How to Present a Medical History
- 1). Give the physician general information about the patient. Introduce the patient by stating the patient's name, age, occupation and social status. For example, begin the medical presentation by stating, "This is Jane Smith, a forty-year old school teacher who lives with her husband and teenage son."
- 2). Provide the physician with a brief summary on the current health of the patient. Include a chronological outline of the medical background of the patient. For example you can say, "Jane was diagnosed with diabetes seven years ago and has been taking insulin ever since. She is experiencing an increasing amount of pain in her left foot and often feels weak and dizzy."
- 3). Use the patient's words to describe the symptoms associated with the medical history. Avoid using abbreviations. Include all risk factors, long-term treatments and current medications. For example, present the information from the patient's viewpoint by stating, "Jane says that the insulin shots seem to help her feel better, but they also make her feel nausea. She struggles with acid reflux and wonders if the medicine she takes for that could be negatively affecting her diabetes."
- 4). Present test results associated with the medical history. Use the test results to help the physician exclude or confirm diagnoses. Familiarize yourself with relevant test results and present the findings that require discussion or appear abnormal. Present a list of tests that could also be performed to confirm a diagnosis based upon a medical history. Present simple, noninvasive and inexpensive tests first. Include extensive, invasive and expensive tests in the presentation if you feel they are necessary for an accurate diagnosis.
