History of presenting illness: A case of Cocaine
Let me call my patient John. John is a 20-year old. He has presented to my clinic with a respiratory system infection, and he is a cocaine user. I would start by knowing more about the current illness. I will ask John to tell me when the illness started. Whether John has taken or is taking any medication. What aggravates or reduces discomfort with the disease. I would also like to understand other signs and symptoms. If John had undergone any tests, I would insist to know the result. Also if he bought any over-the-counter drugs would be of importance (Adler, 1997).
The second thing important to know from this patient is the past medical history. I would like to know whether john has had a chronic disease from childhood. I will seek to know whether any chronic disease exist in John’s family lineage. I will also want to know whether he has ever been hospitalized, had surgery, has any allergies, or had all immunizations (Binder, 2010).
Thirdly, I will do a systems review. This will include the energy levels, and a comprehensive head to toe examination that will include the head, respiratory system, circulatory system, digestive system, musculoskeletal system, cardiovascular and emotional history and status (Binder, 2010). Here, I will be relating with any noted history about hospitalization or a disease.
I will then take the personal history of john. This will include his occupation, habit, where he was born and brought up, his financial and psychological status. After this, I will take his family history. This will include any family challenges, break up and diseases. This will be followed by John’s physical exam which will include the vital signs. Lastly I will do the laboratory investigations, get the impression and plan for his care.
Adler, H.M. (1997). The history of presenting illness as treatment: Who’s listening and why does it matter? Journal of the American Board of Family Medicine, 10(1), 28-35.
Binder, J. (2010). History of presenting illness. Current Clinical Practice, 2010, 31-56.
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