Integrated Medical Education Resources: 130909P - LITERATURE REVIEW ON HISTORY TAKING

Background reading for Year 3 Medical Students at the Faculty of Medicine King Fahad Medical City on September 9, 2013 by Professor Omar Hasan Kasule Sr.

Effective history taking can discover information for policy making not available in archival sources[1].History and physical examination predict diagnosis and prognosis quite well[2]. A patient with fever thought related to hip surgery infection was correctly diagnosed as Q fever based on a good history[3]. A good history distinguished seizure from syncope[4]. Kawasaki disease risk was determined from careful history taking from parents about early life diseases in the absence of any other symptoms or signs[5]. Good history taking was effective in screening for knee injuries[6]. It can help provide quick intervention by distinguishing traumatic from inflammatory knee conditions[7]. Physical examination did not add anything to the diagnosis obtained from a good history of knee meniscal tears[8]. A good history was all what was needed to diagnose and treat immediately shoulder injuries[9].

Most diagnoses can be made confidently based on history alone but a few non-specific conditions will require further investigations to clinch the diagnosis[10] for example history and physical examination are not good predictors of arrhythmias[11].

The practices of taking history leave much to be desired. Limitations were found in taking and interpreting cancer family histories[12]. Wide variation in recording alcohol histories were found among house officers[13]. Poor history taking resulted in missing cases of alcohol abuse[14]. Dissatisfaction with esthetic surgery arose more from poor history than from the technical surgical problems[15].

History taking has expanded beyond the traditional fields to include several dimensions. A spiritual history can provide useful clinical information[16]^,.A competence history is based on patient empowerment[17]. A family history was useful in diagnosis of ophthalmologic conditions[18]. Sexual histories discover disease causation from sexual behavior or sexual dysfunction due to disease. Practitioners’ reluctance to take sexual histories led to missing HIV infection[19]. Failure to ask about anal intercourse led to missing diagnoses of unexplained urogenital symptoms[20]. Practitioners were reluctant to take sexual histories of adolescents in the presence of parents or on the assumption of chastity[21] and as a result missed important findings. They also were reluctant to take sexual histories from urology patients[22]. Sexual histories were missed in routine history whereas the patients would be positive about responding if asked[23].

Modern information and communication technology has been used to aid history taking. Computer assisted interviewing has advantages in more systematic data collection but interferes with doctor-patient interaction[24]. Computer assisted has not been compared to pen and paper in a randomized trial of history taking to detected elevated risk of diabetes[25]^,[26].

Pressure of time causes medication histories in emergency rooms to be incomplete and inaccurate[27]. Use of a questionnaire can improve medication history taking[28]. Use of questionnaire was more reliable in detecting sleep disorders than use of history[29].

Students experienced stress in taking patient histories[30]^,[31].Standardized patients are effective in teaching history taking to students[32]. They are satisfied in using virtual patients to learn history taking[33]. Review of videotaped interviews is useful in teaching students about history taking[34]. It is recommended to observe history taking by students during training[35]. A special tool, Sexual Events Classification, can be used to teach sexual history taking[36].

REFERENCES