How to take a history
The history
is the most important part of your patient interaction. From it you glean the most information of anything you do.
It should be thorough but efficient. It should anticipate your differential diagnosis.
It should be open-ended, but controlled.
Sounds difficult? It is.
But it is not impossible, fair physician. Like getting to heaven, one gets lots of exhortation to take a good history,
but awfully little direction in doing so. We shall try to correct the medical omission in these pages.
The theological omission we expressly decline to address.
In these pages, we will learn to organize our
history of present illness
around a basic algorithm, generally applicable,
which starts with what the patient tells you, then iterates through until you come out with a fairly complete picture of what is going on.
We presume that you already know:
how to take a history, in general.
You know to start with a chief complaint, move to history of present illness, then go to past medical history with relevant illnesses,
operations, medications, allergies. You know to add the family and social history to this inquiry.
If this sounds unfamiliar, please refer to a standard text on history and physical taking before moving to these pages.
The purpose of these pages is to organize and make effective the history of present illness, perhaps the most important part of the history.
So, to task.
The three steps to taking a history of present illness are:
...in that order.
