Taking a history: Introduction and the presenting complaint

The clinical encounter usually consists of the steps shown in fig 1. A good history is very important for making a diagnosis. Examination and investigations may help to confirm or refute the diagnosis made from the history.

The history will also tell you about the illness as well as the disease. The illness is the subjective component and describes the patient's experience of the disease.

Try to follow the sequence history, examination, investigation when you see a patient. A common mistake is to rush into investigations before considering the history or examination.

It is easy to mindlessly order a battery of tests. There are many problems with this approach:

• Investigations cannot be used in isolation—is the x ray finding or blood test result relevant or an incidental finding?
• Investigations can be inaccurate—there can be problems with technique, reagents, or interpretation of the findings
• Investigations pose risks—radiation exposure, unnecessary further procedures, and so on
• Investigations can be costly, to the patient and to society.

Always remember to treat the patient and not the investigation. And remember that although we talk about “the patient,” you should consider “the person.”

Structure

Fig 1: Steps in a clinical encounter

You should use the following as a guide until you develop your own style and one that you feel comfortable with. You are at liberty to …