Scribd
Upload
180 views1 page

Comprehensive Medical History Guide

The document provides a template for documenting a patient's history and physical examination. It includes sections for collecting a history of present illness, past medical history, social history, family history, review of systems, and physical examination. The history of present illness section guides the clinician to obtain detailed information about symptoms, including their quality, radiation, severity, timing, exacerbating and alleviating factors, and related symptoms. Relevant systems should be questioned in more detail. The physical examination section lists vital signs and a general exam including checks for jaundice, anemia, cyanosis, clubbing, edema and lymphadenopathy.

Uploaded by

basssssem
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
180 views1 page

Comprehensive Medical History Guide

The document provides a template for documenting a patient's history and physical examination. It includes sections for collecting a history of present illness, past medical history, social history, family history, review of systems, and physical examination. The history of present illness section guides the clinician to obtain detailed information about symptoms, including their quality, radiation, severity, timing, exacerbating and alleviating factors, and related symptoms. Relevant systems should be questioned in more detail. The physical examination section lists vital signs and a general exam including checks for jaundice, anemia, cyanosis, clubbing, edema and lymphadenopathy.

Uploaded by

basssssem
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

The History (Hx) The relevant system(s) - positives AND negatives.

The first sentence (rehearse 20 times): The other systems - positive findings ONLY.
Name,
Age, Summary
(Occupation),
(Ethnicity), Investigation (Ix)
Sex, Bedside (dipstick urine; peak air flow meter)
Presenting complaint. Bleed - Haem (FBP, coag), Biochem (U+E, LFT, TFT, Glucose, Cholesterol), Special (PSA,
cultures, cardiac enzymes(3 days) )
Section 1: Imagery (eg. ECG, CXR, AXR, ECHO, CT)
HPC - include history of the whole relevant system, including risk factors. Invasive (fine needle biopsies, ERCP)
Symptoms = PQRST EAR:
Position Management (Dependent on Hx)
Quality Diagnosis = Hx + Ex + Ix
Radiation Sieve: TIN MAIDENS = Trauma, Infection, Neoplasm, Metabolic, Alcohol/Autoimune,
Severity Iatrogenic/Idiopathic, Degenerate, Endocrine, Neurological, Smoking
Timing (Onset, Duration, Does it come and go?) Management = Diagnosis + Rx
Exacerbating factors
Alleviating factors Treatment (Rx):
Related Symptoms Conservitive
PMHx Medical
Surgery
Section 2:
DHx - *ALLERGIES* From Dr Smith:
SHx = SWARM (Smoking+Alcohol, Work, Accomodation, Relatives, Money) (or "A Mars a Set scene: Age/Occupation
Day Helps you Work (job, income), Rest (home, family) and Play (smoking, alcohol & HPC: Red flags
hobbies)" ) Start
Progression
Section 3: Relevant Systemic Questions: Resp, CVS
FHx PMHx: relevant at top
ROS - Other systems: Drugs *Allergies*
BMJ TRADES CD = BP(hypertension), MI, Jaundice, TB, Rheumatic fever, Asthma, SHx: *ADLs*, social support, smoking, alcohol, occupation
Diabetes, Epilepsy, Stroke, Clots, Duodenal ulcer. FHx
Always: Weight loss, appetide. SQ
Resp: SOB (+ distance can walk), wheeze, cough, sputum (+colour, how much), haemoptysis.
CVS: Pain, palpitations (+tap rhythm), hypo/hypertension, orthnopea (how many pillows),
PND, ankle swelling.
Abd: Pain, dsyphagia, indigestion, vomiting, haematemesis, change in bowel habit,
diarrrohea/constipation, blood in stool.
Geno-uriary: Frequency, nocturia, incontinence, haematuria, bad smell, poor stream,
hesitancy, post micturation dribbling.
In female: pregancies, heavy periods, intermenstrual bleeding, recurrent abortions, premature
menopause.
Nervous: Fits, faints, visual disturbances, severe headaches, parathesia, memory loss,
weakness, coordination.
General: Skin problems, arthritis.

The Examination (Ex)


General appearance - including oxygen mask, nebs, etc.
BP, Pulse, Temp, RR.
JACCOL (Jaundice, Anaemia, Cyanosis, Clubbing, Oedema, Lympadenopathy).

You might also like