Medical history

The medical history of a patient is the most important and useful element in making an accurate diagnosis more valuable than other physical examination or diagnostic test. the medical interview easy process of gathering data that will lead to an understanding of the disease and the underlying physiological process. Tobi effective an interviewer must possess good communication skill and be allowed to nonverbal clue as well as to the verbal message. Often, more information is conveyed by non-verbal action and tone of voice than by words. The objective used to obtain an accurate and comprehensive picture of the patient’s situation including the nature and timing of symptom emotional factors including types of stress and past medical condition that may place the patient at greater risk for certain disease.

The medical interview

The accuracy and usefulness of the medical interview depend on the physician’s ability to elicit information pertinent to the problem at hand and on the patient’s accurate recall and articulation of the sequence of symptom. this may be difficult because meaningful data may be forgotten if the patient is experiencing pain or emotional distress. the skilled interviewer know when to use silence open ended question or specific close ended question to explore avenues in which the most useful information may be found. The real reason for the patient visit may not be apparent until a report has been established and the person feel comfortable describing what is most bothersome. Problems that are emotionally threatening may not be voiced until adequate coverage is summoned sometimes not until the end of the appointment when the patient hand is on the door knob. A complete medical history consists of an account of the present illness the past medical history family history occupational background psychosocial history and review of body system. An account of the present illness which include the circumstance surrounding the one set of recent health change and the chronology of subsequent event that have led the patient to seek medical care is essential to understanding the cause of the disease process. Current medication I listed in the medical history because they may play a role in the current illness. The past medical history is an overall view of the patient health prior to the present illness. It should include previous hospitalisation, injuries, operations, and any significant elders that may not have required hospitalization. Allergies are included here if not listed separately.

Family history

Included in a family history at the age and state of health of each immediate family member as well as the cause of death of any parent grandparent and other close relatives. Of particular importance are genetic or environmental disease that have known risk. If a close relative such as father died of heart attack (acute myocardial infarction) before the age of 60 all his children are at greater risk of suffering an early heart attack. This risk increase if there is other factors such as hypertension which is high blood pressure or elevated serum cholesterol are present. Similarly a history of some cancer such as colon cancer increase the risk for offspring to develop that types of cancer. the development of lung cancer in a parent provides even greater impetus for close relative to avoid smoking. Other disease that may have hereditary or environmental route are diabetes, hypertension, tuberculosis, depression, and other form of mental illness arthritis and epilepsies. Actually any disease that arise in two or more members of a family suggested a possible predisposing factor and the patient should be considered to be at increased risk for this condition. The occupational history is important because the working place may be a source of toxin such as chemical or cigarette smoke that place one at higher risk of cancer or other disease. The psychosocial history information on education lifestyle marital status and religious belief may influence future medical decision asthma patient smoking history alcohol intake and use of such control sultans as marijuana or cocaine. The review of body system allow the physician to identify any other symptom that have not been noted previously and that may influence the patient current state of health provides subtle clues to the diagnosis. All major body system review in an orderly manner is really from the head down to the extremities. The intent is to uncover any past anus or problem that have not been previously identified and that may now or later influence the patient’s health. For example the patient may describe leg pain while walking which could be an early indication of blood vessel occlusion and increase the physician concerns about possible coronary arteries disease that otherwise may not have been suspected.

Reference

The new encyclopaedia britannica volume 17