History taking

(History of Present Illness)
HPI 1
SOPDCRT

• Site 
• Onset (sudden, insidious) 
• Progress (up/ static/ down, on and off, colicky- i.e. baseline symptoms) 
• Duration 
• Characteristic 
• Relieving/ aggrevating factors, Radiation 
• Triggering factors 
• Severity

HPI 2

• cause/ DDx
• risk factors
• association
• Cx
• Cx to treatment

Systemic review

• (open ended) Do you have any other discomfort, how many
• any PAIN anywhere
• (close ended)- SCREENING Q
• 0/ (Gen) fever/ chill/ rigor, wt loss, malaise, appetite
• 1/ (CVS) SOB, abn heart beat, ankle swelling
• 2/ (Resp) Cough/ sputum, wheeze, cough out blood, ENT
• 3/ (GI) (UGI) swallowing problem? (MGI) Do you vomit/ diarrhoea or constipation? (CRT) Does your bowel and stool normal? (HBP) yellow skin, tea color urine
• 4/ (CNS) syncope, behaviour/ eye/ speech/ hearing, limbs/ head problems- numbness/ weakness
• 5/ (Renal) urinary problem, swelling
• 6/ (Haem) bleed/ bruises, neck/axillary/groin lumps
• 7/ (Endo)
• 8/ (Rheum) jt/ m/ bone pain, problems, stiffness, oral ulcer, eye
• 9/ (Skin) any skin (mucosal, genital) and jt problems?

other Hx 

'FD PASS MTV'

• FAMILY
• TRAVEL
• DRUG
• PAST
• ALLERGY
• SOCIAL
• SEXUAL
• MENSTRUAL
• TRAVEL
• VACCINATION

SEXUAL Hx

• (woman) contraception, menses, pregnancy, lactation
• (man) erectile dysfx (as many drugs can affect e.g. diuretics/ DM etc), contraception, frequency of shaving
• (detail sexual hx)
• 'S'exually active
• 'E'xtramarital relationship
• 'X' cross-> sex with man/ women or both
• 'U'aginal/ oral/ anal sex
• 'A'nal
• 'L'ife- contraception, unprotected sex

(STD)

• time- frequent, last exposure
• place- (for resistance of drug- imp)
• person- homo/ bisexual, no., method- oral, anal
• contraception/ condom
• hx of STD

Social Aspect
SUPPORT (self- belief/ leisure/ financial status, family, friends, colleague, religion, self-help group, social network)

• daily activity 1 at DAY life (from morning to night e.g. work/ school, travelling, meal)
• daily activity 2 at HOME (from bed to toilet, kichen, stairs, door; cloth, eat, live)
• daily activity 3 WEEK (weekdays, weekends, holiday, leisure)
• daily activity 4 YEAR (schooling, work, marriage, sex, kids, parents)
• How disease/ disability affect the above