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?