History Outline

History Outline

·        History:

o   Identifying data

o   Presenting complaint (or complaints) eg Cough with green sputum 2 days, Dizziness 4 weeks

o   History of presenting complaint

o   Drug and medication use, including allergies, OTC drugs, herbal/alternative medicines

o   Past medical and surgical history (including hospital admissions)

o   Screen for hypertension, heart disease, asthma, diabetes, epilepsy, rheumatic fever, TB, bleeding tendency, hepatitis B

o   Family history of illness (if genetic illness draw family tree)

o  Social history: smoking, alcohol, job, living situation, social supports, overseas travel, functional history in the elderly or disabled

o  If a child, then obstetric, neonatal, growth and development, immunisations

o  Review of systems

o  At end of history always ask „is there anything else you want to tell me‟

o  Note mental function and communication: dementia/delirium common

·        Physical Exam:

o  Vital signs: temperature, respiratory rate, pulse, blood pressure

o  General observations: distress, pallor, hydration, cyanosis, weight

o  Relevant systems exams

·        Formulation and problem list:

o  List of active problems or clusters of problems (always include smoking if they smoke)

o  List of inactive problems or clusters of problems

o  For each problem, list a set of differential diagnoses, investigations to establish which it is, immediate management, other management strategies

·        Progress notes:

o  Changes in symptoms

o  Changes in physical exam or investigation

o  Assessment of what this means

o  Plan for what to do now