History Taking in Modified Long Case

1) Presenting Illness (Open ended)
(chief complaint/presenting complain or whatever you call it, you'll need it to expand your differentials and present!) 

2) History of Presenting Illness (HOPI)

• onset (first time?)
• progressive/gradual
• duration/frequency 
• SOCRATES if pain
• severity of presenting illness
• ADL affected?
• aggravating/relieving factors
• associated symptoms
• Precipitating factors for this onset(?)

*By the time you have finished your history of presenting illness, you should already have some ideas on what is the most likely diagnosis(provisional) and what are the differentials. 

3) Specific questions for provisional diagnosis (Closed ended)

4) Ask questions to exclude the differentials. 

5) Constitutional/Red flag symptoms to rule out malignancy (LOA/LOW)

6) Past Medical/Surgical History +Drug history + allergy history

• Have you been admitted to the hospital before for whatever reasons that would need further follow up?

• How many types of medications are you taking at home?

7) Family history

8) Social History (smoking, alcohol, occupation, sexual, ivdu/tattoo)

9) Systemic Review  

10) Have I missed asking you anything or is there anything else that you would like to tell me?