History of previous illness (HPI) is a chronological description of development and progress of the present disease of the patient from the first symptom of the presenting problem. History of presenting illness may also be referred to as the history of the chief complaint- HCC. Taking an accurate and chronological history of presenting illness might be the most difficult but is the essential part of any consultation. The more a physician has knowledge and experience in clinical practice, the simpler it becomes to take a good history of presenting illness. The patient's complaints should be written in order of relevance, phrased in medical terms and should not be altered by leading questions. In instances where the patient's words are used, they should be written in inverted commas, for example, ‘palpitation' and the physician should find out exactly what they mean to the patient.
An excellent history of presenting illness should have a proper order of onset of symptoms. For instance, the mnemonic ‘SOCRATES' that stands for the site, onset, character, radiation of symptom, other symptoms associated with the symptom, the timing of the manifestation, exacerbating factors of the symptom and its severity (Linder, 2015). A patient with a sore throat, for example, should have the onset of the symptom documented. Was the symptom gradual or acute in onset? The site of a sore throat is the throat; therefore, the site should be omitted. Any relieving factors such as medication should be documented, associated factors such as a cough, hoarseness and inflamed tonsils are also essential to document (Linder, 2015) . Timing and exacerbating factors should also be documented and grading of its severity. Severity can be graded by asking the patient to quantify using a scale of 1-10 1ith ten being the most severe.
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Review of systems (ROS) is documentation of specific body systems the patient may be experiencing. It involves both the symptoms that the patient is experiencing and those that they deny having experienced (Ofstad et al. 2016). For a patient with a sore throat, it would be important to evaluate the respiratory system, the cardiovascular system that includes rheumatic endocarditis that is preceded by a sore throat and gastrointestinal tract (Habib, 2016) . For the respiratory system, inquiry on dyspnea, cough, fever, breathlessness, hoarseness, chest pain, rhinorrhea and wheezing (Pasterkamp & Zielinsk, 2018) . For the cardiovascular system, chest pain, orthopnea, palpitations, dyspnea on exertion, PND- paroxysmal nocturnal dyspnea, peripheral edema, and claudication. The alimentary tract should have an abdominal pain inquiry, dysphagia, heartburn, nausea, vomiting, diarrhea, melena, hematochezia, and jaundice (Slade & Larsen, 2015).
Diagnosis by definition is the determination of the nature of a disease or other problems by examination of the signs and symptoms (Richardson, Wilson, & Guyatt, 2015) . Clinically, a patient with should have a good clinical history and physical examination. To confirm a diagnosis, lab investigations are also done. In the case of a sore throat, after a detailed history on all systems and a physical examination, possible illnesses are generated from the doctor's knowledge. Fever, hoarseness of voice and rhinorrhea indicate possible infection. Investigations such as full blood count indicating leukocytosis confirm the presence of infection and a throat swab may indicate the actual pathogen causing the sore throat. Differential diagnosis is the process of distinguishing between two or more conditions that share similar signs and symptoms (Adler, Adler-Klein, & Gasbarra, 2008) . For a sore throat, the differential diagnosis may be bacterial pharyngitis, allergies or thyroiditis ( Cevc, 2017). Prognosis is the likely course that the illness is likely to take.
SOAP notes are one of the activities medics use to communicate with each other and for future reference. It stands for Subjective, Objective, Assessment and Plan which represent its format. Information received from patient history is subjective, additional information from physical exam and investigations (lab and imaging) are objective, and the assessment is a diagnosis from the subjective and objective areas (Seo et al. 2016). The plan involves the management intended from the impression that is generated. History and Physical (H&P) includes the history of presenting illness, past medical history, past surgical history, allergies to medicines, relevant family history, and social history.
References
Adler, S. N., Adler-Klein, D., & Gasbarra, D. B. (Eds.). (2008). A pocket manual of differential diagnosis . Lippincott Williams & Wilkins.
Cevc, G. (2017). Differential diagnosis and proper treatment of acute rhinosinusitis: Guidance based on historical data analysis. Allergy & Rhinology , 8 (2), ar-2017.
Habib, G. (Ed.). (2016). Infective endocarditis: epidemiology, diagnosis, imaging, therapy, and prevention . Springer.
Linder, J. A. (2015). A sore throat: avoid overcomplicating the uncomplicated. Annals of internal medicine , 162 (4), 311-312.
Ofstad, E. H., Frich, J. C., Schei, E., Frankel, R. M., & Gulbrandsen, P. (2016). What is a medical decision? A taxonomy based on physician statements in hospital encounters: a qualitative study. BMJ open , 6 (2), e010098.
Pasterkamp, H., & Zielinski, D. (2018). The history and physical examination. In Kendig's Disorders of the Respiratory Tract in Children (Ninth Edition) (pp. 2-25)
Richardson, S. W., Wilson, M., & Guyatt, G. (2015). The process of diagnosis. Users guides to the medical literature: a manual for evidence-based clinical practice .
Seo, J. H., Kong, H. H., Im, S. J., Roh, H., Kim, D. K., Bae, H. O., & Oh, Y. R. (2016). A pilot study on the evaluation of medical student documentation: assessment of SOAP notes. Korean journal of medical education , 28 (2), 237.
Slade, P. M. E., & Larsen, M. P. (2015). Case Report: Dysphagia, dysphonia and sore throat following cerebral infarction: an unexpected cause. BMJ case reports , 2015 .
