Give 4 descriptors/adjectives for each complaint
- Modifying Factors
- Associated Symptoms
Get the ACTUAL story. Why did the patient come NOW?
- Did something change or worsen?
- Did family force them to come?
- Do they have a family history of something similar?
Present the pertinent RED FLAGS for each complaint (some examples)…
- Sudden and Severe
- Neck Stiffness
- Neurologic Complaints
- Back Pain
- Saddle Anesthesia
- Bowel/Bladder Incontinence
- Chest Pain
- Family history of MI at same age
- PE risk factors
- Sudden and Maximal/Tearing
Get their doctor’s names
- Primary care provider
- Pertinent specialists
Don’t get bogged down giving too much medical history during your presentation. Simply write down the important facts for reference and present a few notable items in your opening sentence.