History-taking and

1 clinical examination

You must be alert from the moment you first dictate it.Treat patients as rational, intelligent human
see the patient. Employ your eyes, ears, nose and beings. They know what worries them better than
hands in a systematic fashion to collect information you do, but they are visiting a doctor to obtain a
from which you can deduce the diagnosis. The diagnosis and if necessary receive treatment. At all
ability to appreciate an unusual comment or minor stages, explain what you are doing, and why
abnormality can lead you to the correct diagnosis. you are doing it.
This skill only develops from the diligent and All questions should be put in simple plain
frequent practice of the routines outlined in this language, avoiding medical terms and jargon,
chapter. Always give the patient your whole and using lay expressions as much as possible. When
attention and never take short cuts. a patient is not fluent in English, an interpreter is
In the outpatient clinic, have patients walk into required. When conducting an interview through
the consulting room to meet you, rather than finding an interpreter, keep your questions short and simple,
them lying undressed on a couch in a cubicle. General and have them translated and answered one at a time.
malaise and debility, breathlessness, cyanosis and You should not use leading questions. Allow
difficulty with particular movements or an abnormal patients to choose their own answers. Do not say,
gait are much more obvious during exercise. ‘Did the pain move to the right-hand side?’ This is
Patients like to know to whom they are talking. a leading question because it implies that it should
They are probably expecting to see a specific doctor. have moved in that direction, and an obliging patient
You should tell patients your name, and explain why will sometimes answer yes just to please you. The
you are seeing them. This is particularly important patient should be asked whether the pain ever moves.
for trainee surgeons and medical students. When the answer is yes, the supplementary question
A parent, spouse or friend who is accompanying is ‘Where does it go to?’ If, however, patients fail
the patient can often provide valuable information to understand the question, a number of possible
about changes in health and behaviour not noticed answers may have to be proposed, which can then
by the patient. Remember, however, that many be confirmed or rejected.
patients are inhibited from discussing their problems Remember that a question that you do not think
in front of a third person. It can also be difficult if is leading the patient may be interpreted incorrectly
the relative or friend, with the best of intentions, if they do not realize that there is more than one
constantly replies on behalf of the patient. When answer. For example, ‘Has the pain changed?’ can
the time comes for the examination, the friend or be a bad question, as there are a variety of ways in
relative can be asked to leave and further questions which the pain can change. It can alter in severity,
can then be asked in private. It is also often helpful if nature, site, etc., but the patient may be so disturbed
a chaperone is present. by the intensity of the pain that they think only of
Talk with patients or, better still, let them talk its severity and forget the other features that have
to you. At first, guide the conversation, but do not altered. In such situations, it often helps to include
 2 Histor y-taking and clinical examination

possible answers to the question, for example, ‘Has the diagnoses given by other doctors (see the point
the pain moved to the top, bottom, or side of your about referral letters above), because neither may be
abdomen or anywhere else?’, ‘Has the pain got correct. Try to tease out the patient’s complaints and
worse, better or stayed the same?’ or ‘Can you walk problems and come to your own conclusions!
as far, less far or the same distance that you could a Complaints should be listed in order of severity,
year ago?’ with a record of precisely when and how they
The patient should provide the correct answer started. Whenever possible, it should be noted why
providing you ask the question correctly. Do not the patient is more concerned with one complaint
be overconcerned about the questions – worry than another.
about the answers, and accept that it will sometimes
take a long time and a great deal of patience and History of the present complaint
perseverance to get a good history.
At some stage, you will read the referral letter, The full history of the main complaint or complaints
which may suggest a diagnosis. It is often better to must be recorded in detail, with precise dates. It is
read this after you have taken your own history as it important to get right back to the beginning of the
can bias your independent opinion. problem. For example, a patient may complain of a
recent sudden attack of indigestion. When further
questioning reveals that similar symptoms occurred
HOW TO TAKE THE HISTORY some years previously, their description should be
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included in this section.

The history should be taken in the order described
below and in Revision panel 1.1. Try not to write Remaining questions about the
and talk to the patient at the same time. It is affected system
however, important to document dates and times and When a patient complains of indigestion, for
drug history and dosage accurately, which you may example, it is sensible, after recording the history of
not recall after you have finished the examination the indigestion, to move on at this point to other
and left the room. Brief notes as you talk to the questions about the alimentary system.
patient are therefore essential.
Always make sure you know and record, Systematic direct questions
the patient’s name and address, age, sex and
occupation. Whenever you write a note about a These are direct questions that every patient should
patient, whether it is a short progress report or a full be asked, because the answers may amplify your
history, make sure that you write down the date and knowledge about the main complaint and will often
time that the patient was seen. reveal the presence of other disorders of which
the patient was unaware, or thought irrelevant.
The present complaint/problem An absence of associated symptoms is often just
as important as positive answers. The standard set
Start by asking the patient what is their main of direct and important supplementary questions
complaint and record the answer. Ask the patient to is described in detail below because they are so
use their own words to describe exactly what it is important. It is essential to know them by heart
that they have found to be wrong with themselves, because it is very easy to forget to ask some of
and not what they have been told is wrong, perhaps them. When you have to go back to the patient to
by another doctor. It is also worth asking ‘What is ask a forgotten question, the answer often proves to
the problem that you want me (e.g. the surgeon) to be very important.
sort out?’ If you ask ‘What is the matter?’, the patient The only way to memorize this list is by practice,
will often tell you what they think is their diagnosis, which means taking as many histories as possible
or what they have been told by others. It is better not and writing them out in full. The answers to every
to know what the patient thinks is the diagnosis, or question must be recorded.
 How to take the histor y 3

Synopsis of a History (Revision Panel 1.1)

Revision panel 1.1
Synopsis of a history (e) Nervous system
Names. Age and date of birth. Sex. Changes of behaviour or psyche. Depression.
Memory loss. Delusions. Anxiety. Tremor. Syncopal
Marital status. Occupation. Ethnic group. attacks. Loss of consciousness. Fits. Muscle
Hospital or practice record number weakness. Paralysis. Sensory disturbances.
Present complaints or problems (PC, CO) Paraesthesias. Dizziness. Changes of smell, vision
Preferably in the patient’s own words or hearing. Tinnitus. Headaches
(f) Musculoskeletal system
History of the present complaint (HPC) Aches or pains in muscles, bones or joints. Swelling
joints. Limitation of joint movements. Locking.
Include the answers to the direct questions
Weakness. Disturbances of gait
concerning the system of the presenting complaint

Previous history (PH)

Systematic direct questions
Previous illnesses. Operations or accidents.
(a) Alimentary system and abdomen Diabetes. Rheumatic fever. Diphtheria. Bleeding
Appetite. Diet. Weight. Nausea. Dysphagia. tendencies. Asthma. Hay fever. Allergies.

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Regurgitation. Flatulence. Heartburn. Vomiting. Tuberculosis. Sexually transmitted diseases.
Haematemesis. Indigestion pain. Abdominal pain. Tropical diseases
Jaundice. Abdominal distension. Bowel habit.
Nature of stool. Rectal bleeding. Mucus. Slime.
Prolapse. Incontinence. Tenesmus Drug history
Insulin. Steroids. Antidepressants and the
(b) Respiratory system contraceptive pill. Drug abuse
Cough. Sputum. Haemoptysis. Dyspnoea.
Hoarseness. Wheezing. Chest pain. Exercise
tolerance Immunizations
BCG. Diphtheria. Tetanus. Typhoid. Whooping
(c) Cardiovascular system
cough. Measles
Dyspnoea. Paroxysmal nocturnal dyspnoea.
Orthopnoea. Chest pain. Palpitations. Ankle
swelling. Dizziness. Limb pain. Walking distance. Family history (FH)
Colour changes in hands and feet Causes of death of close relatives. Familial illnesses
(d) Urogenital system in siblings and offspring
Loin pain. Frequency of micturition including
nocturnal frequency. Poor stream. Dribbling. Social history (SH)
Hesitancy. Dysuria. Urgency. Precipitancy. Marital status. Sexual habits. Living
Painful micturition. Polyuria. Thirst. Haematuria. accommodation. Occupation. Exposure to
Incontinence industrial hazards. Travel abroad. Leisure
In males: Problems with sexual intercourse and activities
impotence
In females: Date of menarche or menopause. Habits
Frequency. Quantity and duration of menstruation. Smoking. Drinking. Number of cigarettes smoked
Vaginal discharge. Dysmenorrhoea. Dyspareunia. per day. Units of alcohol drunk per week
Previous pregnancies and their complications.
Prolapse. Urinary incontinence. Breast pain. Nipple
discharge. Lumps. Skin changes
 4 Histor y-taking and clinical examination

The alimentary system Vomiting This is the forcible ejection of stomach or

(see Chapters 15 and 16) intestinal contents through the mouth as the result
Appetite Has the appetite increased, decreased, or of involuntary spasms of the oesophagus, stomach
remained the same? If it has decreased, is this caused and abdominal wall. If patients do vomit, how often
by a loss of appetite, or is it because of apprehension do they do so? Is the vomiting preceded by nausea?
as eating always causes pain? What is the nature and volume of the vomit? Is it
recognizable food from previous meals, digested
Diet What type of food and when does the patient food, clear acidic (burning) fluid or bile-stained fluid
eat? Are they vegetarian, or do they avoid any (bitter-tasting)?
particular foods? Is the vomiting preceded by another symptom
such as indigestion pain, headache or giddiness?
Weight Has the patient’s weight changed, and if so, by
Does it follow eating, and what is its relationship to
how much and over how long a time? Many patients
food? Is it effortless?
never weigh themselves, but they usually notice if their
clothes have got tighter or looser, and friends may Haematemesis This is defined as the vomiting
have told them of a change in physical appearance. of blood. Always ask if patients have ever vomited
blood because it is such an important symptom. Old,
Teeth and taste Can they chew their food? Do altered blood looks like coffee grounds.
they have their own teeth? Do they get odd tastes Some patients have difficulty in differentiating
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and sensations in their mouth? Are there any between vomited or regurgitated blood and
symptoms of water brash or acid brash? (This is the coughed-up blood – haemoptysis (see Chapter 2).
sudden filling of the mouth with watery or acid- Haemoptysis is usually pale pink and frothy.
tasting fluid – saliva and gastric acid, respectively.) When patients have had a haematemesis, always
Swallowing Do they have any difficulty in ask whether they have had a recent nose bleed. They
swallowing (dysphagia)? If so, ask about the type of may be vomiting swallowed blood.
food that causes difficulty, for example solids, liquids Patients are rarely able to make useful guesses at
or both, and the level at which they feel the food the amount of blood vomited up, and the addition of
sticking. Also ask about the duration and progression gastric juice makes questions on the volume of blood
of these symptoms, and whether swallowing is painful. vomited of little value. Associated collapse and/or
faintness suggests major blood loss has occurred.
Regurgitation Do they regurgitate? This means the
effortless return of food into the mouth. It is quite Indigestion or abdominal pain (dyspepsia) This
different from vomiting, which is associated with a is correctly defined as difficulty in digesting food and
powerful involuntary contraction of the abdominal is usually accompanied by discomfort or abdominal
wall. If they do regurgitate, what comes up? Is it pain and often by heartburn and belching (see above).
fluid or solid? Regurgitated food is either digested, Some patients call all abdominal pains indigestion;
or recognizable and undigested? the difference between a discomfort after eating and
How often does regurgitation occur and does a pain after eating may be very small.
anything, such as bending over, stooping or straining, It is therefore better to concentrate on elucidating
precipitate it? the important features of the pain or discomfort,
its site, time of onset, severity, nature, progression,
Flatulence Does the patient belch frequently? Does duration, radiation, course and precipitating,
this relate to any other symptoms? exacerbating and relieving factors.
Heartburn This is a burning sensation experienced Jaundice This is a yellow colouration of the tissues
behind the sternum, caused by the reflux of acid into as a consequence of excessive quantities of bile
the oesophagus. Patients may not realize that this pigments accumulating in the blood (see Chapter 15).
symptom comes from the alimentary tract, which is Have the patient’s skin or eyes ever turned
why it must be specifically asked about. If patients yellow? When did this happen, and how long did it
do experience heartburn, how often does it happen last? Were there any accompanying symptoms such
and does anything precipitate it, such as lying flat or as fever, abdominal pain or loss of appetite? Did the
bending over? skin itch?
 How to take the histor y 5

Did the faeces or urine change colour? Pain on defaecation Does this occur? If so, when
Have they had any recent injections, drugs or does the pain begin – before, during, after or at
blood transfusions? times unrelated to defecation? Are there any other
Have they been abroad, and what immunizations aggravating or relieving factors?
have they had?
Prolapse and incontinence Does anything
Abdominal distension Have they noticed that their come out of the anus on straining? Does it return
abdomen has become swollen (distended)? What spontaneously or have to be pushed back?
brought this to their attention? When did it begin, Is the patient continent of faeces and flatus? If
and how has it progressed? Is it constant or variable? not, does anything cause incontinence, such as
What factors are associated with any variation in standing or coughing? Are they aware that they are
the distension? being incontinent, and is it associated with a severe
Is it painful or accompanied by pain? Does it urge to pass stool?
affect their breathing? Have they had any injuries or anal operations in
Is it relieved by belching, vomiting, passing flatus the past?
or defaecation? If they are female, what is their obstetric history?
Have they lost weight or had any urinary
problems? Tenesmus Do they experience a constant and
If female, could they be pregnant, and when was urgent desire to pass stool (see Chapter 16).

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their last period?
The respiratory system (see
Defaecation This is the act of discharging bowel Chapter 2)
contents though the anus (see Chapter 16) How Cough This is the abrupt/explosive expulsion of air
often does the patient defaecate per day? Are the from the lungs through partially closed vocal cords,
actions regular or irregular? causing a characteristic noise and often producing
What are the physical characteristics of the stool?: mucus (sputum; see below).
● Colour: brown, black, pale yellow, white, silver, How long have they had a cough, and how often
bloody (see below)? do they cough? Does the coughing come in bouts?
● Consistency: hard, soft, frothy or watery? Does anything, such as a change of posture,
● Size: bulky, pellets, string- or tape-like? precipitate or relieve the coughing?
● Specific gravity: does it float or sink? Is it a dry or a productive cough (with sputum;
● Smell?: is it particularly foul? see below)?

Beware of the terms ‘diarrhoea’ (a frequent and Sputum This is the mucus/pus that is coughed
copious discharge of liquid faeces) and ‘constipation’ up. What is the quantity (teaspoon, dessertspoon,
(an infrequent or difficult bowel evacuation of hard etc.) and the colour (white, clear or yellow) of the
faeces). These terms are often misinterpreted by sputum?
the patient, and should not be written in the notes Some patients only produce sputum in the
without also recording the frequency of bowel action morning or when they are in a particular position.
and the consistency of the faeces (see Chapter 16).
Haemoptysis This is coughed-up blood (see
Rectal bleeding Has the patient ever passed any Chapter 2).
blood in the stool? Has the patient noticed it? Was it frothy and pink,
Was it bright or dark? Were the amounts large which is suggestive of heart failure? Were there red
or small, and on how many occasions did it occur? streaks in the mucus, or clots of blood?
Was it mixed in with or on the surface of the stool, What quantity was produced? How often does
or did it appear only after the stool had been passed? the haemoptysis occur?
Flatus or mucus passage per rectum Is the patient Shortness of breath/dyspnoea (see Chapter 2)
passing more gas (flatus) than usual, or has it ceased? Do they become breathless? Is dyspnoea present at
Has the patient ever passed mucus (slime) or pus rest? Do they wheeze (make a rasping or whistling
(yellow/green opaque liquid)? sound, which suggests asthma)?
 6 Histor y-taking and clinical examination

How many stairs can they climb? How far can a number of other causes of ankle swelling (see
they walk on a level surface before the dyspnoea Chapters 2 and 10).
interferes with this or stops them? Can they walk
and talk at the same time? Dizziness, headache and blurred vision These
Is it present when sitting, or made worse by lying are some of the symptoms associated with
down? Dyspnoea on lying flat is called orthopnoea. hypertension and postural hypotension. They can
How many pillows do they need at night? also be caused by neurological, vestibular or ocular
Does the breathlessness wake them up at night – disorders (see Chapter 3).
this is called paroxysmal nocturnal dyspnoea – or get
worse if they slip off their pillows? Peripheral vascular symptoms (see Chapter 10)
Severity of dyspnoea can be graded numerically Does the patient get pain in the leg muscles on
(see Chapter 2). exercise, which interferes with walking (intermittent
Is the dyspnoea induced or exacerbated by claudication)? Does it occur in the thigh, buttocks,
external factors such as allergy to animals, pollen or calf or foot? How far can the patient walk before the
dust? Does the difficulty with breathing occur on pain begins? Is the pain so bad that they have to stop
breathing out or in? walking? How long does the pain take to wear off?
Can the same distance be walked again?
Pain in the chest (see Chapter 2) Ascertain the In a man, a recent loss of penile erections in
site, severity and nature of the pain. Chest pains can
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association with buttock claudication suggests

be continuous, pleuritic (made worse by inspiration), occlusion of the abdominal aorta or internal iliac
constricting (see below) or stabbing. artery (Leriche’s syndrome).
Is there any pain in the limb at rest? Which part
The cardiovascular system (see
Chapter 2) of the limb is painful (typically, this is the foot)? Does
the pain interfere with sleep? What positions relieve
Cardiac symptoms the pain (typically, hanging the foot over the side
Breathlessness/dyspnoea These are defined by of the bed or getting up and walking around). Do
the same questions as those described above. analgesic drugs provide any relief?
Are the extremities of the limbs cold? Are there
Orthopnoea and paroxysmal nocturnal colour changes in the hands, particularly in response
dyspnoea These symptoms are particularly to cold, classically from white, to blue, before turning
associated with heart failure (see Chapter 2). red? Raynaud’s phenomenon (see Chapter 10) is
Pain Cardiac pain typically begins in the midline rarely associated with all the typical changes in colour.
behind the sternum (retrosternal), but may Does the patient experience any paraesthesias
occasionally be experienced in the epigastrium. It in the limb (tingling or numbness) which indicates
is often described as constricting or band-like. The critical ischaemia and a limb at risk?
patient should be asked if the pain radiates to the Has the patient experienced any transient
neck or to the left arm, and whether it is exacerbated weakness of the limbs (transient ischaemic attack),
by exercise or excitement and relieved by rest (all loss of vision (amaurosis fugax, or fleeting blindness)
suggestive of cardiac pain). or difficulty with speech. These symptoms may
presage a full-blown stroke (see Chapter 10).
Palpitations These are episodes when the patient
becomes aware of a sudden fluttering or thumping of
the heart in the chest.These symptoms are indicative The urogenital system (see
of an arrhythmia but can be caused by extrasystoles. Chapters 17 and 18)
Ankle swelling/oedema Do either the ankles or Urinary tract symptoms
legs swell? When do they swell? What is the effect on Pain Has there been any pain in the loin (kidney),
the swelling of bed rest and/or elevation of the leg? groin or suprapubic region (bladder)? What is its
It is important to consider cardiac failure in nature and severity? Does it radiate to the groin or
patients with ankle oedema, although there are scrotum, suggesting a ureteric calculus?
 How to take the histor y 7

Micturition How frequently does the patient pass prolapse of the vaginal wall or cervix or any urinary
urine, and how many times by day and by night? incontinence, especially when straining or coughing
Is the volume and frequency excessive (polyuria)? (stress incontinence)?
Is the patient thirsty? Do they drink excessive
volumes of water, suggesting diabetes? Pregnancies Record details of the patient’s
Is micturition painful (dysuria)? What is the pregnancies – number, dates and complications.
nature and site of the pain?
Is there any difficulty with micturition, such as Breasts (see Chapter 13) Do the breasts change
a need to strain or to wait to get started? How is during the menstrual cycle? Are they ever painful or
the stream? Can it be stopped at will? Is there any tender, and does this occur premenstrually (cyclical
dribbling at the end of micturition? These symptoms breast pain)?
suggest prostatism. Has the patient noticed any swellings or lumps
Does the bladder feel empty at the end of in the breasts? Did she breast-feed her children? Has
micturition, or do they have to pass urine a second there been any nipple discharge or bleeding? Has
time (double micturition; see Chapter 17)? she noticed any skin changes over the breasts, or any
change in contour?
Haematuria (blood in the urine) Has the patient
ever experienced this? Where in the stream and how
often did it occur? Was there any associated pain? The nervous system (see Chapter 3)

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Mental state Is the patient placid or nervous? Has
Pneumaturia The patient may notice bubbles in the the patient noticed any changes in their behaviour or
urine, suggesting a fistula between bladder and bowel. reactions to others? Patients will often not appreciate
Incontinence of urine Does this occur with such changes themselves, and these questions may
urgency or on coughing and straining (stress have to be asked of close relatives.
incontinence)? Does it occur continuously without Does the patient get depressed and withdrawn, or
awareness (true), or is it associated with discomfort are they excitable and extroverted?
and a full bladder (overflow)? In females, is there any
history of prolapse with stress incontinence? Brain and cranial nerves Does the patient ever
lose consciousness or have fits (epilepsy)? What
Genital tract symptoms – male happens during a fit? It is often necessary to ask a
Scrotum, penis and urethra Has the patient any relative or a bystander to describe the fit. Did the
pain in the penis or urethra during micturition or on patient lie still or jerk about, bite their tongue or pass
intercourse? Is there any difficulty with retraction of urine? Was the patient sleepy after the fit? Was there
the foreskin, or has there been any purulent urethral any sense (an aura) that the fit was about to develop?
discharge now or in the past (sexually transmitted Has there been any subsequent change in the senses
infections)? of smell, vision and hearing?
Has the patient noticed any pain or swelling of Is there a history of headache? Where is it
the scrotum, and can he achieve an erection and experienced? How long has it been occurring, and
satisfactory ejaculation? Is the patient fertile? when does it occur? Are the headaches associated
with any visual symptoms (migraine, hypertension,
Genital tract symptoms – female tension and raised intracranial pressure)?
Menstruation When did menstruation begin (the Has the face ever become weak or paralysed?
menarche)? When did it end (the menopause)? Have any of the limbs been paralysed (strokes or
What is the duration and quantity of the menses? Is demyelinating disease), or has the patient ever
menstruation associated with pain (dysmenorrhoea)? experienced pins and needles in a limb (paraesthesias)?
What is the nature and severity of the pain? Is there Has there ever been any buzzing in the ears, or
any abdominal pain midway between the periods dizziness (vestibular symptoms)?
(mittelschmerz)? Has the patient noticed any pain Has there ever been any loss of speech (aphasia)?
on intercourse (dyspareunia)? Can the patient speak clearly and use words properly?
Has the patient had any vaginal discharge? What Do they know what they want to say but cannot
is its character and amount? Has she noticed any express it (expressive dysphasia)?
 8 Histor y-taking and clinical examination

Peripheral nerves Are any limbs or part of a limb Immunizations

weak or paralysed? Is there ever any loss of skin
sensation? Does the patient experience any tingling Most children are immunized against diphtheria,
or pins and needles in the limbs (paraesthesias), tetanus, whooping cough, measles, mumps, rubella
suggestive of peripheral neuropathy or nerve and poliomyelitis. Ask about these, as well as about
compression? smallpox, typhoid and tuberculosis vaccination.
Many individuals, especially medical staff, will
The musculoskeletal system also have been immunized against viral hepatitis, and
Ask if the patient suffers from pain, swelling or this is worth recording.
limitation of the movement of any joint. What
Family history
precipitates or relieves these symptoms? What time
of day does this occur? Are any limbs or groups of Enquire about the health and age, or cause of death,
muscles weak or painful? of the patient’s parents, grandparents and any brothers
Can the patient walk normally? and sisters who have died or have familial diseases.
Are there any known congenital musculoskeletal Also ask about any children who may have died
deformities? or developed specific diseases.
Draw a family tree if there is an obvious familial
Previous history of other illnesses, disorder (e.g. neurofibromatosis).
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accidents or operations You will need information about the mother’s

pregnancy if the patient is a child. Did she take any
Record, with dates, the history of any conditions drugs during pregnancy? What was the birth weight?
that are not directly related to the present complaint. Were there any difficulties during delivery? Was the
Ask specifically about a previous diagnosis of physical and mental development normal in early
tuberculosis, diabetes, rheumatic fever, tropical life?
diseases and bleeding tendencies. The likelihood
of intimate contact with carriers of the human Social history
immunodeficiency virus and of other sexually
Record the patient’s marital status, and the type and
transmitted infections should be explored, especially
place of their dwelling (e.g. lives in a hostel or of no
if the patient’s lifestyle is considered to be high risk.
fixed abode).
Ask about the patient’s sexual orientation and
Drug history their occupation, with special regard to contact with
hazards such as dusts, asbestos and chemicals.
Ask whether the patient is taking any drugs.
What are the patient’s leisure activities?
Specifically, enquire about insulin, steroids,
Has the patient travelled extensively or lived
antidepressants, diuretics, antihypertensives, hormone
abroad? List the countries and the dates if these
replacement therapy and the contraceptive pill.
appear to be relevant.
Patients usually remember about drugs they are
taking which have been prescribed by a doctor, but Habits
often forget about self-prescribed drugs.
Does the patient smoke? If so, what do they smoke –
History of allergies cigarettes, cigars or a pipe? Record the frequency,
quantity and duration of their smoking habit.
Patients should be specifically questioned on their Does the patient drink alcohol? Record the type
known allergies to drugs, especially penicillin and quantity consumed (in units/week) and the
and other antibiotics, and also to adhesive plaster. duration of the habit. 1 unit = a very small glass of
A history of hay fever, asthma and eczema is worth whisky, half a small glass of wine or a half/third of a
noting as is any previous episodes of anaphylaxis. pint of beer.
Write all the patient’s known allergies in Does the patient have any unusual eating habit
large letters on the front of their notes. (e.g. are they a vegan)?
 An example of how to take a detailed histor y of pain 9

AN EXAMPLE OF HOW TO TAKE Time and mode of onset

A DETAILED HISTORY OF PAIN It may be possible to pinpoint the onset of the pain
very precisely, but if this cannot be done, the part
The method of taking a history from a patient with
of the day or night when the pain began should be
‘pain‘ is now used as an example of how to take
recorded. Ask if the pain began gradually or suddenly.
a detailed history.
When pain has a truly acute/sudden onset,
Pain is an unpleasant sensation of varying
patients often remember the time precisely, or exactly
intensity. We have all experienced pain. It is one
what they were doing at the time. This occurs when
of nature’s ways of warning us that something is
a viscus perforates or a blood vessel splits (dissects)
going wrong in our body. It can come from any
or ruptures.
of the body’s systems, but there are certain features
Inflammation, infarction or obstruction of a
common to all pains that should always be recorded.
hollow viscus all produce a pain of more insidious
Tenderness is pain induced by a stimulus,
onset.
such as pressure from the doctor’s hand, or forced
You should record the calendar dates on which
movement. Remember that the patient feels pain –
the pain occurred, but it is also very useful to add in
the doctor elicits tenderness. It is possible for
brackets the time interval between each episode and
a patient to be lying still without pain and yet
the current examination, because it is these intervals,
have an area of tenderness. Patients may complain
rather than the actual dates, that are more relevant to

C H A P T E R 1 | H I S T O R Y-TA K I N G A N D C L I N I C A L E X A M I N AT I O N
of tenderness if they happen to have pressed their
the problems of diagnosis.
fingers on a painful area or have discovered a tender
For example, write, ‘Sudden onset of severe
spot by accident. Thus, tenderness can be both a
epigastric pain on 16th September, 2013, at
symptom and a physical sign.
11.00 a.m. (3 days ago)’; remember that such
A careful history of ‘a pain’ frequently provides
comments are useless if you forget to record the date
the diagnosis, so you must question the patient
and time of the examination.
closely about each of the following features.

Severity
Site
Individuals react differently to pain. What is a ‘severe
Many factors may indicate the source of the pain, pain’ to one person might be described as a ‘dull
but the most valuable indicator is its site. ache’ by another. Avoid adjectives used by a patient
It is of little value to describe a pain as ‘abdominal to describe the severity of their pain. A far better
pain’; you must try to be more specific. Although indication of severity is the effect of the pain on the
patients do not describe the site of their pain in patient’s life:
anatomical terms, they can normally point to the site ● Did it stop the patient going to work?
of maximum intensity, which you should convert ● Did it make the patient go to bed?
into an exact anatomical description. ● Did they try proprietary analgesics?
When the pain is indistinct in nature and spreads ● Did they have to call their doctor?
diffusely over a large area, you must illustrate the area ● Did it wake the patient up at night, or stop
in which the pain is felt and the point (as indicated them going to sleep?
by the patient) of maximum discomfort. ● Was the pain better lying still, or did it make
It is also worthwhile asking about the depth of them roll around?
the pain. Patients can often tell you whether the pain The answers to these questions provide a better
is near to the skin or deep inside. Splanchnic pain indication of the severity of a pain than words such
from an organ, which is experienced through the as mild, severe, agonizing or terrible.Your assessment
autonomic system, is poorly localized to the midline, of the way the patient responds to their pain, formed
while somatic pain from the body’s surface layers while you are taking the history, may influence your
is well localized. diagnosis.
 10 Histor y-taking and clinical examination

Nature or character of the pain describe the nature of their pain, do not press the point.
You will only make them try to fit their description
Patients often find it difficult to describe the nature to your suggestions, which may be misleading.
of their pain, but some of the adjectives that are
commonly used, such as aching, stabbing, burning, Progression of the pain
throbbing, constricting, distending, gripping or
colicky, are clearly recognized by most people. Once it has started, a pain may progress in a variety
‘Burning and throbbing’ sensations are of ways:
within everyone’s experience. Almost everyone ● It may begin at its maximum intensity and
has experienced a burning sensation in the skin remain at this level until it disappears.
following contact with intense heat, so when a patient ● It may increase steadily until it reaches a peak
spontaneously states that their pain is ‘burning’ in or a plateau, or conversely it may begin at its
nature, it is likely to be so. Most have experienced a peak and decline slowly.
throbbing sensation at some time in their life from ● The severity may fluctuate. The intensity
an inflammatory process such as toothache, so this of the pain at the peaks and troughs
description is also usually accurate. of the fluctuations, and the rate of
A ‘stabbing pain’ is sudden, severe, sharp and development and regression of each peak,
short-lived. Hopefully, few of us have experienced may vary.
a real stabbing!
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● The pain may disappear completely between

The adjective ‘constricting’ suggests a pain that each exacerbation.
encircles the relevant part (chest, abdomen, head or ● The time between the peaks of an abdominal
limb) and compresses it from all directions. A pain colic indicates the likely site of a bowel
that feels like an iron band tightening around the obstruction. In upper small bowel obstruction,
chest is typical of angina pectoris, and is almost the frequency of the colic is approximately
diagnostic of this. every 1–2 minutes, whereas in the ileum it is
When patients speak of ‘tightness’ in their chest every 20 minutes, and in the large bowel every
or limb, do not immediately assume that they have a 30–60 minutes.
constricting pain.They may be describing a tightness ● It is essential to find out how the pain
caused by distension, which may occur in any has progressed and ascertain the timing of
structure that has an encircling and restricting wall, any fluctuations before its nature can be
such as the bowel, bladder, an encapsulated tumour determined.
or a fascial compartment. Tension in the containing
wall may cause a pain that the patient may describe
as ‘distension’, ‘tightness’ or a ‘bursting feeling’. End of the pain
A ‘colicky pain’ comes and goes like a sine wave. A pain may end spontaneously, or as a result of some
It feels like a migrating constriction in the wall of a action taken by the patient or doctor. The end of a
hollow tube that is attempting to force the contents pain is either sudden or gradual. The way in which
of the tube forwards. It is not a word that many a pain ends may give a clue to the diagnosis, or
patients use, and it is dangerous to ask them if their indicate the development of a new problem.
pain is ‘colicky’ without giving an example. This is Patients always think that an improvement in
not difficult, because most of us have experienced their pain means that they are getting better. They
intestinal colic during an episode of diarrhoea, are usually right, but sometimes their condition
and many females have suffered colicky pains with may have become worse, for example an intestinal
their periods or in labour. Remember that not all perforation relieving the colic but causing peritonitis
recurring, intermittent pain is necessarily colic; it and septicaemia.
should also have a gripping nature.
‘Just a pain, doctor.’ Many pains have none of Duration of the pain
the features mentioned above and defy description!
They may vary in severity from a mild discomfort The duration of a pain will be apparent from the
or ache, to an agonizing pain that makes the patient time of its onset and end, but it is nevertheless
think they are about to die. When a patient cannot worthwhile stating the duration of the pain in your
 An example of how to take a detailed histor y of pain 11

notes. The length of any periods of exacerbation or Referred pain

remission should also be recorded.

Factors that relieve the pain

Position, movement, a hot-water bottle, aspirins and Inflammation
other analgesics, food or antacids may all relieve of diaphragm
the pain. The natural response to a pain is to search
for relief. Sometimes patients try the most bizarre
remedies, and many convince themselves that these Fig. 1.1 Pain referral.
help, so accept some of their replies to this question
with caution.
hopelessly wrong, you may get some important
Factors that exacerbate the pain insight into their worries.
A patient will sometimes appear obsessed with
Anything that makes the pain worse, such as
the cause of their condition. Careful questioning may
movement, eating or opening the bowels, is also
reveal that compensation will be gained or lost as a
likely to be known to the patient.
consequence of your opinion! Nevertheless, always
The type of stimulus that exacerbates a pain
listen to the patient’s views with care and tolerance.
will depend on the organ from which it emanates

C H A P T E R 1 | H I S T O R Y-TA K I N G A N D C L I N I C A L E X A M I N AT I O N
and on its cause. For example, intestinal pains may
be made worse by eating particular types of food,
Psychogenic cause
while musculoskeletal pains are affected by joint Beware of patients whose mental attitude to their
movements, muscle exercise and posture. If the initial pain symptoms seems out of proportion – either
description has indicated the source of the pain, you over-responding to them or ignoring them. The
can ask direct questions about these potential triggers. patient whose symptoms do not fit any known
pattern who tells you with a big smile that they have
Radiation and referral ‘terrible’ pain, or who, while complaining of severe
You should always ask if the pain is experienced pain, appears quite unconcerned (‘la belle indifference’)
anywhere else or has moved from its initial site. may well be neurotic, hysterical or fabricating their
symptoms and even physical signs (Munchausen’s
Radiation This is the extension of the pain to syndrome, see Chapter 15).
another site while the initial pain persists. For A diagnosis of Munchausen’s syndrome or
example, patients with a posterior penetrating psychogenic cause should only be made when all
duodenal ulcer usually have a persistent pain in the possible organic causes for the patient’s symptoms
Date: 21.05.201
epigastrium, but the pain may also spread through have been excluded. In this situation, your clinical
to the back. The extended
Author: BROWSEpain usuallyTitle: has The
theSymptoms
same and Signs of Surgical
experience is your greatest help. Proof Stage: 1
Disease Date: 02.04.201
character as the initial pain.
Cactus Design and Illustration Ltd
A pain that occurs in one site and then disappears
before reappearing in another site is not radiation: it
is a new pain in another place.
Revision panel 1.2

Referred pain This is pain that is felt at a distance The features of a pain that must be
from its source. For example, inflammation of the
elicited and recorded
diaphragm causes a pain experienced only at the tip of Site
the shoulder (Fig. 1.1). Referred pain is caused by the Time and mode of onset
inability of the central nervous system to distinguish Record the time and date of onset, and the way
between visceral and somatic sensory impulses. the pain began – suddenly or gradually

Cause Severity
Assess the severity of the pain by its effect on the
It is often worthwhile asking patients what they patient
think is the cause of their pain. Even if they are
 12 Histor y-taking and clinical examination

Experienced clinicians usually begin the routine

Revision panel 1.2 (continued ) physical examination with a provisional or
Nature/character differential diagnosis in mind that has been gleaned
Aching, burning, stabbing, constricting, from the history. The full impartial systematized
throbbing, distending, colicky examination is then often modified to look for specific
signs that confirm or refute the working diagnosis.
Progression When, however, a sign is elicited that refutes this, the
Describe the progression of the pain. Did it astute clinician returns to the textbook routine.
change or alter?
Students and trainees must not follow this method.
The end of the pain Although it is understandable and practical when
Describe how the pain ended. Was the end used by an experienced consultant surgeon in a
spontaneous, or brought about by some action busy clinic, it is inherently dangerous! Students must
by the patient or doctor? discipline themselves to use the standard textbook
routine for every physical examination if mistakes
Duration are to be avoided. When this is abandoned, some
Record the duration of the pain parts of the examination will be omitted, which can
Relieving and exacerbating factors have serious consequences.
The easiest way to ensure that your examination is
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Radiation complete is to learn the routine by heart and repeat

Record the time and direction of any radiation it to yourself during the examination.While looking
of the pain; remember to ask if the nature of the at a lump, say to yourself ‘site, size, shape, …’. If you
pain changed at the time it moved do not do this, you will find, when you come to
present the case or write the notes, that you have
Referral
forgotten to elicit some of the lump’s physical
Was the pain experienced anywhere else? features, necessitating a re-examination of the patient.
Cause Always maintain the basic pattern of looking,
Note the patient’s opinion of the cause of feeling, tapping and listening:
the pain ● Inspection.
● Palpation.
● Percussion.
THE CLINICAL EXAMINATION ● Auscultation.
In the musculoskeletal system, percussion and
The following chapters of this book each deal with auscultation are replaced by moving the joint (look,
a specific region of the body and its surgical diseases. feel, move).
The methods of examination peculiar to each region
are described in detail in the relevant chapter. Note It is often best to examine initially
The emphasis to date in this introductory chapter the part of body that is the source of the
has been on the importance of taking a precise and patient’s complaint, before completing the full
full history, but it now moves on to a description of examination of all other systems.
the basic plan of a physical examination.
Your ability to perform a thorough clinical
examination can only be improved by frequent GENERAL ASSESSMENT
bedside practice. Examine as many patients, as you
can as this experience increases fluency. Repetition is The first part of the physical examination is
the secret of learning. This axiom applies as much to performed when taking the history. While you are
the doctor as it does to the sportsman or the concert talking to the patient, you can observe the patient’s
pianist. Your visual, tactile and aural appreciation of general demeanour, and their attitudes to their
the patient’s physical signs will improve by repeatedly disease. These observations will inevitably affect the
exercising these senses. manner in which you conduct the examination.