Guide to Clinical Examination/Quick Guide/General medical history
For more detailed information see History Taking, Examination and Advice
- 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)
- 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?
- [ How to examine patients, The Apprentice Doctor™ e-book course]