Professional Documents
Culture Documents
Socrates
Socrates
Name
Address
Date of birth
Date of admission
Presenting complaint
History of presenting complaint
Previous medical history
Systems enquiry
Drug history and allergy
Family history
Social history
Conclusion/summary
Exacerbating and relieving factors - does anything make the pain better
or worse?
Severity - does the pain interfere with daily activities or with sleep?
Medical
Surgical
Tuberculosis
Hypertension (myocardial infarction and strokes)
Rheumatic fever
Epilepsy
Astham, anxiety and arthritis
Diabetes and depression
Systems Enquiry
Gastrointestinal function
Genitourinary function
Musculoskeletal function
Neurological function
Family history
Are your father, mother, brothers, sisters alive? - If they have died, at
what age did he/she/they die? What did he/she/they die of?
Do they have any current illnesses?
Do any illnesses run in your family?
Social history
Conclusion/summary
After you have taken the history summarize your findings under appropriate
headings. Once you have completed the history ask the patient whether they
have any other particular worries or concerns that you hve not discussed.
Thank the patient and explain, if appropriate, that you would now like to
examine them.
Summary
Date and time
Place of
consultation
Patient's name, age
and occupation
Presenting
complaint
Summarize both the current problem and the means by which the
patient came to medical attention
e.g. - referred by GP, with a 3 hour history of severe central chest
pain, - brought to the Accident and Emergency department by
boyfriend after taking an overdose of paracetamol
History of present
illness
Medical:
TB
Hypertension
Rheumatic fever
Epilepsy
Asthma
Diabetes
Surgical
Obstetric
Family history
Social,
occupational and
travel history
Drug and therapy
history
include allergies