Please help on medical histroy

Published

I am having difficulty to write my clients medical history. The reason is that she is diagnosed with so many diseases. I really do not know where to start. My instructor said that I can outline the diagnoses but I have to write it like a written format. I looked her chart for information but did not find much info... so I ended up interviewing my client. She is 81 and when you ask her questions that related to her health history she would say one thing and then jump to another... It was just like out of order...Here is what I got form her and chart... Please I need help how to start it any suggestion would be nice.....Her primary diagnoses are:-

1) Hypothyroid (underactive)(subjective)

2) Diabetic type 1

3) Insomnia

4) Anemia

5) Respiratory

6) Irregular heart beat

7) Constipation

8) Chest pain

9) Edema

10) Cholesterol

Specializes in med/surg, telemetry, IV therapy, mgmt.

This is a history. History is usually presented in a chronological order. Chronological means arranged in order of occurrence.

+ Join the Discussion