The word ‘patient’ is derived from the latin, patiens, meaning sufferance or forbearance. The overall purpose of medical practice is to relieve suffering. In order to achieve this purpose, it is important to make a diagnosis, to know how to approach treatment and to design an appropriate scheme of management for each patient.
Two major steps of making the diagnosis
a. To establish the clinical data by history taking and physical examination
b. To interpret the clinical data
Direct specific questions
Indirect inviting questions to know the general condition of the patient
If the previous admission is related to the current illness, details could be mentioned in appropriate place in the history of present illness
. If details of previous admission required, it could be mentioned under past illness
The main complaint(s) that compelled the patient to seek medical attention It should be written in patient’s words and not necessarily in medical terminology
favor migrainous headache
Last paragraph of the History of the Present Illness
Mention any apparent reduction in strength and weight which provides clues to the general condition of the patient during admission