General medical history

Data gathering

  • HPC – History of presenting complaint
  • PMH – Past medical history and previous surgeries
  • DH – Drug history – include over the counter and allergies
  • FH – Family history
  • SH – Social history
    • Who is at home
    • Alcohol, Drugs
    • Occupation
    • Driving
    • Pets
    • Layout of home – stairs, bathrooms, bedrooms
    • Activities of daily living – washing self, getting dressed, toilet, meals, shopping

 

Clinical management

  • Investigations
  • Explanation
  • Treatment
    • Lifestyle
    • Medications
    • Refer
  • Follow-up / Safety-net