Thursday, June 5, 2008

New Doctor Visit: The Medical History

How much should be in a medical history? What details are relevant? What aren’t? Should it be done by age? Or by symptom? There are many ways to create a medical history. Here are some ideas.

When I first started out writing up a medical history for my daughter, I began with the family background, conditions I had and medications I took while pregnant with her, and what happened during birth. Then I proceeded with problems she had as an infant, then at one, then at two…. When I was done, I realized that some problems repeated each year, and some had vanished from the list.

I then approached it a different way. I wrote it up by symptom, or cluster of symptoms, age they appeared, and then what happened to those symptoms. I put it into a table form (using an Excel spreadsheet). This method was much more revealing. I found that as time went on, we would think of more to put into it, since I was doing it looking back over a couple decades. It might have been much easier if we had started this method sooner.

Combined with a current medication list (more on this in the book) and medication history, the medical history by symptom cluster was the most concise method I came up with—one that is not as overwhelming as the simple chronological list, and much more informative at a glance. If the doctor wanted to look at, for instance, migraines, she could quickly see what helped and what didn’t, possibly gaining more insight into the underlying pathophysiology of other symptoms.

The headings along the top (see table below) are: 
  • Age Began or Diagnosed 
  • Problem or Diagnosis
  • Age Addressed
  • Treatment or What Ameliorated the Condition?
  • Result or Reason for Treatment Discontinuation

Here is a sample of such a method—for privacy reasons, this is NOT taken from my own daughter’s actual medical history. In addition, since this is just an example, it is not nearly as detailed as the actual one we have for my daughter. Hers is about 12 pages long in landscape format. Is that too long? Well, I have had doctors appreciative of the detail, and others that had the opinion that it is too long and no doctor would read it.

When looking at a medical mystery, however, I am convinced that including every symptom and symptom cluster is critical. How can we know what is relevant and what is not? That’s why you are seeking specialists.

An example of a symptom that made me into a believer of including all symptoms is something as seemingly insignificant as an intermittent bowel problem since toddlerhood. It turned out to be immensely intertwined with a later diagnosis of osteoporosis which resulted from an intestinal malabsorption problem!

So I suggest you keep a detailed summary if only for your own sake—to keep track of how much things have improved, and how much is still left to go. No symptom will be overlooked, and you can always do another quick summary of symptoms left to be addressed.

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Last Updated:
29 July 2011

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