History taking

Summary

Clinical history taking is the most important part of making a clinical diagnosis of a patient's condition. As a skill, it develops with experience, so that ultimately it becomes comprehensive yet focused on making the diagnosis. Below is a guide to the components of clinical history taking that are important.

Patient details

Name, age, occupation.

Presenting complaint (PC)

In the patient's own words, the reason that has led to their presentation. Avoid using a diagnosis as the presenting complaint (e.g. use ‘chest pain’ as opposed to ‘angina’).

History of presenting complaint (HPC)

Explore each of the patient's, symptoms in greater detail. For each symptom, explore the mode of onset, progression of the symptom, its severity, exacerbating and alleviating factors, associated symptoms, and any possible explanation the patient may give for its cause. Important components of the HPC are:

Pain: onset (sudden or gradual), site, character (sharp, dull, aching, burning, throbbing), radiation, intensity (out of 10), duration (constant versus waxing and waning), relieving factors, exacerbating factors (eating, movements such as coughing, breathing), and associated symptoms. Two particularly important characters of pain that deserve mention are:

1. ▪ Peritonitis – inflammation of the peritoneum causes this characteristic pain which is often sharp, and exacerbated by sudden movements such as coughing, and walking. Peritonism may be localized or generalized depending on the degree of inflammation.

2. ▪ The ‘colics’ – these are pains produced by an obstruction of a hollow muscular viscus which continues to peristalse and contract despite the obstruction. They are severe, waxing and waning pains, and are often described by the patient as the worst kind of pain they have ever experienced (e.g. biliary colic and renal colic).