First of all we have to introduce ourself as a Healthcare provider and ask the patient about his name his biodata and then we ask what brings you to the hospital the patient then explains to us his presenting complaints
It is very necessary that the patient must not be interrupted as he is narrating his presenting complaints
However if the patient is very slow in narration or does not disclose it fully we may of the patient tell me in detail your complaint
Only if there is a doubt that the patient is not able to present his complaint fully by himself then we ask leading questions or probing questions otherwise we try our best to minimise leading questions
Keep in mind some questions such as what else and how et cetera to seek more and more on presenting complaints and there are few things which should be asked in relation to any presenting complaint such as when did the complaint start what was its severity on onset what was the body part involved how has its progression been whether it is improving resolving what are the aggravating factors what are the relieving factors what treatment did the patient she was their self medication but there adverse effects from those medications and the associated symptoms for example in case of fever 1 main ask the duration of the fever the recorded temperature the pattern of fever the medication short for fever the associated things like earache flu headache eye discharge body Rash joint complaints pain abdomen chest pain shortness of breath loose motions vomiting anorexia
Then we ask other complaints on a similar pattern their details then the past medical history the history of previous Hospital admissions may be included in past history vaccination history the dietary history allergies and immunizations the history of drugs family history the social economic history the occupational history and in case of children feeding history but history development of history and concluding all based on this we draw a probable diagnosis
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