01Principles and purposeThe professional or clinical skill and the decisions it supports.
A clinical history is both evidence collection and a therapeutic interaction. The patient supplies symptoms, experience and goals; records, relatives and observations may add context. Start broadly enough to hear the presenting account, then narrow deliberately. A rigid checklist can collect every heading yet miss why the patient attended, what changed today, or which feature makes the situation dangerous. A safe history therefore alternates between listening, hypothesis generation, clarification and synthesis.
Chronology is the spine of the history. Establish the state before illness, precise onset, sequence of events, trajectory, episodic pattern, triggers, relieving factors and response to previous action. Link symptoms on the same timeline instead of cataloguing them independently. Severity is not only a number: ask what the person can no longer do, whether sleep, intake, mobility or cognition changed, and whether deterioration is continuing. Negative findings matter only when they were sought reliably and meaningfully reduce a live hypothesis.
A problem representation compresses the encounter without flattening it. Include age or life stage only when relevant, major susceptibility or exposure, tempo, anatomical or physiological syndrome, severity and a few discriminators. 'A 68-year-old with pain' is too thin; a transcript of every answer is too long. A useful synthesis might describe an older person with abrupt pleuritic unilateral chest pain, hypoxaemia and recent immobility, without fever or reproducible tenderness. This representation activates illness scripts and makes competing mechanisms comparable.
Reasoning and communication remain visible at closure. Summarise the narrative in plain language and invite correction. State what is known, what remains uncertain and what must happen next. For handover, separate observed facts from interpretation and pending data. For examinations, adapt depth to the task: an AKT stem rewards discriminators and probability; a CPSA or SCA encounter also rewards rapport, agenda, safety-netting and shared decisions; PACES requires concise synthesis linked to findings and management priorities.
Key points
- Begin with the patient's agenda and an open account, then clarify chronology, severity, functional effect and urgent symptoms without losing the person's own meaning.
- Build hypotheses while listening, but test them with neutral questions and keep at least one credible alternative until discordant data have been explained.
- A problem representation is a one-sentence synthesis of who the patient is, the tempo and syndrome, relevant context and the discriminating positives and negatives.
- Convert raw details into semantic qualifiers such as acute or chronic, focal or diffuse, progressive or episodic, while preserving exact measurements and uncertainty in the record.
- Medication, allergy, pregnancy possibility, function, social setting, exposures, family history and the patient's ideas, concerns and expectations can change risk and management.
- End by summarising back, correcting misunderstandings, naming immediate concerns, agreeing next steps and documenting source, reliability and outstanding information.
- In AKT questions use the representation to compare mechanisms; in CPSA, PACES and SCA tasks show the same reasoning through focused questions, explanation and shared planning.
02Situations and prioritiesThe context, relevant information and actions that matter most.
The reason for attendance, desired outcome, concerns and social circumstances often determine which otherwise similar clinical problem needs action now.
Hyperacute, acute, subacute, chronic, progressive, relapsing and episodic courses constrain mechanisms more powerfully than an undifferentiated symptom label.
Choose positives and genuine negatives that materially separate leading hypotheses; do not inflate the summary with normal details that change no probability.
Age, pregnancy, immune state, medicines, procedures, travel, occupation, family pattern and baseline function alter prior probability and consequences.
Cognition, language, distress, collateral history and record completeness affect confidence; disagreement between sources is itself information to resolve.
Ideas, concerns, expectations and practical constraints influence consent, adherence and the acceptability of investigation or watchful waiting.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Open narrative followed by focused clarification - Why
- Capture the patient's account before testing diagnostic hypotheses.
- Interpretation and limitations
- Preserve the person's words for key symptoms, then clarify timing, quality, severity and associations with neutral questions; leading questions can manufacture confirmation.
- 02
Chronology reconstruction - Why
- Identify causal order, progression and decision points across symptoms and interventions.
- Interpretation and limitations
- Anchor events to dates or memorable reference points and align medicines, exposures and responses; vague sequencing weakens causal inference.
- 03
Medication and allergy reconciliation - Why
- Detect treatment effects, interactions, omission, toxicity and preventable prescribing risk.
- Interpretation and limitations
- Record medicine, formulation, route, actual use and indication, and distinguish allergy phenotype from intolerance; an imported list may not reflect current use.
- 04
Focused systems enquiry - Why
- Search for discriminators, complications and coexisting problems after initial hypotheses form.
- Interpretation and limitations
- Select questions from live mechanisms and safety threats; a universal recital adds noise and a negative answer is weak when comprehension or recall is limited.
- 05
Collateral and record comparison - Why
- Verify baseline, events, medicines or function when the primary account is incomplete.
- Interpretation and limitations
- Document who supplied information and where accounts differ; collateral evidence complements rather than automatically overrides a capacitous patient's account.
- 06
Teach-back summary - Why
- Check that clinician and patient share an accurate account and next-step understanding.
- Interpretation and limitations
- Invite correction after a concise synthesis and ask the patient to explain the plan in their own words; simple agreement does not prove understanding.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseCompress breathlessness into a useful representationA 72-year-old reports three days of worsening breathlessness; inputs include orthopnoea, ankle swelling, missed diuretic tablets, no pleuritic pain, and reduced walking distance.+
- 1Organise the inputs by tempo and mechanism: acute-on-chronic congestion is supported by orthopnoea, oedema, functional decline and interrupted treatment, while absent pleuritic pain weakens but does not eliminate embolic disease.
- 2Add relevant context and severity rather than every detail: older age, established treatment suggesting prior fluid disease, and inability to walk the usual distance materially alter risk and urgency.
- 3State the representation: a 72-year-old with three days of progressive congestive breathlessness and functional decline after missing diuretic therapy, with orthopnoea and oedema but no pleuritic pain.
- 4Use the representation to prioritise physiological assessment and focused cardiac-respiratory examination while retaining infection, arrhythmia and pulmonary embolism as alternatives requiring targeted evidence.
- 5Verify by reading the sentence back against the raw history: every included feature changes probability or urgency, no unsupported diagnosis is asserted, and the patient confirms the timeline and medicine interruption.
02Consultation methodMove from narrative to hypotheses without interruptionA patient presents with several symptoms and a strong concern about cancer.+
- 1Allow an initial uninterrupted account, acknowledge the cancer concern and establish which symptom or decision matters most today.
- 2Construct a timeline and ask neutral discriminating questions for serious, common and reversible explanations.
- 3Summarise both clinical pattern and concern, explain the current level of uncertainty and agree examination or investigation priorities.
- 4Close with explicit deterioration advice, responsibility for results and a time or condition for reassessment.
03Handover approachSeparate evidence, inference and unfinished workA colleague must continue assessment after transfer between clinical areas.+
- 1Lead with identity, current physiological risk and the one-sentence problem representation.
- 2Provide key observed positives, meaningful negatives, treatment or response, and relevant background in decision order.
- 3Label the leading interpretation and important alternatives as hypotheses rather than facts.
- 4Name pending results, required review time, escalation triggers and the person accepting responsibility.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- After each encounter, check that the documented problem representation still matches the patient's corrected account and the observed clinical state.
- Track pending collateral information, medication reconciliation and results with a named owner and an explicit review point.
- When new evidence conflicts with the original representation, rewrite it rather than appending facts to a stale diagnostic frame.
- Use feedback from supervisors or recordings to review interruptions, unexplored cues, leading questions, jargon and closure quality.
- For exam practice, compare the same case as an AKT stem, a focused consultation and a handover to test whether the core reasoning survives each format.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Compression is a diagnostic act
Choosing which facts enter one sentence exposes the clinician's weighting. If the sentence cannot distinguish hypotheses, the history or synthesis needs refinement.
Negatives need provenance
'No confusion' is strong after direct assessment and collateral confirmation, but weak when copied from an old note or asked through an unsuitable interpreter.
Function calibrates severity
A change from independent shopping to breathlessness while dressing may communicate deterioration more reliably than an isolated adjective such as severe.
Silence can be data loss
Rapid closed questioning may suppress sensitive exposures, safeguarding concerns or a second agenda; privacy and an explicit final invitation can recover them.
Uncertainty should be operational
Name what evidence would raise or lower each serious alternative, who will obtain it, and what change should trigger earlier reassessment.
07Common pitfallsFrequent interpretation and management errors.
- 01
Turning the history into a checklist recital before the patient has described the problem in their own order.
- 02
Calling a copied medicine list reconciled without asking what the person actually takes, how and why.
- 03
Including age, comorbidities or absent symptoms in the representation merely because they are available rather than discriminating.
- 04
Treating an early diagnostic label as established fact and asking only questions that support it.
- 05
Ending after information gathering without summary, correction, agreed next steps, result ownership or safety-netting.
- 06
Presenting uncertainty as vagueness instead of defining the leading possibilities and the evidence needed next.