A detailed patient history and physical exam form the foundation of patient evaluation and vital patient data that enables efficient, quality patient rounds.　

On the other hand, a poorly documented history and physical may leads to confusion, serious omission of vital data and inefficiency on patient rounds. In this age of modern technology with equipment such as CT, MRI and PET scanners, the history and physical exam seem to be slowly evolving into a relic of a past era! Both attending physicians as well as residents in training seem to rely more heavily on laboratory and imaging modalities than history to establish the diagnosis. “However no part of the patient evaluation is more essential to diagnosis than the patient history. The importance of skillful data collection is underscored by the widely accepted understanding that the medical history contributes 60% to 80% of the information needed for accurate diagnoses.” Thus to neglect the patient history denies the physician of a “vital” diagnostic tool.

The basic outline structure for the patient history and physical exam usually includes the following:
l Identification: patient name, age, gender, race, and occupation
l Chief Complaint: （in the patient's words）
l HPI: （history of present illness）
l PMHx: （past medical history）

l Medications: should include current meds as well as medication allergies　

l ROS: review of systems
l Social Hx.: includes family situation （married, divorced, single）, habits; cigarettes, alcohol or illicit drug use, sexual behaviorl Physical Exam:

l Impression/Diagnosis:

l Treatment Plan:　

l Self- introduction: Upon arrival at the patient's bedside, the physician should first try to establish rapport with the patient by using “nonverbal cues” such as maintaining eye contact or extending a hand to shake the patient's hand （if “culturally” acceptable）. The physician or student should first introduce him or herself and state their reason for the visit. Also, they should ask the patient's permission to interview them.　

Here are a few specific points about each section of the history outline:

1. Identification -- This should include the patient's name, age, sex, race and occupation for example: “Mr. Jones is a 55 yr. Old Caucasian male who works as a farmer.” The patient's name written in the history allows future interviewers to address the patient by his name which conveys a sense of patient respect. The age, race, sex and occupation are an important as many diseases are not only gender and age dependent, but may also occur more commonly in specific ethnic and occupation groups.

2. Chief complaint -- This should be written in the patient’s words. For example “chest pain” rather than “angina”. Also the duration of the chief complaint should be noted “chest pain for 1 hour”. Before moving on to the HPI, it would be appropriate to perform a “survey of problems” asking the patient if there are any other current problems bothering them. Once these have been listed, the interviewer can come back to the original Chief Complaint the patient presented with and obtain the details in the HPI. However “associated” symptoms should be descried in the HPI.　

3. HPI (History of Present Illness) --The history of the present illness is a more elaborate description of the patient's chief complaint and is the most important structural element of the medical history. This section should give the following details about the chief complaint (s):　

a. Detailed description of the “chief complaint”; “a dull crushing chest pain” including body location of the complaint.
b. A chronological history and sequence of the chief complaint.
c. What circumstances precipitated it: climbing stairs, emotional upset such as anger, or sexual intercourse.
d. What circumstances relieve it: resting for a few minutes.

4. ROS (Review of Systems) -- This section is too often omitted. Although it is somewhat cumbersome to go through a “complete” review of systems and it may not be necessary to do so for “each” admission, at least one “complete” review of systems should be documented in the patient's medical record. For subsequent admissions the history could simply refer back to the “complete ROS” documented on a specified date. However, even with subsequent admissions, a minimum would be to include in the HPI a “pertinent” ROS of the organ - system of Chief complaint.

5. Social History -- This section is the most neglected section of the patient history performed in China. Vital information such as smoking history, use of alcohol or illicit drugs and sexual behavior can give invaluable clues to the diagnosis. Cigarette smoking is a risk factor for a vast array of diseases including cancer, coronary heart disease, COPD and GI diseases. In China, the prevalence of smoking among females is only about 5%. However, it's gradually increasing among young females. Thus physicians frequently forget to ask females about their smoking history. Also documentation of the patient's marital status (divorced)and family situation may give clues to the early diagnosis of anxiety or depression. A brief family medical history should also be included if not already mentioned in the HPI.

Although we've described a nice, neat “outline” for the patient history, when the medical student first begins to interview take a history, he quickly discovers that fitting patient's responses into a “neat” history and physical outline is indeed a challenge and requires much patience and practice! Patients have not been told their responses are to “fit” into a structured format! When asked a specific question by the medical student/physician interviewer, they may assume they should give as much information as possible, thus the interviewer is forced to “sift” through their response and retain only the pertinent data for the medical record.　

In summary, the patient history is the most important aspect of patient evaluation as it guides the physician team's decisions concerning diagnostic work up and formulation of a treatment plan. As mentioned the medical history contributes more towards the diagnosis than any other test (60% to 80% of the information needed to make the diagnosis). Further it can help to establish rapport where the patient not only learns to trust their physician but also is more likely to heed their advice.