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as confidential
How the patient may end the
consultation: “If at any time you
Presenting complaint
Ask the patient to describe the symp-
tom or problem that brought them to
hospital by using an open ended
In the first of a two part series about taking a medical question: “What has happened to
history, Nayankumar Shah takes a look at the bring you to hospital?” or “What
introduction and the presenting complaint seems to be the problem?” You
should show interest to facilitate this.
Clearly, you want answers but you
also wish to develop a rapport with
the patient as well as understand him
or her (and you will not do this
through a series of closed questions).
The patient’s narrative gives
The clinical encounter usually con- able with. You are at liberty to re- important clues as to the diagnosis
sists of the steps shown in fig 1. A organise the order. For instance, you and the patient’s perspective of their
good history is very important for could go to the systems review after illness. You should not interrupt.
making a diagnosis. Examination and the history of the presenting com- Most patients’ initial response will last
investigations may help to confirm or plaint. Whatever order you use, how- fewer than two minutes. So it is worth
refute the diagnosis made from the ever, you need to ensure that you get while to give this amount of time to
history. all components of the history (fig 2). let the patient describe in their own
The history will also tell you about words the problem that has led to
the illness as well as the disease. The their present situation.
illness is the subjective component Introduction and details Thus, history taking involves the
and describes the patient’s experi- You should always begin by introduc- use of communication skills. You
ence of the disease. ing yourself. This should include need to develop your skills in:
Try to follow the sequence history, your status as well as the educational G Opening and closing a consulta-
examination, investigation when you reason for the encounter. For exam- tion
see a patient. A common mistake is ple, “My name is... I am a... year medi- G The use of open and closed ques-
to rush into investigations before cal student, and I have come to talk tions
considering the history or examina- to you to learn how to take a medical G The use of non-verbal language
tion. history.” G Active listening
It is easy to mindlessly order a bat- It is then useful to obtain some G Showing respect and courtesy
tery of tests. There are many prob- background information about the G Showing empathy
lems with this approach: patient including their name, age, G Being culturally sensitive.
G Investigations cannot be used in marital status, and occupation. This is not just an academic exer-
isolation—is the x ray finding or To establish rapport, and to put cise—management of the patient is
blood test result relevant or an the patient at ease, it often helps to dependent on these aspects. If you
incidental finding? continue the interview by consider- do not communicate properly you
G Investigations can be inaccurate—
there can be problems with tech- Fig 2
nique, reagents, or interpretation Components in
Outline of history taking Issues to deal with
of the findings taking a medical
G Investigations pose risks—radia-
history Introduction and
patient’s details
tion exposure, unnecessary fur-
ther procedures, and so on
G Investigations can be costly, to the Presenting complaint and Coping with illness
history of the presenting complaint
patient and to society.
Always remember to treat the
patient and not the investigation. Past medical and surgical history
And remember that although we talk
about “the patient,” you should con- Medications, drug
sider “the person.” history, and allergies
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