History taking
Presenting Complaint
This is what the patient tells you is wrong, for example: chest pain.
History of Presenting Complaint
Sticking with chest pain as an example you should ask:
Site: Where exactly is the pain?
Onset: When did it start, was it constant/intermittent, gradual/ sudden?
Character: What is the pain like e.g. sharp, burning, tight?
Radiation: Does it radiate/move anywhere?
Past Medical History
Gather information about a patients other medical problems
Drug History
Find out what medications the patient is taking, including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc.
Family History
Gather some information about the patients family history, e.g diabetes or cardiac history. Find out if there are any genetic conditions within the family, for example: polycystic kidney disease.
Social History
This is the opportunity to find out a bit more about the patient’s background. Remember to ask about smoking and alcohol.
Review of Systems
These are the main systems you should cover:
CVS
Respiratory
GI
Neurology
Genitourinary/renal
Musculoskeletal
Psychiatry
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