Presenting complaint PC

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After the initial introduction, many clinicians obtain basic details of the patient's background such as age. date of birth, marital status, previous or present occupation and ihe number of dependants. Thereafter it is important to estahlish the patient's presenting complaint or complaints. Sometimes questions such as 'what are you complaining of?' may be misinterpreted. While recommending a flexible approach to different situations, one format is to ask the patient 'what is your main problem' and then 'when were you last in your usual state of health?' This leads to the request 'please tell me what has happened to you since then'. This approach is also useful in documenting the nature of the presenting complaint, or complaints if several (Table 1.5). Case recording is dealt with at length in Chapter 9.

TABLE 1.5 Examples ol the presenting complaint(s)

PC 'Headache at the back of my head'

Duration 2 hours

PCs !. 'Crushing chest tightness with

Duration 40 minutes

breathlessness'

2. Increasing tiredness

Duration 2 weeks

Note the wording. Use the patient's language and not technically correct terms like occipital headache, retrosternal pain and dyspnoea

The presenting complaint, as described by the patient, is the body of the history. Patients should he encouraged to give their history right up to the time of the interview with a minimum of interruption. The clinician's aims at outset are threefold: first, to keep ihe history flowing, e.g. 'so what happened then?'; second, to identify those aspects of the history which are incomplete and require further closed questions, and finally to observe the patient, picking up clues about the patient's emotional state, intelligence and understanding that may also influence subsequent inquiries, the physical (or mental) examination and the explanation.

The history of the presenting complaint can be viewed as a series of layers, not all of which need So be explored in each case (Fig. 1.6). Patients vary in how they react to the same pathology. The clinician has to take account of this when assessing the significance of the disease to this individual, and when deciding how best to handle the problem.

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