According to the experts, approximately 80% of a medical diagnosis is made from taking a ‘medical history’ (essentially talking and dissecting through what’s happened as well as gathering background information)? The examination contributes ~10% to the diagnosis, and investigations a further ~10%. So the main contributor to arriving at a diagnosis is pure conversation; which is why Telemedicine services like ours work, but also why effective communication is key to accurate diagnosis and subsequent management.
In a nutshell, the standard ‘medical history’ structure includes:
1. History of presenting complaint
= What it is that has brought you to seek medical attention and specific details about this issue e.g chest pain, left sided, squashing pain, occurred at 10:30am whilst walking the dogs, lasted 15 minutes, resolved on its own, never had it before.
2. Your past medical history
= All your previous diagnoses (minor complaints such as common colds or gastro need not be mentioned unless excessively recurrent, but generally, everything you know about your history should be mentioned) e.g. high blood pressure (hypertension), high cholesterol, diabetes (type 2), left knee replacement
3. Medication history and allergies
= Regular medications, ‘as required’ medications as well as allergies to medications
Eg Telmisartan 40mg once /day, Simvastatin 20mg once /day, Metformin 1g twice /day
4. Social history
= Your occupation, who’s in the household, smoking, alcohol, drugs
Recalling previous diagnoses or regular medications (including doses) can often be a challenge at the best of times let alone under pressure. Keeping a list of each in your wallet is one option, taking phone photos of your medication boxes is another, but my personal favourite is using a smartphone app – which is still little known.
How your smartphone can keep you healthy
This week, let’s see how it works on an iPhone:
Even with your iPhone is locked, you can you can access your medical information and emergency contacts:
To set up your Medical ID, go to the ‘Health’ app on your phone
This app is incredibly useful for encounters with unfamiliar healthcare staff, emergency departments or after hours GPs. The added bonus of setting up the Medical ID on your smartphone is that your NOK (next of kin) can be contacted in an emergency without passcode access to your phone – useful if you lose your phone or are involved in an accident.
However, since the information you choose to add is accessible with your phone locked, sensitive information probably ought to be omitted.
Want to get even healthier with your smartphone? Download our My Emergency Dr app and when you need advice in a hurry or an after hours doctor, just press CALL DOCTOR and within minutes you’ll be talking face to face with a senior, experienced specialist emergency doctors in Australia. You can also receive x-ray requests and prescriptions right on your phone.
My Emergency Dr: wherever you are, we will be there.
- Peterson MC, Holbrook JH, Von Hales D et al. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992; 156: 163-165.
Hampton JR, Harrison MJG, Mitchell JRA et al. Relative Contributions of History-taking, Physical Examination, and Laboratory Investigation to Diagnosis and Management of Medical Outpatients. BMJ 1975; 2: 486-489.