A. Identification and Chief Symptom. This is very important to know the current patient’s symptoms if they are insomnia, lost appetite, hallucination, delusional, crying, lost of interest, gain weight, or fatigue. Chief complaints are referred to as presenting problems, clinical syndromes, or reasons for visit (University of Nevada school of medicine, 2021). Sometimes it can be as short as “I’m depressed.” It is usually a direct quotation. The patients who seek for medical attention because they cannot understand what cause their discomfort, panic, crying, lost appetite, or constant worries? These chief reasons can be the clues for providers to make diagnostic decision and treatment plans. Therefore, the chief complaint needs to be document correctly. These discomfort and abnormal symptoms need to be monitor carefully and treat them in timely manners. B. History of Present Illness. What are the factors that trigger the current illness? The histories can provide the provider the clues, the backgrounds, and the triggers. Some patients may experience frustrations from their job, discouraged by their coworkers, and suppressed by their supervisors. Do they patient seek for consultation? Have they ever hospitalized for their substance abuse situations? Have they got into legal events because of drinking? When does it start? How severity it is? How long does it last? How long is the duration of the drinking? Are there any specific parts involved? How severe it is (duration of the pain, scale? Triggers?) What is the pace of the discomfort? (intermittent, continuous, or chronic?) Under certain circumstances, the patients develop anxiety, depression, or panic disorders. Therefore, those values and clues are so precious for providers to analyze (UC San Diego School of Medicine, 2021). We must collect the insights of the data, information, and active listen to our patients’ histories. A successful interview and communication skills can help the providers to obtain valuable clues; therefore, the patients’ diagnosis can be done correctly
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