There is not a (good)doctor on this planet that will disagree with what I am about to say: Patient History can save your @$$!!! Especially with very difficult cases presenting abnormal symptoms. Sometimes you have to run a test to check for absolutely every disease, disorder, infection, or virus out there before finding out what's wrong with your patient, and other times you only have to pay attention to the words that come out of their mouths. A good place to start is to make the correct words come out of their mouths.
Patient history should be done along with a physical examination, for the body knows things that the person's conscious does not. Here is a simple, general walk-through to help you out!
1. Listen to the main reason that they came to the hospital. This may already be your answer, or help you with your next main focus.
2. Have them describe the pain. What kind of pain is it? Sharp, chronic, random, occurring when the patient moves a certain body part or presses a certain area? Where, exactly, does it hurt? How long has it been going on? Is there anything that they have done that has relieved the pain?
3. History: ask for past history of ailments that may cause the symptom they mentioned? Has a family member ever had an ailment that may cause the symptoms they mentioned*? You should also ask about sexual activity: What is their sexual orientation? How often do they have sexual intercourse? How many new sexual partners have they had in the past 6 months? Do they smoke? How often do they drink? Are they on drugs? How many times a day does this person pee? Have they had a change in appetite recently? Have they lost weight? Is there blood in their urine? ((There should never be blood in a person's urine. It is not normal.)) I want you to know this person better than their best friend does.
4. What medications are they taking? Pain relievers and vitamins count!
5. Physical: First comes the easy school-nurse stuff. Take their temperature. Look in their ears. Have them follow a flashlight with their eyes. Et cetera. Then, you should check areas pertaining to the area the patient complained about. For example, if they complain of abdominal pain, you should check their tummy. Press into the stomach with your hand and feel for the body's reaction. Things you are looking for: Pain when your hand goes inward, pain when your had comes out, or tightened muscles.
6. Now is time to tell your patient what you think is wrong with them. There may be occasions when you have to say, "I honestly am not sure." This is not a bad thing; it just means that the patient is a little more difficult than most. Do not be ashamed and be honest with your patient. There also may be times when you have to say that your initial impression is that they have something as serious as cancer, and you have to realize that this is scary for the patient. Comfort them and reassure them that you aren't sure, but Do. Not. Lie.
* The older a patient is, the less a family history is relevant, but you should still ask.
Patient history should be done along with a physical examination, for the body knows things that the person's conscious does not. Here is a simple, general walk-through to help you out!
1. Listen to the main reason that they came to the hospital. This may already be your answer, or help you with your next main focus.
2. Have them describe the pain. What kind of pain is it? Sharp, chronic, random, occurring when the patient moves a certain body part or presses a certain area? Where, exactly, does it hurt? How long has it been going on? Is there anything that they have done that has relieved the pain?
3. History: ask for past history of ailments that may cause the symptom they mentioned? Has a family member ever had an ailment that may cause the symptoms they mentioned*? You should also ask about sexual activity: What is their sexual orientation? How often do they have sexual intercourse? How many new sexual partners have they had in the past 6 months? Do they smoke? How often do they drink? Are they on drugs? How many times a day does this person pee? Have they had a change in appetite recently? Have they lost weight? Is there blood in their urine? ((There should never be blood in a person's urine. It is not normal.)) I want you to know this person better than their best friend does.
4. What medications are they taking? Pain relievers and vitamins count!
5. Physical: First comes the easy school-nurse stuff. Take their temperature. Look in their ears. Have them follow a flashlight with their eyes. Et cetera. Then, you should check areas pertaining to the area the patient complained about. For example, if they complain of abdominal pain, you should check their tummy. Press into the stomach with your hand and feel for the body's reaction. Things you are looking for: Pain when your hand goes inward, pain when your had comes out, or tightened muscles.
6. Now is time to tell your patient what you think is wrong with them. There may be occasions when you have to say, "I honestly am not sure." This is not a bad thing; it just means that the patient is a little more difficult than most. Do not be ashamed and be honest with your patient. There also may be times when you have to say that your initial impression is that they have something as serious as cancer, and you have to realize that this is scary for the patient. Comfort them and reassure them that you aren't sure, but Do. Not. Lie.
* The older a patient is, the less a family history is relevant, but you should still ask.
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