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

History of presenting complaint

Past medical history

 Medications

 Adverse drug reactions

Smoking / Alcohol / Recreational drugs

Review of symptoms

Psycho-social history

Functional history / ADLS