Question 1
The element of the history that includes the patient's experiences with illnesses, surgeries, injuries and treatments, current medications, and allergies is the
◦ chief complaint
◦ history of present illness
◦ review of systems
◦ past medical history
Question 2
If the physician is unable to obtain a history from the patient or other source (such as family), then the physician should
◦ review the patient's previous chart and produce a history, also taking into consideration the patient's current condition
◦ describe the patient's condition or other circumstance and note why there is no history documented
◦ wait until the patient is able to give a coherent history
◦ create a history based on her assessment of the patient