Medical Essay on Patient History

The art of taking patient history is globally used in the medical field to diagnose an individual. A wide variety of information is gathered during this process that plays a critical role in identifying the needs of the patient and the most appropriate measures to be given. The care giver gathers information about the clients disease or ailment through well-administered questions which might be either closed or open ended. Proper patient history taking is based on good communication between the patient and the doctor, nurse or care giver. A history is a shared experience between the client and the physician. It is important for a physician or medical care provider to have proper consultation skills to gather relevant information. An ideal patient history reveals a clients ideas, concerns, and expectations as well as any other diagnosis. The patients perspective is of core significance as it helps the doctor in providing the best intervention. Also, it depends on the dominant presenting symptoms, the patients concerns, and the past medical, social, or psychological needs of the patient. In most cases, a general framework presents itself during the taking of patients history. This structure consists of; presenting complaint, history of the presenting complaint, such as investigations, previous treatments, and also referrals already arranged and provided. Consequently, a patients past medical history is significant, and this may include significant past diseases, surgery, injury, trauma or any other complications that could be of importance during diagnosis.

Also, a patients medication history is taken to help in identifying the medicinal patterns that the client has been undertaking. This helps in creating a baseline during the diagnosis of an ailment. The drug history also gives a clear preview of all over-the counter medications and any other allergies that might be present. Consequently, family history is of great significance during the taking of a patients history as it provides the clients genetic information which is important in diagnosing genetic-related ailments. Likewise, the care giver gathers social history that includes smoking, drug addiction, alcohol consumption, marital status, occupation, hobbies, and baseline functioning. This aspect of the patients social history provides a patients social behaviour which is a core determinant of various diseases. Moreover, the medical care provider gathers information concerning their systemic review. This report covers the musculoskeletal system, gastrointestinal system, genitourinary system, cardiovascular system, and also the central nervous system. This gives a general preview any ailments in the various systems of the body. The patient also needs to give their feeling or perception about their health. It is important in the sense that the immediate requirements of the patients will be recognized, and therefore appropriate medical interventions implemented.

In conclusion, the general layout of the consultation room could influence the patients history. A well suited and comfortable environment gives the client much confidence to reveal all the information required from him in the process of consultation. Most importantly, good communication should be established by the doctor immediately the patient walks in for consultation. An appropriate rapport significantly improves the outcome i.e. the interventions to be provided. Unnecessary questions during consolations should always be avoided by the medical care givers as they limit the patients from truthfully answering the questions. A patients history reveals the health status of the individual, and therefore proper diagnosis can be administered through this.