1. Preliminaries Self-introduction: full name __ year medical student from Monash University Explain what you are going to do: take medical history will involve asking some questions about your current illness, past illness, lifestyle etc. all information obtained will be kept confidential and only be revealed to the GP Obtain consent Obtain patient’s biodata: Full name Age Occupation Marital status 2. History of Presenting Complaint – WWQQAA + B + ICE “What brings you here today?
” / “How can I help you today? ” Where When Circumstances: Is the condition different from when it first started? Quality Temporal factors: How did the condition change over time? Quantity Aggravating and alleviating factors Associated symptoms Beliefs Impact Concerns Expectations 3. Systems Review + Risk Factors SYSTEMS REVIEW MSK PNS CVS Pain Swelling Joint stiffness (morning/after activity) Loss of motion Loss of function Deformity Weakness Instability Fever.
Weight loss Fatigue Seizures or Fits Fainting Dizziness Vertigo Headache Paraesthesia/Anaesthesia Weakness (One/Both sides) Gait or Movement Problems Visual, Hearing, Smelling disturbance Neck stiffness Disturbance of sphincter control (bowel, bladder) Head injury with loss of consciousness Chest pain/heaviness Exertional dyspnoea Paroxysmal nocturnal dyspnoea Orthopnoea Ankle swelling Palpitations Intermittent claudication Syncope Fatigue RISK FACTORS MSK PNS CVS Age >50.
Gender Obesity Occupation and Sport Family history Infections Medication (eg. corticosteroids >2 months) Overseas travel Poor diet (inadequate dietary calcium and vit D) Smoking Excess alcohol PH of musculoskeletal injury or other conditions Past history of cancer Smoking Diabetes Alcohol Diet (eg. vit B12 deficiency) Malabsorption Infections (Shingles, Meningitis) Cancer Drug use and abuse Injuries Hypertension PH of CVD (eg. MI, IHD, CABG, stroke).