As physicians we use three major sources of information in making a diagnosis of a medical illness:
1) Medical History
2) Physical Exam
3) Labs and studies (Like X-rays and EKGs)
Of these three, a thorough medical history is usually the most important component and often the least accurate or detailed. When you only have 15 or 20 minutes with your physician you need to maximize that time. The more you do in preparation for a visit the more accurate information the physician will have and the more likely you will get the right intervention or therapy. The motto here is "come prepared" with an accurate record or description of your symptoms. Your effort to think about your symptoms, and preferably even keep a medical diary, has many benefits. It forces you to take stock of your symptoms and to track them over time. Below we are going to review the key list of questions to ask yourself, which you can then provide to your doctor even prior to the visit (fax it to them a few days before.
Where are the symptoms located? is the symptom always in the same location, or does the location vary? If you have pain, does the pain radiate or spread to another area? For example if you have abdominal pain after eating, where exactly is the pain? Is it on the right or left side or in the middle?
When did you first notice it? When does it occur, what time of day or night? Does it come and go (can you go days or weeks without it) or is it persistent? How long does each episode last? Is it seasonal? Is there a relationship to meals? Is there a relationship to physical activity. Is it related to tyour menstural cycle ? Does it awaken you from sleep?:
If it is pain, what kind of pain? Is it a throbbing, cramping, pressure sensation, or other quality? Try to describe in your own words the sensation you are experiencing.
Does eating make it better? Is it related to what position you are in? Have you taken any medications for it and how have they worked?Does eating aggravate it?
Are there any other symptoms that accompany the main symptom. If the main symptom is shortness of breath is there a cough, diarrhea, urinary symptoms (foamy urine or blood in the urine). Is there nausea or stomach upset? Are there fevers or sweats? Even if youdo not think they are connected, list other symptoms here.
Think back if you have ever experienced similar symptoms in the past. Now with your new personal health record this should be easier. A prior history of the same symptom can be an important piece of clinical information.In summary, I strongly urge you to prepare this type of medical diary and to focus on your symptoms before you seek help from your doctor. You are more likely to avoid unnecessary testing and get optimal care if you come prepared.
The health diary is where this information should be written. As soon as you develop a symptom that you feel is important to evaluate with your doctor begin a new section of the health diary. I would title that page by naming the symptom. for example, "chest burning". then begin your entries. Below I've created an example:
New Symptom: Chest Burning
9/20/2017: I began developing chest burning in late August of 2010. It started abruptly after eating out (Indian food). It was in the upper mid chest (between breasts) and lasted for 2 hours then subsided. It was a burning discomfort but did not radiate anywhere. It stayed in my chest. I took a tums, which helped. I had no other symptoms with it.
10/15/2017: I've had about 5 more episodes like the one above and certain foods like tomato sauce make it worse. I'm taking more tums but found more relief with OTC prilosec, which a friend recommended. I have an appointment with my Dr next week
10/22/2017: I met with my doctor who LOVED MY HEALTH DIARY and thinks my symptoms are due to GERD ("reflux"). However, he found some blood in my stool and i'm set up for a colonoscopy and upper endoscopy. He prescribed protonix 40 mg daily and I stopped prilosec.
10/27/2017: The colonoscopy was normal but the upper scope showed irritation according to doc. No ulcers. Recommended I stay on prilosec and he gave me a diet to follow to reduce symptoms. (I ENTERED THE GERD AND SCOPES ON MY PROBLEM SHEET. ENTERED PROTONIX TO MED SHEET)
12/1/2017: My symptoms are entirely resolved. I'm being careful with diet and Dr. Smith said I could stop protonix now.
01/10/2018: Off the protonix and all is still well as long as I stick to the diet. (I REMOVED PROTONIX FROM MY MED SHEET)
