HOW TO WRITE HISTORY OF PRESENTING COMPLAINT

 When writing the history of presenting complaints in a patient's case sheet, it is crucial to gather detailed and accurate information about the patient's symptoms and their progression. Here are the steps to follow:

1. Begin with the Date and Time: Start by recording the date and time when the patient first noticed the symptoms or when they became significant enough to seek medical attention.

2. Introduce the Patient: Provide the patient's name, age, and any other pertinent demographic information. This helps to identify the individual and establish context.

3. Establish the Chief Complaint: Clearly state the primary reason the patient is seeking medical care. This should be a concise summary of their main symptoms or concerns.

4. Record the Onset and Duration of Symptoms: Ask the patient to explain when they first noticed the symptoms and how long they have been experiencing them. Document the specific date and time if available.

5. Gather Information about the Progression: Ask the patient how the symptoms have evolved over time. Determine if they have worsened, improved, or remained constant. Note any significant changes.

6. Explore the Character of Symptoms: Inquire about the specific characteristics of the symptoms. Determine if they are sharp, dull, aching, throbbing, burning, or any other relevant description. This helps to better understand the nature of the complaint.

7. Assess the Severity: Determine the intensity of the symptoms by asking the patient to rate their pain or discomfort on a scale of 1-10. Record any impact on their daily activities or quality of life.

8. Investigate Associated Factors: Inquire about any factors that may exacerbate or alleviate the symptoms. For example, ask about position, movement, temperature, food, or medications. These details can provide important clues.

9. Identify Any Related Symptoms: Ask the patient if they have noticed any additional symptoms that are connected to the primary complaint. These may include secondary pain, signs of infection, or changes in bodily functions.

10. Consider Relevant Medical and Social History: Explore the patient's prior medical conditions, surgeries, allergies, and medications that may contribute to or influence the presenting complaint. Also, inquire about any social or environmental factors that may be relevant.

11. Document the Patient's Own Words: Whenever possible, use direct quotes or phrases from the patient to describe their symptoms. This helps capture their experience accurately and enhances communication.

12. Review for Completeness and Accuracy: Before finalizing the history of presenting complaints, review your notes to ensure that all relevant information has been recorded and that it accurately reflects the patient's history.

Remember to approach the patient with empathy, attentiveness, and respect while gathering their history of presenting complaints. This thorough evaluation sets the foundation for appropriate diagnosis and treatment planning.