chapter  1
29 Pages

History taking and examination

ByPeter Kopelman, Dame Jane Dacre

The diagnostic value of the history will vary from patient to patient, and is generally dependent on the patient’s presenting complaint. A complaint of chest pain should trigger a series of questions related to the possible causes, whereas a complaint of tiredness may be less clear-cut. The social history offers the interviewer an opportunity to get to know the patient better, but can obviously be a sensitive area of enquiry. It is important that students are aware of such sensitivities and use common sense when asking questions. Electronic medical records provide a structure for documenting a patient’s progress once a presumptive diagnosis has been made. Such records identify presenting problems and list them in automatically generated correspondence. The inclusion of both active and inactive problems is most helpful because it will alert a doctor to the entirety of past problems at each consultation with the patient.