Social history

In medicine, a social history (abbreviated "SocHx")[1] is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.

## Components

Components can include inquiries about:

* Substances
* Alcohol
* Tobacco (pack years)
* illicit drugs
* occupation
* sexual behavior (increased risk of various infections among prostitutes, people who have sex with people for money, and males engaging in anal-receptive intercourse)
* prison (especially if tuberculosis needs to be ruled out)
* travel
* exercise
* diet
* Firearms in household (especially if children or persons with cognitive impairment are present)

## Relation to history

CMS required history elements[2] Type of history  | CC | HPI | ROS | Past, family, and/or social

|
|
|
|

Problem focused  | Required  | Brief  | N/A  | N/A
Expanded problem focused  | Required  | Brief  | Problem pertinent  | N/A
Detailed  | Required  | Extended  | Extended  | Pertinent
Comprehensive  | Required  | Extended  | Complete  | Complete

## References

1. ↑ "Medscape.com". http://www.medscape.com/viewarticle/414658.
2. ↑ "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original on 2012-04-11. https://web.archive.org/web/20120411172702/https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval_mgmt_serv_guide-ICN006764.pdf. Retrieved 2011-02-27.

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Medical examination and history taking

Medical history|

* Chief complaint
* History of the present illness
* Systems review
* Nursing assessment
* Allergies
* Medications
* Past medical history
* Family history
* Social history
* Psychiatric history
* Progress notes
* Mnemonics
* SAMPLE
* OPQRST
* SOAP
* COASTMAP

Physical examination|

| General/IPPA|

* Inspection
* Auscultation
* Palpation
* Percussion

|

Vital signs|

* Temperature
* Heart rate
* Blood pressure
* Respiratory rate

HEENT|

* Oral mucosa
* TM
* Eyes (Ophthalmoscopy, Swinging-flashlight test)
* Hearing (Weber, Rinne)

Respiratory|

* Respiratory sounds
* Cyanosis
* Clubbing

Cardiovascular|

* Precordial examination
* Peripheral vascular examination
* Heart sounds

* Other
* Jugular venous pressure
* Abdominojugular test
* Carotid bruit
* Ankle-brachial pressure index

Abdominal|

| Digestive|

* Liver span
* Rectal
* Murphy's sign
* Bowel sounds

|

Urinary|

* Murphy's punch sign

Extremities/Joint|

* Back (Straight leg raise)
* Knee (McMurray test)
* Hip
* Wrist (Tinel sign, Phalen maneuver)
* Shoulder (Adson's sign)
* GALS screen

Neurological|

* Mental state
* Mini–mental state examination
* Cranial nerve examination
* Upper limb neurological examination

Neonatal|

* Apgar score
* Ballard Maturational Assessment

Gynecological|

* Well-woman examination
* Vaginal examination
* Breast examination
* Cervical motion tenderness

Assessment and plan|

* Medical diagnosis
* Differential diagnosis

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