1. Introductory information
2. Presenting complaint
3. History of presenting complaint
4. Past medicalsurgical history
5. Gynecological history
6. Family history
7. Socialpersonal history
8. Drug history
9. Systems review

Introductory information

• Introduceshake hands.
• NameWhat age are you now [name clues: ethnicity or age-specific dz].
• Where from [if relevant].

Presenting complaint

• What is the problem lately. Alternatively: What is the problem thatbrought you to hospital [record in pt's own words].

History of presenting complaint

SOCRATES:

• Site: wherelocal/ diffuse"Show me where it is worst".
• Onset: rapid/ gradualpatternworse/ betterwhat did whensymptom began.
• Character: vertigo/ lightheadedpain: sharp/ dull/ stab/ burn/cramp/ crushing.
• Radiation [usually just if pain].
• Alleviating factors"What do you do after it comes on?"
• Time course: when last felt wellchronic: why came now.
• Exacerbating factors"What are you doing when it comeson?".
• Severity: scale of 1-10.
• Associated symptoms.
• Impact of symptoms on life: "Does it interrupt your life".

• "Were you referred here by your GPor did you come in throughcasualty?" 

Past medicalsurgical history

• Past illnessesoperations.
• Childhood illnessobs/gyn.
• Tests and treatment prescribed for these.
  • Drugs remaining relevant: corticosteroidsOCPanti-HTNchemotherapyradiotherapy.
• Checklist of dz's:
  MJ THREADS:
  MI
  Jaundice
  TB
  HTN ["Anyone told youyou have high BP?"]
  Rheumatic fever
  Epilepsy
  Asthma
  Diabetes
  Stroke
• Problems with the anesthetic in surgery.

Gynecological history

• Time of menarcheif periods regularmenopause.
• Possibility of pregnantnumber of childrennumber of miscarriages.
• Length of cycleslength of periodfirst day of your last period.

Family history

• The current complaint in parents/ siblings: healthcause of deathage ofonsetage of death [eg: heart dz  bowel CAbreast CA].
• Health of parents/ siblings/ children: "Are your parents stillalive?" "How is the health of your..."
• Hereditary dz suspected: do a family tree.

Socialpersonal history

• Birthplaceresidence.
• Race and migration [if relevant].
• Present occupation [and what do they do there]level of education.
  • Any others at workplace with same complaint.
• Social habits [if relevant].
• Smoking: "Ever smokedhow many per dayfor how longtype [cigarettepipechew]".
• Alcohol: do you drink. If yes: typehow muchhow often.
• Travel: wherehow lived when thereimmunization/ prophylactic statuswhen went [if relevant].
• Marital status [and quality]health of spouse/ childrensex activity[discretelyif relevant].
• Other household memberspets [if infections/ allergies]social supportwhether patient can manage at home: "Who's with you there athome".
• Dietphysical activity.
• Community care: home helpmeals on wheels. 
• "Is there some things that worry you about the symptoms you arehaving?"

Drug history

• Prescriptions currently on [don't trust their written dosesdo your ownwhen re-prescribe].
• Over-the-counters.
• OCP.
• SupplementsHRT.
• Alternative medications.
• Recreational drugs.
• Allergies: drugs [and what was reaction]dyes. Pt. often will confuse side effect with a reaction.

Systems review

• See Systems Review.

General Exam »

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