Expansion
Presenting complaint, history, past history, drugs, allergies, family, social, systems review
Expansion
- Presenting complaint: in the patient’s own words
- History of presenting complaint: chronological, with SOCRATES for pain and the relevant system-specific questions. Include ideas, concerns and expectations
- Past medical history: including the classic screening list of diabetes, hypertension, ischaemic heart disease, stroke, asthma, epilepsy, jaundice, tuberculosis, and previous surgery and anaesthesia
- Drug history: prescribed, over the counter, herbal, and adherence
- Allergies: and crucially what happened
- Family history: with ages and causes of death where relevant
- Social history: smoking in pack years, alcohol in units, recreational drugs, occupation, travel, pets, housing, function and activities of daily living, support at home, driving
- Systems review
The social history is disproportionately important in older patients and in discharge planning, and is the section most often skimped.
Red flags should be screened for explicitly in every history: weight loss, night sweats, fever, appetite change, and system-specific alarm features.
Close by summarising back to the patient and asking whether anything has been missed, which reliably surfaces omissions.