Guide to Clinical Examination/Quick Guide/General medical history

For more detailed information see History Taking, Examination and Advice

The crux

• 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

• 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?