- Diagnosis
- History
- Examination
- Investigations
- History
- Management
- Interventions
Basic History-Taking
Good clinical history-taking is the first important step in diagnosis. The history can be used to understand the patient's presenting issue, as well as the biological, psychological and social context that forms the background of the presenting issue.
History of Presenting Complaint (HPC)
- For each symptom - SOCRATES
Site
Localised / generalised, unilateral / bilateral
Onset
Sudden / gradual, situation, following trauma
Character
Sharp, dull, burning, tightness
Radiation
E.g. down the arm, across the back
Associations
Any other symptoms e.g. shortness of breath, nausea / vomiting
Timing
Duration, frequency, changes through the day, constant / fluctuant / episodic
Exacerbating & Alleviating Factors
Exertion / rest, medications, movement, breathing, eating, stress
Severity
On a scale of 1-10, with 10 being the worst
Past Medical History (PMHx)
Medication History
Vaccination History
Family History (FHx)
Social History (SHx)
Recent Travel
Especially to developing countries
Family
Relationship status, children
Living Situation
Where, who they live with, low or highset
Vocation
Education, occupation, source of income
Diet
On an average day
Exercise
Time spent exercising, type of exercise, tolerance
Mobility
Aids, transfers, number of stairs in home, mods
Activities of Daily Living
Cooking, cleaning, laundry, toileting, shopping
Who does what, any assistance with these
Degree of Support Available
Physically and psychologically
Impact of Presenting Complaint
On relationships, work etc.
Substance History
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