- For the past developments in medicine, see History of Medicine and categories History and Medical history
Most medical interactions start with "taking a history". Exceptions are in life-threatening situations such as ALS, ATLS but even here a brief history is often necessary (e.g. AMPLE). Most medical practioners will develop their own style as their experience builds and no single way can be consistently demonstrated as better. A certain amount of standardisation allows for easier communication and reduces the chances of important facts being missed. Even then a story can improve on retelling and many an exotic diagnosis will leap out from a key point, sometimes forgotten by a patient but remembered later or by others.
Whilst taking a history, it is conventionally deemed important that "open" questions are used such as "tell me about this pain" rather than "does it hurt if you cough?". This allows the patient to bring their real concerns into the discussion and also tries to reduce the chances of the patient giving you the aswers they think you want to hear.
Good history taking establishes a rapport between the practitioner and patient, leads to the most precise diagnosis possible with the available facts and also illicits any additional factors that may guide treatment decisions.
A basic history
- Presenting complaint (PC)
- In their own words, what is it that is bothering the patient.
- History of presenting complaint (HPC)
- This is the major area to concentrate on. Questions should concentrate on how symptoms started, nature of symptoms (e.g. burning/stabbing/crushing pain), whether they are constant/intermittent/spasmodic,etc. and any excacerbating/relieving factors. With a particular diagnosis in mind (for exclusion or inclusion) additional questions may become obvious.
- Past medical /surgical history (PMH/PSHx)
- what else has happened to this patient in the past? are the current symptoms related?
- Drug history (DHx)
- conventionally also includes an allergy history (NKDA - No Known Drug Allergies)
- Family History (FHx)
- Sometimes relevant to assess risk of a certain diagnosis
- Social history (SHx)
- More than just smoking and alcohol consumption, should include assessing ability to cope independently with disease or any treatments proposed
- Systemic Enquiry (SE)
- A safety net promoted at medical school, it should not be forgotten as an additional tool by more experienced practioners if the diagnosis is less than clear or dropped by the inexperienced solely to demonstrate their "experience". It allows practioners to run through a list of important symptoms, system by system to ensure that important information was not missed in earlier parts of the discussion.
There is a sociological phenomenon of groups finding common language as a means of identification and protection and the medical specialities are no different - although they will promote the. This extends into the way histories are taken and below is a selection of more focussed histories for different specialities.
- A specific symptom such a localised pain, acute trauma or cough usually allows an effective directed history to be taken
- A single pathology is likely to be managed effectively by a directed history
- A non specific symptom such as weight loss, falls, confusion or dizziness is less likely to be resolved without wide systematic enquiry
- Multiple pathologies and chronic systemic illnesses are unlikely to be managed effectively without wide systematic enquiry
- The systems review can allow recovery from the situation where the patient presents with a specific symptom or as a single pathology and a wider context is otherwise missed:
- eg ptosis presenting to Ophthalmologist and ENT surgeon, who fail to consider Horner's syndrome causes can give symptoms such as back pain from the pancoast's tumour's secondary deposit before the primary is big enough to see on a chest X-ray, so delaying the diagnosis.