As you progress in your career and gain experience, in general the history and examination should become more focussed.
History
You should ask questions to include/exclude differentials (e.g. rather than asking the whole of SOCRATES for chest pain, after hearing the patient’s description, ask ‘does the pain radiate to the back?’ if you need to exclude dissection, ‘does the pain get worse on exertion?’ if angina is a differential)
In addition to an open question regarding past medical history, you should also ask specifically about conditions related to differential diagnoses or risk factors (e.g. in likely MI, ask specifically about diabetes, hypertension, high cholesterol, smoking)
Ask about relevant family history and include travel/sexual histories when relevant
Social history is always important for older patients and asking peoples occupations is helpful to put things in context
Examination
Quickly determine if the patient is well or unwell
Circulation: peripheral pulse rate/volume, capillary refill, peripheral temperature
Rather than doing all parts of the system exam, or examining every system, look for specific signs related to the history – look for signs of the diagnosis/differential, the cause and complications of the condition – you should think about exactly what you are looking for and why
Note the presence or absence of relevant signs
Examples of the specific signs you should look for for specific conditions are listed in the ‘condition signs’ notes in the examinations section and differential diagnosis of common presentations notes in the acute section.
Triad of things to consider during the clinical assessment
