Effective History Taking

A reliable history is always the best source of clinical information but is also the area most vulnerable to corruption or misinterpretation

Skilful history taking is cheaper and more effective than a battery of tests.

A badly taken history may lead to unnecessary investigation, inappropriate treatment, wasteful consumption of resources - at worst, harm to the patient

Although there are defined components in the history taking, the clinical interview is far from 'routine' or mechanical.  It should be taken intelligently and thoughtfully.

From the moment the patient utters the first sentence, a series of mental processes should immediately begin to interpret and synthesise the information provided.

There are real questions behind the questions that you ask:

Profile

Does the age, sex, ethnicity and place of birth or residence give clues about the spectrum of common problems usually seen

e.g. the likely cause for a fever is will be different between a returned traveller from Western Africa from a young baby from Metropolitan Adelaide

Presenting complaint

• What is the differential diagnosis of common or important conditions based on their presenting complaint?
• What further questions do I need to confirm or exclude the diagnoses?

History of presenting complaint

• Are the  pattern of symptoms consistent with the diagnosis? e.g. poorly localised colicky abdominal pain with vomiting and abdominal distension.
• Are there are other symptoms consistent with a known cause or chain of causes? e.g. recurrent groin swelling which has now become irreducible and tender, worsening angina leading to increased GTN use and an episode of syncope
• Do the symptoms provide an indication of severity? e.g. fevers and vomiting of faeculent material

Past medical history

• Is the previous diagnosis correct?  Was the diagnosis arrived at by sound diagnostic criteria or adequate investigation?
• Are the symptoms similar to a previous episode of an existing condition? e.g. chest pain similar to previous anginal symptoms or reflux symptoms?
• How serious is their illness?  Associated with complications or recurrent problems?   Life threatening episodes or hospitalisations?
• How well managed are their existing conditions?   Are they on complex or advanced medical therapy?  Requires frequent escalations of treatment?
•  e.g.
  1. Poorly controlled non-compliant Type I diabetes with early diabetic nephropathy.  Currently on insulin infusion pump.  Frequent admissions with either DKA or recurrent hypoglycaemia. 
  2. Mild asthma maintained well on steroid inhalers and infrequent of bronchodilators.  Regularly reviewed by GP. No admissions to hospital and required one course of oral steroids for exacerbation in the last 5 years.
• Do current conditions predispose the patient to other problems e.g. Dyspnoea in a patient with rheumatoid arthritis = ?Pulmonary fibrosis
• Are there proposed treatments which might be contraindicated e.g. Prescribing a beta-blocker for a patient with hypertension with a past history of asthma?

• Are there other treatments that may be considered but are excluded because of a problems with a previous trial?

 Medications

• Does the therapeutic regime provide clues about the nature of the condition and its severity? e.g. frusemide alone vs ACE-I, spirinolactone, beta-blocker
• Are there any side effects or drug interactions which are related to the presenting complaint? e.g. syncope episodes from combined B-blocker and Ca-channel blocker
• Is the medication regime too complicated for the patient?  Is inadequate response due to wrong treatment or poor compliance?
• Is the patient compliant?  How much will this affect treatment?
• Does the regime require special monitoring e.g. drug levels, side effects, organ damage?
• Will they interact with other medications or other medical conditions? e.g. warfarin and amiodarone, steroids and diabetes
• Has there been a recent change in regime that might either lead to worsening control of the disease or increased likelihood of side-effects?
• Is a proposed treatment likely to fail due to previous lack of patient acceptance, physical/mental limitations, non-compliance or side-effects?

 Adverse drug reactions

• Are there any contraindications to medications which I am likely to prescribe?
• Are previous reactions likely to recur or be of significant concern?

Smoking / Alcohol / Recreational drugs

• Will this level of usage put them at significant risk of complications?
• Is there an underlying psychosocial reason for this use? e.g. marijuana use to manage psychotic symptoms
• Has abstinence been in response to a significant medical illness? e.g. smoking after a myocardial infarction

Review of symptoms

• Are there any other separate issues which need further assessment or investigation?
• Are there undiagnosed medical problems that may cause or interact with the presenting complaint?  e.g. Recurrent black stools + Dyspnoea = Symptomatic anaemia from chronic upper GI bleeding.

Psycho-social history

• Are there any psycho-social circumstances that will make it difficult for the patient to manage their conditions?
• Are there any dependents who are reliant on the health and wellbeing of the patient?
• Are there any available resources that can supplement any deficiencies in the patient's situation?
• Does the patient require assistance to comply with treatment?

Functional history / ADLS

• Will a minor medical condition significantly impact on their usual level of function?
• Is the patient physically or mentally capable to comply with medical instructions?