LEARN It! Challenge 1, Topic 1
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History

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A good medical history guides the rest of the workup and often lead directly to a diagnosis. 

The clinician asks questions, not to be nosy but to get clues as to what happened and what are the risks.

History often has several parts such as:1. Chief Complaint: This is in the patients’ own words why they are there to see a doctor. An example could be: “I cut myself in the kitchen, and my thumb is bleeding.” In this situation, this statement itself is the diagnosis. If the patient had said, “I get short of breath quickly,” then many more questions and exams may be needed to solve the mystery of the cause and start finding a treatment. 2. History of present illness: This focuses on the current problem in detail. For instance, what makes you short of breath? What makes it better? How far can you walk before you feel the symptoms? How long has this been going on?3. Social History: This looks at factors that may affect the problem. For example, what kind of work do you do? Is it dusty? Did you buy a dog or cat? Do you smoke? Do you live with smokers?4. Family History: This seeks to consider if there are hereditary things that might be relevant. Is there asthma in the family? Lung cancer? Heart disease? These all could be a factor in the person’s shortness or breath and the likelihood of what may be the cause for the current patient.

The better the patient can share information with the clinician, the easier it is to get the riddle solved of what is wrong, make the diagnosis, and start treatment.

Doctor explaining prescription to senior patient 

Be part of the team with good communication and build a trusting relationship with your caregiver to assist your client with the process.