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.
- Poorly controlled non-compliant Type I diabetes with early diabetic
nephropathy. Currently on insulin infusion pump. Frequent
admissions with either DKA or recurrent hypoglycaemia.
- 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?