<aside> 📢 This is a general approach to history taking, there are no disease-specific findings listed.

</aside>

General History

Basics

• Sanitize & don PPE if appropriate
• Introduce yourself & take permission
• Patient demographics
  • Name
  • Age
  • Gender
  • MRN
  • Nationality & Residence
  • Date of admission & location of admission (referral, ER, etc)
• Demographics of Historian
  • Relation to patient
  • Name
  • Reliability!!

Chief Complaint

• What brought you to the hospital/clinic?
• Presented to: ER, outpatient, inpatient
• Allow the patient to list the reasons of admission, do SOCRATES based on the basic complaint
• Is this the first time this happens?
• Is the patient a known case of any illness?
• Was their state of health normal until the presenting complaint?

History of Presenting Illness (HPI)

• SOCRATES
  • Site
  • Onset
  • Character
  • Radiation
  • Associated symptoms
  • Time
  • Exacerbating/alleviating factors
  • Severity
• Constitutional symptoms
  • Fever — peak value, site of measurement, any pattern
  • Loss of appetite
  • Weight loss — NET change in weight, change in clothes size
  • Night sweats
  • Lethargy