Clinical exam · History taking and the interview
Chief complaint and history of present illness !
- History
The chief complaint is the reason for the visit in the patient's words; the present illness is the full story of that problem.
Updated 2026-11-01
What it is
The chief complaint sums up in one sentence why the patient has come and is recorded verbatim, in quotation marks. The history of present illness tells the problem in chronological order: how and when it began, how it evolved, what comes with it, what has been done and how it is today. It is the most important part of the history, because the first diagnostic hypotheses come from it.
What it must include
- A brief, verbatim chief complaint.
- Time since onset.
- The attributes of each main symptom.
- Associated symptoms and pertinent negatives.
- Previous visits, tests and treatments for the same problem.
- Current status and impact on daily life.
How to ask
- 'What brings you in today?' and record the answer verbatim.
- 'When did you last feel completely well?' to fix the onset.
- 'How did it start: suddenly or gradually? What were you doing at the time?'
- 'How has it changed since then: better, worse, the same, coming and going?'
- 'What other symptoms have you noticed along with this?'
- 'What have you done or taken for it, and did it help?'
- 'Have you seen anyone for this before? Did you have any tests?'
- 'Why did you decide to come in today in particular?'
Test yourself
Think of the answer, then tap the question to see it.
How is the chief complaint recorded?
In one short sentence, in the patient's own words and in quotation marks, without turning it into a diagnosis.
What is a pertinent negative?
A symptom the patient does not have whose absence helps point towards or rule out a diagnosis, for example no fever in abdominal pain.
Which question helps fix the true onset of the present illness?
'When did you last feel completely well?', because many patients remember their last healthy day better than their first symptom.
Related
- Analysing a symptom: onset, site, character, radiation and more
- The clinical history: its parts and their order
- The medical interview: rapport, open questions and listening
- Review of systems
- Pain assessment and pain scales
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: 12.3 Collection of Assessment Data - Fundamentals of Nursing | OpenStax (OpenStax, Rice University, 2024); Resolución número 1995 de 1999 (julio 8): por la cual se establecen normas para el manejo de la Historia Clínica (Ministry of Health (Colombia), 1999).
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Representative model, for educational purposes only.