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Clinical Semiology: The clinical history · Components of the Clinical History

How a clinician builds a patient's history, from the chief complaint to red flags, and why it so often points to the diagnosis.

For learning, not medical advice: for your own health, ask a doctor or another qualified professional.

Clinical Semiology · 25 questions

Try 3 questions

1. What is the "chief complaint" in a clinical history?

  1. The main reason for the visit, in the patient's words
  2. The most serious finding on the physical exam
  3. The doctor's working diagnosis after the exam
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Answer: The main reason for the visit, in the patient's words

The chief complaint records why the patient came, briefly and ideally in their own words, before any interpretation by the clinician.

2. Which part of the history tells the story of the current problem in order, from its onset to today?

  1. History of present illness
  2. Past medical history
  3. Review of systems
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Answer: History of present illness

The history of present illness develops the chief complaint chronologically: onset, course, characteristics and what has already been tried.

3. A clinician asks about each body system in turn (skin, heart, lungs, bowels) to catch symptoms the patient didn't mention. What is this called?

  1. Differential diagnosis
  2. Review of systems
  3. Physical examination
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Answer: Review of systems

The review of systems is a structured checklist by organ system, meant to uncover symptoms the patient forgot or thought unimportant.

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