- The backbone and guidance for the history
- Utilize most time in this part
- Narrative, time sequenced writing interrupted by open questions
- After the patient takes time to tell story , close this session by asking direct closed questions to fill gaps in the story.
- Try as you can to avoid using the medical terms when you write the story.
- Many patients have their own hypothesis regarding their symptoms and disease, don’t be leaded.
Analysis of the chief complaint/s • mnemonic SOCRATES
- Site ⇒ Ask where the symptom is exactly and whether it is localized or diffuse. Ask the patient to point to the actual site on the body.
- Onset ⇒ does the symptom came on rapidly , gradually or instantaneous and how it goes is it continuously or intermittently
- Character ⇒ ask the patient what is meant by the symptom. If there is pain, is it sharp, dull, stabbing, boring, burning or cramp-like?
- Radiation (pain or discomfort)
- Alleviating factors
- Timing ⇒ duration
- Exacerbating factors
- Severity ⇒ you can use scale (0 to 10)
Complete reviewing of the target system in this part.