Diagnostics Paths

🩺 1. Chief Complaint (CC)

“What brought you in today?”

The opening question identifies the main symptom or problem in the patient’s own words (e.g., “chest pain,” “shortness of breath,” “fatigue”).

πŸ“‹ 2. History of Present Illness (HPI)

A detailed exploration of that main complaint, often using a framework such as SOCRATES (for pain) or similar mnemonics:

Mnemonic Meaning Example Question
S Site Where exactly is the pain?
O Onset When did it start? Sudden or gradual?
C Character What is it like (sharp, dull, burning)?
R Radiation Does it spread anywhere?
A Associated symptoms Any nausea, sweating, or breathlessness?
T Time course Is it constant or does it come and go?
E Exacerbating/relieving factors What makes it worse or better?
S Severity How bad is it on a scale of 1–10?

🧬 3. Past Medical History (PMH)

“Do you have any other medical conditions or have you been hospitalized before?”

Covers previous illnesses, surgeries, hospital stays, and ongoing conditions (e.g., diabetes, hypertension).

πŸ’Š 4. Drug History and Allergies

“Are you taking any medications or supplements?”

Includes prescribed drugs, over-the-counter medicines, herbal remedies, and allergies (especially drug allergies).

πŸ‘¨‍πŸ‘©‍πŸ‘§‍πŸ‘¦ 5. Family History (FH)

“Are there any health problems that run in your family?”

Identifies genetic or hereditary conditions (heart disease, cancers, diabetes, etc.).

🌍 6. Social History (SH)

“Can you tell me a bit about your lifestyle?”

Includes occupation, smoking, alcohol, recreational drugs, exercise, diet, and living situation — crucial for context and risk assessment.

🩸 7. Review of Systems (ROS)

A systematic screening through major body systems to uncover symptoms the patient may not have mentioned.
Typical systems reviewed:

  • General: weight loss, fever, fatigue

  • Cardiovascular: chest pain, palpitations

  • Respiratory: cough, wheeze, shortness of breath

  • Gastrointestinal: nausea, vomiting, diarrhoea, constipation

  • Genitourinary: frequency, pain, blood in urine

  • Neurological: headaches, weakness, sensory changes

  • Musculoskeletal: joint pain, stiffness

  • Psychiatric: mood, sleep, anxiety

🧍 8. Physical Examination

Structured head-to-toe inspection guided by the symptoms:

  • Vital signs (BP, HR, temp, O₂ sat)

  • Inspection, palpation, percussion, auscultation (IPPA)

  • Focused tests for relevant systems

🧩 9. Differential Diagnosis and Plan

After gathering data, the clinician:

  • Forms differential diagnoses (most likely → least likely)

  • Orders investigations (bloods, imaging)

  • Initiates treatment or referrals as appropriate

If you like, I can show you the exact structured template doctors often use on paper or in EMRs (Electronic Medical Records) — including all question headings — or a condensed version suitable for your Remedy Dragon diagnostic app, aligned with modern clinical reasoning frameworks.

Would you like the formal clinician template or the adapted digital version for patient self-reporting next?

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