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Guide to Clinical Examination/Quick Guide/General medical history

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For more detailed information see History Taking, Examination and Advice

The crux

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  • Demographic information (age, ethnicity, etc.)
  • Presenting complaint (and how long)
  • History of the presenting complaint (ask relevant symptoms here)
  • Past medical history (record significant negatives)
  • Medications (remember drug allergies!)
  • Family history
  • Social history (smoking, alcohol, living situation)
  • Review of systems (take into account Anatomy, Physiology, Etiology & Function)

Review of systems[1]

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  • malaise? energy? weight? sleep? fever?
  • chest pain? shortness of breath? oedema? palpitations? fainting?
  • cough? sputum? haemoptysis? wheeze?
  • nausea? vomiting? abdo pain?
  • diarrhoea? constipation? melaena?
  • urinary freq? polyuria? nocturia? dysuria? change in urine colour?
  • loin or pubic pain?
  • discharge? menstruation? PV bleeding?
  • headache? blackouts? collapse?
  • changes to vision? hearing? changes in speech?
  • limb weakness? walking problems?
  • anxiety? depression?
  • thirst? temperature tolerance?
  • joint pain or swelling? bone pain?
  • rashes? itching? easy bruising? petechiae? bleeding?
  • skin infection?

References

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  1. ↑ [ How to examine patients, The Apprentice Doctor™ e-book course]
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