Open question about presenting complaint
“So what’s brought you in today” Taking a Medical History
Key Cardiovascular Symptoms
 Chest pain
 Dyspnoea
Pain Other symptoms  Palpitations
 Syncope
 Oedema
 Claudication
 Systemic symptoms such as
fatigue, fever, sweating, weight
loss or gain
Site Time course
Onset Onset Key Gastrointestinal Symptoms
Character Exacerbating or relieving factors  Dysphagia or odynophagia
Radiation Character  Nausea or vomiting
 Gastroesophageal reflux
Associated symptoms Associated symptoms  Abdominal pain
Time course Previous episodes  Abdominal distension
Exacerbating or relieving factors Severity  Altered bowel habit or stool
consistency
Severity
 Systemic symptoms such as
fatigue, fever, malaise, jaundice,
appetite, weight loss
Key Gynaecological Symptoms
 Abnormal vaginal discharge
 Abnormal vaginal bleeding
Summarise discussion Explore patient’s perspective
 Vulval itching or discomfort
Ask if there are any other symptoms if not already covered
 Abdominal or pelvic pain
 Urinary frequency or urgency
Ideas regarding symptoms  Altered bowel habit
Concerns about symptoms  Abdominal distension
Expectations from consultations  Systemic symptoms such as
Signpost when ready to move on fatigue, fever, weight loss
Key Respiratory Symptoms
 Dyspnoea
 Cough
 Sputum
 Wheeze
 Haemoptysis
 Chest pain
 Systemic symptoms such as
fatigue, fever, sweating, weight
loss
Key Mental Health Symptoms
 Unexplained mood changes
 Loss of interests or pleasure
 Fatigue or low energy
 Excessive fears, worries and
anxieties
 Disruption of sleep or eating
patterns
 Agitation and difficulty
concentrating
 Low confidence and social
withrawal
 Slowing of movements
 Delusions or hallucinations
 Suicidality
Medical History Drug History Family History Social History
 Current or previous medical  Regular medications  Relevant diseases in family  Smoking
conditions  Over the counter drugs members  Alcohol
 Surgical history  Contraceptive pill  Contact with others who are  Recreational drug use
 Previous hospital admissions  Home oxygen unwell
 Diet
 Allergies  Recreational drugs  Any unexplained deaths in
family members  Exercise
 Herbal remedies
 Living situation
 Activities of daily living
 Occupation
 Hobbies
 Travel history
 Sexual history