History Writing in Medicine


Starts from the moment when the patient enters the room (only possible in outpatient department), what’s the gait of the person? Does he/she have an abnormal walking pattern, use a stretcher? Etc

In, in- patient department starts with a smile and a general handshake. Be as polite as much as you can and introduce yourself. There are three things that just happened, you visualized his/her face and shook his/her hands, and these two gestures tell you more about the disease. The smile, well it helps to establish the rapport.

One of the most important factors, in history writing; understanding the patient, being empathetic and noting down the key points that he /she describes. Also, one of the most difficult aspects of communicating with the patient lies in comprehensibility. Does he/she understand what you are trying to ask? For example, if you ask an old lady from the village, if she has diabetics, she would not understand and she might utter an insignificant answer like Yes / No and later on, complications might occur when you start treatment. For this case, the most appropriate question would be; has the health worker warned you about avoiding any sweet food?

Going to their level, understanding them and treating the patient as the centre of your attraction are the key ways to deal with history. If you get a call in the middle of the history, (try keeping your mobile’s at silent mode or more appropriately turn it off). The more you treat your patient like your girlfriend or boyfriend, the more you can succeed in becoming what you have worked so hard all your life.

There is a gap between the doctors that are made today and the regular patients. My point being, in order to get an MBBS degree, you need minimum 15 Lakh taka or rupees and the parents who can afford this money hail from a middle class family, who have raised their children well enough to avoid any hardships in life. So there is gap between what the patient’s try to convey and the student/doctors who try to understand them, especially in the South Asian countries and that’s when the patients complain about how med students and doctors misbehave with them.  Well, it’s a matter of practice and human nature that we are dealing here; best way to avoid this gap is to deal with as many patients as you can.

History helps you make a provisional diagnosis but the true diagnosis or definite diagnosis comes after some investigations and if the senior in charges says so. You can never have a perfect history without practice and the cooperation of the patient. Treat your patient well, they can pass you or they can fail you, it entirely depends on their co-operation and if some patient passes a comment like “I think you will become a great doctor, I will pass you!” your efforts and your sacrifices are worthwhile!

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2 thoughts on “History Writing in Medicine

  1. Thats why they say in med schools that 90% of diseases are diagnosed with good history only n you can never say patient is ‘uncooperative’ for your history, it’s your weakness that you couldn’t make him/her comfortable n cooperative. The imp of history can’t be ignored even in this techno world. n Ya, i agree with u that there is gap between pt n docs due to educational level, financial status n wateva other things. We shd try to come to their level to understand wat they are saying. n it needs a lot of practice.

  2. Sarina
    I am impressed with your writing.
    Its true that most of the disease can be diagnosed through appropriate history taking. In fact WE ADVICE INVESTIGATION TO CONFIRM THE DIAGNOSIS THROUGH HISTORY-TAKING AND CLINICAL EXAMINATION
    Shahjahan

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