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Your Doctor Visit

Mark E. Reiber, MD, FACS, FAAOA

Medical decision-making is hard work

In the office,  at social events, even at the grocery store, allergy doctors hear the same questions. “I have had a cough for weeks, what should I take?” “Why does my nose run all the time?” “What’s the best medicine for allergies?” The expectation is a doctor can listen to a few sentences, or do a brief once-over, and know the correct diagnosis and best treatment. This may work on TV, but rarely in real life.

In today’s world, there’s much to consider  and a snap decision based on limited information is just bad medicine.

All medical decisions are made from both subjective and objective information. Subjective information is ‘the story’, the symptoms, the ‘history of present illness”. Past medical problems, surgical procedures, family history, social factors, drug allergies and medication usage all provide background. Objective information comes from a physical examination, laboratory tests, X-Rays, and other tests. It is the hard facts that can be seen and measured. When these two are combined sound medical decisions can be made.

The patient’s responsibility

Subjective data is highly dependent your communication skill. It is critical to tell your story accurately, completely, and yet efficiently. A good doctor will let you tell the story, but he also knows how to fill in blanks.

Some background information is always needed such as the current medications, allergies, past medical conditions, and previous operations.  It is best to keep a running list of these and bring it with you to doctor visits.   There may also be previously performed tests that you can provide.

The physician’s responsibility

Objective information is usually dependent on the doctor’s skill and experience. An expert physician knows what to ask, where to look, and how to recognize key information.

The interpretation of tests results is usually far more challenging than simply looking at the normal range of values and comparing results. Data must be considered in context. When an abnormal or unexpected result is encountered, the astute physician will question it, look for an explanation, and try to either support or refute the result as real or false.

Time is Limited

When you visit a physician, you want his time, experience and skill. You are asking him to consider all he hears, feels, and sees, so be prepared to give him as much as you can in the time you have.

Much like a theater performance, you are on stage with the physician as your audience. Think and plan ahead. Make notes and arrange what to bring.  Give the important facts first.

Make sure all the needed information is available

Remember, the doctor can only make decisions based on the information he has available. Bring X-Rays, reports, medications and other related information to your visit. Do not rely on others to have sent information ahead of time.

How to Diagnose a Problem

Proper diagnosis is systematic, methodical and rational. Early in medical school, physicians are trained in the same methods of diagnosis. There are four parts of a medical evaluation: the history, the examination, the assessment and the plan.

Know Your History

The history consists of a chief complaint, history of present illness, past medical and surgical history, medications, family history, allergies, past treatment plans, and other key information.

Chief Complaint

It's generally a single sentence, such as “my left ear hurts”. It quickly focuses the physician’s attention to a set of problems. The “wrong” chief complaint can get things off track.

Allergy chief complaints include sneezing, watery eyes, nasal congestion, rashes, nasal polyps, headache or a diagnosis such as recurrent sinus infections. It is best to give symptoms and not a diagnosis. Discussing a diagnosis before all the facts are in can “short circuit” the process.

History of Present Illness

This is the true meat and potatoes of patient history.

The key elements are:
  • Duration: How long has this problem been present? It is one of the most important facts. Sneezing that has been present for a few days only may be the common cold, but sneezing that has been recurrent for years is much more likely to be a symptom of allergy.

    Be as specific as possible. Tell the physician if the problem has been present in the past, and is recurrent, or if it is continuous.
  • Location: Where is the problem? For some complaints, this is as simple as left or right.

    Headaches are common in allergy and sinusitis. If the pain is in the back portion of the head, it is much more likely a tension headache. Pain only on one side of the head may be a classic migraine. Pain in the temples may be related to TMJ and pain in the midface may be from a tooth source.
  • Quality: This refers to the nature of the complaint. For pain, this may be sharp, stabbing, dull, throbbing, or vague.
  • Severity: Is the pain the worst of your life? On a scale of 1-10, how severe is the problem.
  • Timing: Is the problem episodic, and when does it occur?
  • Context: What causes the symptom to start? Does the problem always occur when you are doing a particular activity, or when you are at a particular location? This is a very important detail for allergic problems.
  • Aggravating and Alleviating Factors: What improves or worsens the symptoms? Are there any treatments that have been tried to this point, and what was the effect?
  • Associated Factors: What other problems are associated with the symptoms. For a patient with nasal congestion, sneezing and drainage, there may be rashes, itchy watery eyes, or ear fullness, pressure, and popping.

The more details you provide, the more completely the physician will understand the problem, and the better the chance of an accurate diagnosis. Stick to the main problem however and don’t wander too far off track with details.

Past Medical and Surgical History

This includes any past medical conditions, operative procedures, hospitalizations and illnesses. Be complete, but only include problems that carry with them a diagnosis. Diabetes, heart disease, strokes, arthritis, appendectomy, broken bones, and childhood diseases such as measles or mumps are just a few examples.

It is helpful to have dates of illnesses or operations and to know doctors that have past records.

Medications

For each medication, you should state the name, the dose, the route by which you take it (orally, patch, etc.), and the frequency (daily, twice a day). You should also include over the counter medications, herbals, and vitamins.

Allergies

List any allergies, sensitivities or reactions to medications, foods or other items such as tape, latex and contacts encountered. List the reaction that occurred (hives, shock, or shortness of breath).

Family History

Include hereditary diseases, illnesses affecting first and second-degree relatives (parents, brothers and sisters, grandparents). List bleeding disorders, severe reactions to anesthesia and other severe medical conditions.

Social History

This is a broad category including occupation, marital status, hobbies, habits such as tobacco, alcohol and drug use, and other recreational activities.

Review of Systems

This is an inventory of symptoms listed to check for problems outside the primary area of concern and not covered by the history and exam.

Physical Examination

Generally speaking, every physical examination will begin with vital signs, including one or more of the following: temperature, blood pressure, heart rate, respiratory rate, height, and weight.

The physical exam for each specialty and problem is unique. It focuses on the area of concern and then broadens to other areas.
Laboratory tests may be included, and for allergy patients this may be skin or blood testing, sinus CT scans, lung function testing, or other blood tests.

Assessment

Once the subjective and objective data is gathered it’s time to draw conclusions and make decisions. When the diagnosis is not obvious, a “differential diagnosis” or a list of possible “suspects” is formed. The plan then is to order further tests or to try treatments that will prove one way or another which diagnosis is correct. As a diagnosis is excluded from the list, this is called being “ruled out”.

Plan

The final step is the plan, when all decisions are made. Medications are ordered, stopped or changed. Tests are ordered and interventions are planned. Be sure you understand and agree with all decisions that are made during this portion of the visit. Take an active role in formulating your plan as you are the one who must implement it.

Be checked again

Finally, schedule a “follow-up” appointment to be seen again.