History Tips

The following are essential for a complete history:

• All the features of the chief complaint (onset, duration, alleviating and aggravating factors, frequency, etc.)
• Past medical history
• Smoking/Alcohol use, as well as illicit drug use
• Allergies
• Current medications, including over the counter medications, herbs, and supplements
• Family history relevant to the presenting complaint
• How the present complaint is affecting the patient’s life
• What the patient thinks is accounting for their symptoms

Physical Examination Tips

The student should always do the following during the exam:

• Introduce the physical examination and ask the patient for permission to examine them
• Always wash hands or use alcohol solution before examining the patient
• Position the patient appropriately
• Drape the patient appropriately, especially when sensitive parts of the body are being examined
• Comment, out loud, about what you are examining for
• Comment to the examiner about your findings
• For exams that require examination of both sides of the body, complete the exam on one side and ask the examiner if he/she would like the student to examine the opposite side