What is important when taking a patient's history of presenting complaints?

Taking a History of Presenting Complaints: A Structured Approach

Core Principle

Begin with open-ended general inquiries (e.g., "What can I do for you today?") rather than closed-ended confirmatory questions, as this approach elicits longer, more detailed problem presentations with more discrete symptoms and improves patient satisfaction. 1, 2

Essential Components to Document

Temporal Characteristics

• Establish precise onset timing by determining when the patient was last at baseline or symptom-free, not when symptoms were first noticed 3
• Document the "last known well time" for time-sensitive conditions, as this determines treatment eligibility 3
• Record duration, frequency, and progression of symptoms over time 4, 3
• Characterize the course pattern: progressive without plateau, stepwise decline, or waxing/waning 3

Symptom Characterization

• Obtain specific descriptions rather than accepting vague terminology like "memory loss" or "confusion" without clarification 4, 3
• Ask patients to provide concrete examples of how symptoms manifest in daily life 4, 3
• Document the nature, location, quality, and radiation of primary symptoms 4
• Quantify severity using appropriate scales or descriptors to establish baseline for comparison 4

Contextual Features

• Explore relationships between symptoms and potential triggers 4
• Document exacerbating factors and alleviating factors 4
• Record modifying factors, as information about what improves or worsens symptoms offers diagnostic clues 4
• Note associated symptoms that may help establish a pattern or syndrome 4

Functional Impact Assessment

• Evaluate how symptoms affect activities of daily living and instrumental activities of daily living 4, 3
• Document impact on functional status, work, and interpersonal relationships 4, 5
• Assess effects on quality of life 4

Risk Factor Documentation

• Obtain information about individualized risk factors relevant to the presenting complaint 4
• For cardiovascular complaints: document vascular risk factors including hypertension, hyperlipidemia, diabetes, smoking, and atrial fibrillation 3
• For neurological complaints: include drug abuse, migraine, seizure, infection, trauma history 3

Previous Interventions

• Document prior treatments attempted, including self-treatments and their effectiveness 4
• Record medication history with dates of initiation and any dose escalations 6
• Note any brand switches or medication errors 6

Patient's Perspective

• Include the patient's understanding of their illness and what they believe is happening 6, 4
• Document the patient's concerns and fears about their symptoms 6
• Ask "What questions do you have?" rather than "Do you have any questions?" 6

Communication Techniques

Opening the Conversation

• Use general inquiries that allow patients to present concerns in their own time and terms 1, 2
• General inquiries produce significantly longer problem presentations (p<0.0001) and more discrete symptoms (p<0.0001) compared to confirmatory questions 1
• Patients report higher satisfaction with physicians' listening (p=0.028) and positive communication (p=0.046) when general inquiries are used 2

Information Gathering Strategy

• Begin with open-ended questions, allowing the patient to tell their story in their own words 5
• Provide information in chunks (small discrete units) and check regularly for understanding 6
• Use mixed framing when discussing outcomes (e.g., chance of cure and chance of relapse) 6
• Practice active listening by maintaining eye contact, nodding, and providing verbal acknowledgment 5

Integrating Multiple Sources

• Integrate information from both patient and informant/care partner to ensure accuracy, especially for cognitive or behavioral symptoms 4
• This is particularly important when patients may have limited insight into their condition 4

Common Pitfalls to Avoid

Vague Documentation

• Never accept vague complaints without translation into precise, medically defined symptoms 7
• A poorly defined symptom loses discriminative power as a diagnostic test and results in "test degeneracy" 7
• Multiple possible interpretations of a single symptom diminish its diagnostic value and expose patients to more test-related risks 7

Overlooking Critical Elements

• Failing to document functional impact leads to missed diagnostic context crucial for treatment decisions 4
• Neglecting modifying factors means missing diagnostic clues about what improves or worsens symptoms 4
• Missing relevant risk factors leads to inaccurate diagnosis and management 4

Rushing the Process

• Not allowing sufficient time for the patient to tell their story compromises diagnostic accuracy 5
• Focusing exclusively on biomedical aspects while ignoring psychosocial factors misses important contributing factors 5
• Overreliance on templates or electronic health records at the expense of patient engagement reduces quality 5

Practical Example: Breathlessness

When assessing breathlessness, structure your inquiry around onset characteristics 6:

Acute onset (minutes to hours):

• Ask about: chest pain, palpitations, fever, cough, leg swelling
• Consider: pulmonary embolism, pneumothorax, acute heart failure, pneumonia

Subacute onset (days to weeks):

• Ask about: fever, weight loss, occupational exposures, medication changes
• Consider: pleural effusion, anemia, medication side effects

Chronic onset (months to years):

• Ask about: smoking history, occupational exposures, exercise tolerance progression
• Consider: COPD, interstitial lung disease, heart failure

For each timeframe, document:

• Specific activities that trigger breathlessness 4
• Severity using validated scales (e.g., Modified Medical Research Council dyspnea scale) 4
• Impact on daily activities (e.g., "Can no longer walk to mailbox without stopping") 4
• Associated symptoms (e.g., orthopnea, paroxysmal nocturnal dyspnea) 4

Documentation Structure

Structure your documentation to establish: 3

1. Overall level of impairment
2. The clinical syndrome present
3. Likely causes and contributing factors

Include relevant negative findings that help exclude differential diagnoses 3, 5

Conclude with a clear summary of the primary concerns and their impact on the patient 4