General: History
  1. Introductory information
  2. Presenting complaint
  3. History of presenting complaint
  4. Past medical, surgical history
  5. Gynecological history
  6. Family history
  7. Social, personal history
  8. Drug history
  9. Systems review
Introductory information
  • Introduce, shake hands.
  • Name, What 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 that brought you to hospital [record in pt's own words].
History of presenting complaint

SOCRATES:

  • Site: where, local/ diffuse, "Show me where it is worst".
  • Onset: rapid/ gradual, pattern, worse/ better, what did when symptom began.
  • Character: vertigo/ lightheaded, pain: 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 well, chronic: why came now.
  • Exacerbating factors, "What are you doing when it comes on?".
  • Severity: scale of 1-10.
  • Associated symptoms.
  • Impact of symptoms on life: "Does it interrupt your life".
  • "Were you referred here by your GP, or did you come in through casualty?" 
Past medical, surgical history
  • Past illnesses, operations.
  • Childhood illness, obs/gyn.
  • Tests and treatment prescribed for these.
    Drugs remaining relevant: corticosteroids, OCP, anti-HTN, chemotherapy, radiotherapy.
  • Checklist of dz's:
    MJ THREADS:
    MI
    Jaundice
    TB
    HTN ["Anyone told you, you have high BP?"]
    Rheumatic fever
    Epilepsy
    Asthma
    Diabetes
    Stroke
  • Problems with the anesthetic in surgery.
Gynecological history
  • Time of menarche, if periods regular, menopause.
  • Possibility of pregnant, number of children, number of miscarriages.
  • Length of cycles, length of period, first day of your last period.
Family history
  • The current complaint in parents/ siblings: health, cause of death, age of onset, age of death [eg: heart dz,  bowel CA, breast CA].
  • Health of parents/ siblings/ children: "Are your parents still alive?" "How is the health of your..."
  • Hereditary dz suspected: do a family tree.
Social, personal history
  • Birthplace, residence.
  • 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 smoked, how many per day, for how long, type [cigarette, pipe, chew]".
  • Alcohol: do you drink. If yes: type, how much, how often.
  • Travel: where, how lived when there, immunization/ prophylactic status when went [if relevant].
  • Marital status [and quality], health of spouse/ children, sex activity [discretely, if relevant].
  • Other household members, pets [if infections/ allergies], social support, whether patient can manage at home: "Who's with you there at home".
  • Diet, physical activity.
  • Community care: home help, meals on wheels. 
  • "Is there some things that worry you about the symptoms you are having?"
Drug history
  • Prescriptions currently on [don't trust their written doses, do your own when re-prescribe].
  • Over-the-counters.
  • OCP.
  • Supplements, HRT.
  • Alternative medications.
  • Recreational drugs.
  • Allergies: drugs [and what was reaction], dyes. Pt. often will confuse side effect with a reaction.
Systems review

General Exam