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Revision panel 1.1

Synopsis of a history
Names; age and date of birth; sex; marital status; occupation; ethnic group; hospital or practice
record number
Present complaints or problems (PC, CO) Preferably in the patient’s own words.
History of present complaint (HPC) Include the answers to the direct questions concerning the
system of the presenting complaint.
Systematic direct questions
(a) Alimentary system and abdomen (AS)
Appetite. Diet. Weight. Nausea. Dysphagia. Regurgitation. Flatulence. Heartburn. Vomiting.
Haematemesis. Indigestion pain. Abdominal pain. Abdominal distension. Bowel habit. Nature of
stool. Rectal bleeding. Mucus. Slime. Prolapse. Incontinence. Tenesmus. Jaundice.
(b) Respiratory system (RS)
Cough. Sputum. Haemoptysis. Dyspnoea. Hoarseness. Wheezing. Chest pain. Exercise tolerance.
(c) Cardiovascular system (CVS)
Dyspnoea. Paroxysmal nocturnal dyspnoea. Orthopnoea. Chest pain. Palpitations. Dizziness. Ankle
swelling. Limb pain. Walking distance. Colour changes in hands and feet.
(d) Urogenital system (UGS)
Loin pain. Frequency of micturition including nocturnal frequency. Poor stream. Dribbling.
Hesitancy. Dysuria. Urgency. Precipitancy. Painful micturition. Polyuria. Thirst. Haematuria.
Iincontinence.
In men Problems with sexual intercourse and impotence.
In women Date of menarche or menopause. Frequency. Quantity and duration of menstruation.
Vaginal discharge. Dysmenorrhoea. Dyspareunia. Previous pregnancies and their complications.
Prolapse. Urinary incontinence. Breast pain. Nipple discharge. Lumps. Skin changes.
(e) Nervous system (NS, CNS)
Changes of behaviour or psyche Depression. Memory loss. Delusions. Anxiety. Tremor. Syncopal
attacks. Loss of consciousness. Fits. Muscle weakness. Paralysis. Sensory disturbances.
Paraesthesiae. Dizziness. Changes of smell, vision or hearing. Tinnitus. Headaches.
(f) Musculoskeletal system (MSkS)
Aches or pains in muscles, bones or joints. Swelling joints. Limitation of joint movements. Locking.
Weakness. Disturbances of gait.
Previous history (PH) Previous illnesses. Operations or accidents. Diabetes. Rheumatic fever.
Diphtheria. Bleeding tendencies. Asthma. Hay fever. Allergies. Tuberculosis. Syphilis. Gonorrhoea.
Tropical diseases.
Drug history Insulin. Steroids. Anti-depressants and the contraceptive pill. Drug abuse.
Immunizations BCG. Diphtheria. Tetanus. Typhoid. Whooping cough. Measles.
Family history (FH) Causes of death of close relatives. Familial illnesses in siblings and offspring.
Social history (SH) Marital status. Sexual habits. Living accommodation. Occupation. Exposure to
industrial hazards. Travel abroad. Leisure activities.
Habits Smoking. Drinking. Number of cigarettes smoked per day. Units of alcohol drunk per week