Question

During a general physical examination, a patient mentions that he has had a few minor episodes of dizziness during the past month, when asked directly by the physician, "Do you ever feel faint or dizzy?" Under what heading would the physician document these symptoms?

A) Past medical history
B) Present illness
C) Family history
D) Social history

Answer 1

The physician would document a patient's episodes of dizziness under the heading of Present Illness as it details the current symptoms and health concerns of the patient.

Step-by-step explanation:

When a patient mentions symptoms of dizziness during a physical examination, the physician would document these symptoms under the heading of Present Illness. This section of the medical record is intended to describe the current symptoms and health concerns of the patient, which in this case is the episodes of dizziness. Past medical history would cover previous established health conditions, family history pertains to the health of immediate family members, and social history involves the patient's lifestyle, occupation, and habits. Medical History is a broad term that encompasses all aspects of a patient's health history, including past and present illnesses.