Basic History-Taking

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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

Allergy History

Vaccination History

Vaccinations
Up to date?

Family History (FHx)

Conditions In the Family
Heart disease, cancer, diabetes, autoimmune Dx
Living Family Members
Health, age, any medical conditions
Deceased Family Members
Age at death, cause of death

Social History (SHx)

Recent Travel
Especially to developing countries
Family
Relationship status, children
Relationship Status
Single / de facto / married / separated / divorced
Children
How many children, how old
Living Situation
Where, who they live with, low or highset
Vocation
Education, occupation, source of income
Education
Level of education attained
Occupation
Current job, past jobs, level of activity, toxin exposure
Source of Income
Occupation / pension / worker's compensation
Hobbies
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

On this page: History of Presenting Complaint (HPC)Past Medical History (PMHx)Medication History Allergy History Vaccination History Family History (FHx)Social History (SHx)Substance History Systems Review

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