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History of presenting complaint examples

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Example 4:

Bloch and Singh, 2001:90

The patient describes an eight-month history of anxiety symptoms, which began two months after a car accident. She experiences apprehensiveness when out of her home, inability to cope with anything out of the ordinary, initial insomnia and irritability, and she has withdrawn socially. More recently she has had trouble concentrating on her work. Five days ago she was taken to her local GP after experiencing a typical attack in the supermarket. She has become housebound since, ruminating that "I'm terrified of suffering a heart attack and dying suddenly like my mother". She has begun drinking up to a bottle of wine a day in an effort, she says, "to calm myself down and make things more bearable".

Writing tip 1:

You may choose to commence this section of the report with a summary of the key issues that you will address, as in the example shown.

The central problem is identified promptly in the first sentence, and relevant key symptoms are outlined immediately in the second sentence. This is important information in an objective diagnostic work-up.

Information on the impact of illness is placed next, helping to contextualise the patient's experience of the central problem and related symptoms. This information will contribute toward a more sophisticated diagnosis that accommodates the patient's experience and response to illness.

Note that in the example all symptoms (whether present or not) relevant to a diagnosis of anxiety and the differential diagnosis) have not been included. This is OK for an introduction but not for the history of presenting complaint.

Writing tip 2:

Chronology is established using three techniques.

  1. The opening sentence not only identifies the central problem but also informs the reader of when the problem first started. This establishes a temporal perspective on the patient's current problem, which is relevant for framing the events when describing the course of the problem. Remember, in this instance, we are referring to the patient's current problem or episode, which may or may not be related to an underlying chronic condition. This means that, having alerted the reader to the fact that this presentation/episode is part of a longer-standing problem, the current episode is described first and then the remainder of the illness course beginning with the first onset of symptoms. This would usually be put in the history of the presenting complaint.
  2. Events are placed in chronological order, which is regularly marked by the use of specific temporal markers, highlighted in the example ( e.g. an eight month history... began two months after, more recently, five days ago, since). This is preferable to a specific date (as the reader then has to calculate the duration).
  3. Temporal perspectives on actions, events, and states of affairs are marked grammatically by appropriate use of English verb tense forms (see notes on Example 5.).

Comment 1

Central problem

Comment 2

Common psychiatric symptoms

Comment 3

Effect on work

Comment 4

This is the precipitant

Comment 5

Impact of illness on work, social relations, and self-care

Comment 6

The history is documented from the patient's perspective. The facts recorded must be based on the patient's description. Where appropriate, incorporate the patient's own words into the report.

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