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Clinical History Format

Providing a well-structured clinical history is essential for obtaining accurate and comprehensive differential diagnoses from the Knidian AI API. This guide offers best practices for formatting clinical histories to achieve optimal results.

Key Elements of a Good Clinical History​

A comprehensive clinical history should include:

  1. Patient Demographics: Age, sex, and relevant demographic information
  2. Chief Complaint: The primary reason for seeking medical attention
  3. History of Present Illness (HPI): Detailed description of the current symptoms
  4. Past Medical History (PMH): Relevant pre-existing conditions
  5. Medications: Current medications and relevant medication history
  6. Allergies: Known allergies, especially to medications
  7. Family History: Relevant family medical history
  8. Social History: Relevant lifestyle factors (smoking, alcohol, occupation)
  9. Review of Systems (ROS): Additional symptoms by body system
  10. Physical Examination Findings: If available, relevant physical exam findings
  11. Laboratory and Imaging Results: If available, relevant test results

Format Examples​

Good Example​

A 45-year-old male presents with chest pain, shortness of breath, and fatigue for the past 3 days. The pain is described as pressure-like, radiating to the left arm, and worsens with exertion. It is relieved somewhat by rest. He rates the pain as 7/10 in severity. He has also experienced mild nausea but no vomiting.

Past medical history includes hypertension diagnosed 5 years ago and hyperlipidemia. Current medications include lisinopril 10mg daily and atorvastatin 20mg daily. No known drug allergies.

Family history is significant for myocardial infarction in his father at age 50. He is a current smoker (1 pack per day for 20 years) and drinks alcohol occasionally. He works as an accountant with a sedentary lifestyle.

Vital signs: BP 150/95, HR 95, RR 18, Temp 37.0°C, SpO2 97% on room air.
Physical examination reveals no jugular venous distention, clear lung fields bilaterally, and no peripheral edema. Heart sounds are regular with no murmurs, gallops, or rubs.

Less Effective Example​

45yo male with chest pain. HTN and high cholesterol. Father had heart attack. Smoker. BP high, otherwise normal exam.

Best Practices​

  1. Be Specific and Detailed

    • Include specific symptom characteristics (onset, duration, quality, severity, aggravating/alleviating factors)
    • Provide precise timing information (when symptoms started, how they've progressed)
    • Include specific measurements and values when available

  2. Use Clear, Concise Language

    • Avoid ambiguous terms
    • Use standard medical terminology when appropriate
    • Spell out abbreviations the first time they are used

  3. Organize Information Logically

    • Present information in a chronological or systematic order
    • Group related symptoms and findings together
    • Clearly separate different sections of the history

  4. Include Pertinent Negatives

    • Mention the absence of symptoms that would be expected with certain conditions
    • Example: "No fever, chills, or night sweats"

  5. Provide Context

    • Include relevant risk factors
    • Mention recent events that might be related (travel, exposures, procedures)
    • Note any similar previous episodes and their outcomes

Common Pitfalls to Avoid​

  1. Overly Brief Descriptions

    • Too little detail makes it difficult to generate accurate differential diagnoses

  2. Including Irrelevant Information

    • Excessive unrelated details can dilute the important clinical information

  3. Diagnostic Conclusions

    • Focus on describing symptoms and findings rather than stating diagnoses
    • Let the API generate the differential diagnosis based on the clinical data

  4. Omitting Key Information

    • Missing important elements like age, sex, or duration of symptoms reduces accuracy

  5. Using Non-Standard Abbreviations

    • Unfamiliar abbreviations can lead to misinterpretation

Language Considerations​

The Knidian AI API supports multiple languages, but for optimal results:

  • Use clear, grammatically correct sentences
  • Avoid regional slang or highly specialized jargon
  • See our Language Support guide for more information