1.
Patient Identification & Demographics
Start by confirming the patient's identity and basic details:
Name
Age
Gender
Date of birth
Occupation
Ethnicity (if relevant to the disease pattern)
Primary language and need for an interpreter
2. Chief Complaint (CC)
This is the primary reason why the patient is seeking medical attention.
Document it in the patient’s own words using quotation marks.
Example: “I have had a severe headache for the past two days.”
3. History of Present Illness (HPI)
This is a detailed exploration of the chief complaint. For a systematic approach, use the
SOCRATES mnemonic for pain-related symptoms:
SOCRATES Mnemonic for Pain Symptoms
Factor Explanation Example
Site Where is the pain located? "Central chest pain"
Onset When did it start? Sudden or "Started 3 hours ago
gradual? suddenly"
Character Describe the nature of the pain "Crushing, tight pain"
Radiation Does the pain spread "Radiates to left arm"
anywhere?
Associated symptoms Any other symptoms with it? "Sweating, nausea"
Time course Has the pain changed over "Worsening over the last
time? hour"
Exacerbating/Relieving What makes it better or worse? "Worse on exertion, relieved
factors by rest"
Severity Rate on a scale of 1-10 "8/10 pain"
For non-pain symptoms (e.g., fever, cough, dizziness), use:
1. Onset – When did it start?
2. Progression – Has it worsened or improved?
3. Duration – Constant or intermittent?
4. Associated symptoms – Any related signs?
5. Exacerbating/Relieving factors – What makes it better/worse?
4. Past Medical History (PMH)
Ask about:
Chronic conditions (diabetes, hypertension, asthma, heart disease).
Past major illnesses (tuberculosis, hepatitis, cancer).
Previous surgeries and hospitalizations.
History of allergies (food, drugs, environmental).
Immunization history (especially in pediatric cases).
5. Medication History
Current medications: Name, dose, frequency, route of administration.
Over-the-counter (OTC) medications or supplements.
Previous medications used for this condition.
History of adverse drug reactions.
6. Family History (FH)
Any genetic or hereditary diseases in family members.
Specific conditions: Hypertension, diabetes, cancer, heart disease, psychiatric
disorders.
Age and cause of death of parents or siblings (if applicable).
7. Social History (SH)
Lifestyle and Habits:
Smoking: Type, duration, packs per day.
Alcohol use: Type, quantity, frequency.
Illicit drug use: Type, method, duration.
Occupation & Living Conditions:
Occupation and workplace exposure (e.g., chemicals, radiation).
Living situation: Alone, with family, in a care home.
Financial and social support: Economic difficulties, stressors.
Diet & Exercise:
Typical daily diet.
Physical activity level.
Sexual History (if relevant):
Sexually active?
Number of partners.
Use of contraception or protection.
History of sexually transmitted infections (STIs).
8. Review of Systems (ROS)
A structured checklist of symptoms from each organ system to ensure nothing is missed:
General:
Fever, chills, night sweats.
Weight loss or gain.
Fatigue, weakness.
Cardiovascular:
Chest pain, palpitations.
Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea (PND).
Leg swelling (edema), syncope (fainting).
Respiratory:
Cough (dry or productive), sputum color.
Shortness of breath, wheezing.
Hemoptysis (coughing blood).
Gastrointestinal:
Abdominal pain, bloating, nausea, vomiting.
Heartburn, acid reflux.
Changes in bowel habits (diarrhea, constipation).
Blood in stool (hematochezia or melena).
Genitourinary:
Urinary frequency, urgency, pain during urination.
Blood in urine, incontinence.
Sexual dysfunction.
Neurological:
Headache, dizziness, fainting.
Weakness, numbness, tingling.
Seizures, memory loss.
Musculoskeletal:
Joint pain, stiffness, swelling.
Muscle pain or weakness.
Endocrine:
Heat/cold intolerance.
Unexplained weight changes.
Increased thirst (polydipsia), increased urination (polyuria).
Hematologic:
Easy bruising or bleeding.
History of anemia.
Psychiatric:
Mood changes, depression, anxiety.
Hallucinations, suicidal thoughts.
9. Summary and Assessment
Summarizing the Key Findings:
“Mr. X is a 50-year-old male with a history of hypertension who presents with sudden-
onset, crushing central chest pain radiating to his left arm, associated with sweating and
nausea. Symptoms started 2 hours ago, worsening with exertion and relieved slightly with
rest.”
Differential Diagnosis (DDx):
Based on the history, list possible diagnoses (e.g., myocardial infarction, GERD, panic
attack).
Plan:
Further investigations (ECG, blood tests, imaging).
Immediate interventions or treatments.
Referral if necessary.
10. Special Considerations
Pediatrics:
Birth history (mode of delivery, complications).
Developmental milestones.
Vaccination status.
Emergency Cases:
Use AMPLE mnemonic for trauma/emergencies:
o Allergies
o Medications
o Past medical history
o Last meal
o Events leading to emergency
