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HISTORY TAKING

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Importance of History Taking

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A thorough history is essential in all fields of medicine. It has often been said that a majority of all diagnosis are suggested or made by the history, even more when aided by a careful physical examination. Although technology has greatly advanced and it is tempting to order a battery of tests to aid in diagnosis, the history remains the most valuable source of information concerning the patient's illness.

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The history serves as the primary source for data gathering and should include both the patient's perspective and account of symptoms as well as information obtained from directed questioning by the examiner. The patient should be allowed to talk without interruption regarding their primary concern, and should also be able to voice an opinion about what he or she believes may be the underlying problem. When more information is needed, the examiner should use nonleading questions to collect further details and permit the patient to answer each question fully before moving on to the next. If the patient is acutely ill, however, it is reasonable for the examiner to limit the patient's time for response in order to allow for prompt evaluation and treatment. When possible, the examiner should speak with family members or close friends in order to better understand the extent of disability and the impact of illness not only on the patient but also on those around the patient.

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Additionally, the time spent during the history allows the patient and examiner to develop a bond that will aid in future diagnosis and therapy. Maintaining eye contact and intent listening will demonstrate the clinician's compassion and understanding. Asking key questions in words the patient understands and using a nonjudgmental tone will enhance communication, instill confidence, and facilitate a trusting relationship that will lend support to acceptance of therapy and compliance with treatments.

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Finally, the history serves as a way to organize the examiner's thoughts, maximize clinical reasoning, and create a comprehensive differential diagnosis. This in turn leads to a more proficient physical examination, appropriate use of diagnostic aids, and prioritization of therapeutic interventions.

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Analysis of a Symptom

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Often the patient will present with a main symptom or complaint for which they seek assistance. In accurately evaluating each symptom, it is important to recall the characteristics of symptom analysis (see Table 16-1). Using each attribute to further define an index symptom is fundamental in recognizing disease patterns and developing a detailed differential diagnosis.

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Table Graphic Jump Location
TABLE 16-1.

Characteristics of Symptom Analysis

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Location
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In determining location of a symptom, it is important to be as specific as possible. Patients will often ...

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