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How to Give a History to your physician.
Your physician will appreciate you if you give a clinical history like a smart medical student. Since physicians are busy and you are in hurry to go back to your work, it would be best for both of you to be effective and efficient.
On your part you can be effective if you give a coherent and complete information. How do you do this? Before you visit your physician list the main concern or “chief complaint” or the reason you decided to make an appointment.
A common chief complaint is “Fever.” The way to recount your child’s fever history is like this: “My child is having fever for 4 days, since Monday morning (Friday is your appointment). The range of the fever is from 101 to 104 every day. We took the temparature under the arm (or rectally). He has no vomiting, diarrhea, runny nose, cough, and not pulling at the ears, and no rashes. He is drinking normally and peeing three times a day. He is not doing anything but sleep and lay at the couch.”
That is a complete “Present Illness” part of the history.
If your child is new to the practice, you should add the Past History portion. “My child had three ear infections in the past six months and had been on two different antibiotics, amoxicillin and omnicef. He had been healthy and never been hospitalized.”
“There is no allergy to any medications. No smokers in the family. We have two cats. Our house is fully carpeted and the heating system is forced air and we live in a house constructed five years ago. There is no other members of the family with serious illnesses before.
Since most parents have computers, it would be best if you type in Miscrosoft Word the “Present Illness” of your child so you won’t forget some details. You can make two copies and you can give one copy to your clinician. (Your clinician will appreciate it especially if their record system is not computerized.)
Next Past History
Leo Leonidas, MD, FAAP; Assistant Clinical Professor in Pediatrics, Tufts University School of Medicine; Attending Pediatrician, Eastern Maine Medical Center, Bangor
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