Present Illness

This section of the history is a complete, clear, and chronologic account of the problems prompting the patient to seek care. The narrative should include the iset of the problem, the setting in which it has developed, its manifestations, id any treatments. The principal symptoms should be well-characterized, ith descriptions of (1) location, (2) quality, (3) quantity or severity, (4) timing, including onset, duration, and frequency, (5) the setting in which they occur, (6) factors that have aggravated or relieved the symptoms, and (7) as sociated manifestations. These seven attributes are invaluable for understanding all patient symptoms (see p._). It is also important to include

"pertinent positives" and "pertinent negatives" from sections of the Review of Systems related to the Chief Complaint(s). These designate the presence or absence of symptoms relevant to the differential diagnosis, which refers to the most likely diagnoses explaining the patient's condition. Other information is frequently relevant, such as risk factors for coronary artery disease in patients with chest pain, or current medications in patients with syncope. The present illness should reveal the patient's responses to his or her symptoms and what effect the illness has had on the patient's life. Always remember, the data flows spontaneously from the patient, but the task of organization is yours.

Medications should be noted, including name, dose, route, and frequency of use. Also list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, birth control pills, and medicines borrowed from family members or friends. It is a good idea to ask patients to bring in all of their medications so you can see exactly what they take. Allergies, including specific reactions to each medication, such as rash or nausea, must be recorded, as well as allergies to foods, insects, or environmental factors. Note tobacco use, including the type used. Cigarettes are often reported in pack-years (a person who has smoked 1/2 packs a day for 12 years has an 18-pack-year history). If someone has quit, note for how long. Alcohol and drug use should always be queried

(see p._for suggested questions). (Note that tobacco, alcohol, and drugs may also be included in the Personal and Social History; however, many clinicians find these habits pertinent to the Present Illness.)

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