Reminder
Patients describe their experience in their language
not doctors' language.
The misunderstanding
Students believe 'history must be in the patient's own words' means presenting whatever the patient or family said — lay or medical — as a clinical finding.
Patients may use lay terms, or medical terms incorrectly. Either way, the clinician must interrogate and verify before presenting.
The distinction
History is obtained in the patient's words. History is presented in
the doctor's language. These are two different stages — and
confusing them produces diagnostic error.
The standard
If you use a medical term in your presentation, you must be able to
defend it. If you cannot — describe instead. Description first.
Label later.
The Defining Principle of This Note
"History is not what the mother said.
It is what you
understood from what the mother said."
Patients speak in experiences. Doctors speak in patterns.
Professional
translation is the skill that connects them.
The Problem
What the misunderstanding looks like
— and why it fails under questioning
Common Student Error
Audio playback instead of clinical translation
What students do ✘
Presenting as tape recorder
Student presenting
"The mother said the child had diarrhoea. The mother said there
was blood in the urine. The patient said he had fits."
Examiner
"Diarrhoea? Are you sure?"
Student
"Yes — that's what the mother said."
What should happen ✔
Presenting as clinician
Translated presentation
"Mother reports 6 episodes of watery stool in 12 hours, no blood,
no mucus."
"Mother noticed red discolouration of urine — no clots, no
dysuria, no confirmed haematuria."
"Child had two episodes of stiffening and jerking movements of all
four limbs, each lasting approximately 2 minutes, with loss of
consciousness and drowsiness after spontaneous recovery."
The student who said "that's what the mother said" has abdicated
clinical responsibility.
The mother is not a doctor. Her terminology does not constitute a
clinical finding. The clinician's job is to interrogate the lay term
and extract the medical content.
The Two Stages
Data collection → Interrogation → Clinical description
— a pipeline
The Professional Translation Pipeline
Three stages — one cognitive process
1
Stage 1 — Receive
Lay Language
Accept free narration, lay terms, and unfiltered description. Do
not correct or reframe during data gathering. Listen fully.
"Loose motion"
"Red urine"
"Fits"
"Breathing fast"
→
Internal
interrogation
2
Stage 2 — Interrogate
Clinical Questions
Ask yourself — and the patient — the clarifying questions that
convert lay experience into clinical data. This is the translation
step.
Frequency? Consistency?
Colour confirmed? Clots?
Focal
or generalised?
Rate? Work of breathing?
→
Clinical
output
3
Stage 3 — Present
Doctor's Language
Present what was clinically established. Use medical terminology
only where criteria are met. Otherwise describe observed features.
"6 watery stools / 12hrs"
"Red discolouration —
unconfirmed"
"Generalised tonic-clonic"
"Tachypnoea with
recession"
"Patient's own words" means respect their experience — not repeat
their terminology.
The patient's meaning must be preserved. The patient's lay labels must
be translated.
Worked Examples
Lay term → Interrogation → Clinical description
— four common presentations
01
Nephrology · Urology
"Blood in urine" / "Red urine"
Term received
"Blood in urine"
"Red urine"
mother's words
Internal interrogation
- What colour exactly — pink, red, brown, dark yellow?
- Was this confirmed by dipstick or microscopy?
- Any clots passed?
- Pain on urination?
- Any medications or foods that could discolour?
Clinical description
"Mother noticed dark yellow discolouration of urine on one
occasion. No clots, no dysuria, no prior urinary symptoms.
Dipstick not yet performed."
Not: "Haematuria." — not yet confirmed.
Not: "Mother said blood in urine."
Red urine is not always haematuria. Labelling it as such before
dipstick or microscopy confirmation commits the clinician to a
nephrology/urology pathway prematurely — and may cause the actual
diagnosis to be missed.
02
Neurology · Paediatrics
"Fits" / "Convulsion"
Term received
"Fits"
"He was shaking"
mother's words
Internal interrogation
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All four limbs or just one or any particular part of the body
shaking?
Would you be able to demonstrate the movement?
Was there loss of consciousness?
Did the child respond to you?
How long did it take?
How was the child upon recovery?
Preceding fever — temperature documented?
Or rhythmic, or tonic posturing?
Clinical description
"Two episodes of generalised tonic-clonic movements, each
lasting approximately 2 minutes, with loss of consciousness and
post-ictal drowsiness for 15 minutes. Associated with fever of
38.9°C."
Febrile seizure — characterised
Not: "Mother said fits."
Not all abnormal movements are seizures. A careful clinical
description is essential to avoid mislabeling. For example,
shivering from fever can be mistaken for fits if not properly
interrogated.
03
Respiratory · Paediatrics
"Breathing fast" / "Difficulty breathing"
Term received
"Breathing fast"
"Difficulty breathing"
mother's words
Internal interrogation
- Rate — measured or observed?
- Noisy? Would you be able to make that sound?
- Increased work — recession, nasal flaring?
- Difficulty speaking or feeding?
- SpO₂ — measured?
Clinical description
"Fast breathing with subcostal recession and nasal flaring. No
audible respiratory noise. Unable to complete feeds."
Increased work of breathing — characterised
Not: "Mother said breathing fast."
The Higher-Level Standard
If you use a medical term — you must be able to defend it.
"Diarrhoea"
WHO definition
Three or more loose or watery stools per day — or more than normal
for the individual. Frequency, consistency, and duration must be
established before using this term.
"Haematuria"
Confirmed finding
Presence of red blood cells in urine — confirmed by microscopy. Visible discolouration alone does not constitute haematuria until a cause is identified.
"Seizure"
Clinical characterisation
Abnormal electrical discharge causing involuntary movement,
altered consciousness, or both. Type, duration, focality, and
post-ictal state must all be characterised before labelling.
The rule: If you cannot state the criteria the term
requires — describe instead. "6 watery stools in 12 hours" is stronger
than "diarrhoea" when the criteria have not been verified.
Description is not weakness. Premature labelling is.
What "Narrative Competency" Fully Means
Three registers — one competent clinician
👂
During history taking
Listen in Lay Language
Accept experience. Accept lay terms. Do not interrupt or reframe.
Capture what the patient means — not what you expect.
→
🧠
During internal reasoning
Think in Medical Language
Interrogate each lay term. Apply clinical criteria. Decide what
the description actually constitutes. This is translation.
→
🗣
During presentation
Speak in Clinical Language
Present what was established, not what was said. Use medical terms
only when defensible. Describe when in doubt.
Connected Frameworks
Professional translation completes the narrative skills in this series
Narrative Competency:
This note teaches what language register
the narrative must be written in. Together they define both the
architecture and the material of a clinical history.
Summarizing Competency:
You cannot summarise a
pattern accurately if the underlying findings have been labelled
prematurely. Clean translation produces clean data — and clean data
produces clean summaries.
Common Student Errors
What failed translation looks like
Repeating lay terms as clinical findings — "mother said fits"
Using medical labels before criteria are verified — premature
diagnosis
Defending a term by citing the source — "that's what she said"
Not knowing the clinical criteria for terms used in the presentation
Treating "patient's own words" as permission to avoid medical
thinking
Adopting a lay description as a confirmed clinical finding without interrogating what was actually observed
Final Take-Home Message
"Patients speak in experiences.
Doctors speak in patterns."
Listen in lay language.
Think in medical language.
Present in clinical language.
That is professional translation.
Obtain in patient's words
Interrogate before labelling
Defend every term you use