, and benefit from, care provided by the doctor." |
Greg E. Sharon MD
The goal of the interview is to obtain personal and symptom information about the patient. The physician must interpret this data in light of his medical knowledge and formulates a description of the patient in biopsychosocial terms; that is, a medical history with integrated biological, psychological, and social history leading to the most likely diagnosis.
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Chief Complaint We ask that patients who present with multiple complaints come up with one main reason they are being seen today. It helps to focus our thoughts and our history on what is really important to the patients. Many patients want to give me a diagnosis i.e. "Then I had a bad migraine." I would rather you describe the symptoms and signs you had not your diagnosis of the illness.
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History of Present illness We like to place things on a timeline so that they make sense with other parts of the history. It is important that we find out when you developed symptoms as it relates to other events. Often these other events seem unrelated. "I developed asthma 3 yrs ago. I moved into my sisters home 3 yrs ago. My sister has two cats." Taken alone not very clear but when placed on a timeline we can see the cat exposure may have led to the development of asthma. |
Food and Drug Allergy In some patients allergy mean reaction. It doesn't. Allergy to a drug means the body has made an allergic antibody (IgE) response to a drug. This leads to allergic reactions and possibly a fatal anaphylaxis. A reaction to a drug may include allergy but more commonly it is a side effect such as "I got diarrhea on Augmentin". Side effects or toxic effect do not mean you can never take the drug again but allergy often means a life long ban. |
Past medical history We want to know what medical disease you have or had and how they are doing now. If your taking a medicine for high blood pressure and it is controlling the blood pressure it doesn't mean you no longer have high blood pressure. Surgery and medical problems are best given with a timeline. We need to know if the diseases you have today are in part caused by past diseases or medications used to treat that disease.
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| Family history We use this critical information to guage your risk of developing a disease or in part more likely to have some features of your family illness. If you can find out what people in your family suffer from and when they developed this illness. . |
"The medical interview has three functions: data gathering, relationship building, and patient education." |
