Preparing for Diagnoses with Patient History Learning Session

During our afternoon session, Dr. Zaineb taught our interns how to take a comprehensive patient history. This lesson was especially valuable for their upcoming diagnoses this Friday, where students will be meeting directly with patients over a Zoom phone call to identify their illnesses and recommend treatments. 

Taking a thorough medical history is very important for a doctor to administer adequate care for the patient they’re meeting with. According to Dr. Zaineb, the essential steps of taking a proper medical history include creating the right environment, building rapport through getting comfortable and conversing, collecting biodata, identifying the presenting complaint, detailing the history of the presenting complaint (Hx PC), conducting a systemic review, and reviewing past medical, family, and social histories.

Biodata includes the patient’s name, age, sex, tribe, religion, and other details, which are commonly remembered through the mnemonic NASTROMA. Dr. Zaineb explained that factors like religion and tribe might make individuals more susceptible to particular illnesses, as do age and even marital status, which ties into the amount of family support an individual may have should they become sick. Even one’s address is important, as the environments in which patients live will definitely have an impact on their health.

Within the history of the patient’s presenting complaint, Dr. Zaineb introduced the "4 C’s" to help interns take a detailed history: course, cause, complications, and care received. Additionally, when assessing pain specifically, she talked about the mnemonic OLD CARTS, which looks at onset, location, duration, characteristics, aggravating or relieving factors, radiation, timing, and severity.

History taking was the topic of the bulk of the lecture, as it encompasses an individual's past medical history, family history, and social history as well. Interns were encouraged to acknowledge past medical conditions or chronic illnesses, any prior blood transfusions, current medication use, and much more to ensure a complete understanding of the patient's background ahead of Friday's calls.