Integrated Medical Education Resources: 140909L - LITERATURE REVIEW ON HISTORY TAKING

Background reading 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].

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