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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].


[1] Rahman A, Chesters J, Savige G, Deacon N. Taking a history: the learnings that national health science forgot.Aust J Rural Health. 2010 Dec;18(6):230-4. doi: 10.1111/j.1440-1584.2010.01166.x. 

[7] Barratt J. Treating knee pain: history taking and accurate diagnoses.Emerg Nurse. 2010 Jul;18(4):26-34; quiz 36.

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[13] Proude EM, Conigrave KM, Britton A, Haber PS.Improving alcohol and tobacco history taking by junior medical officers.Alcohol Alcohol. 2008 May-Jun;43(3):320-5. Epub 2008 Feb 29.

[15] Blackburn VF, Blackburn AV.Taking a history in aesthetic surgery: SAGA--the surgeon's tool for patient selection.J PlastReconstrAesthet Surg. 2008 Jul;61(7):723-9. Epub 2008 Apr 18.

[16] Larocca-Pitts MA.FACT: taking a spiritual history in a clinical setting.J Health Care Chaplain. 2008;15(1):1-12.

[17] AustFam Physician. 2011 Sep;40(9):735-8.  A competency history--an additional model of history taking.Bridge S
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[23] Kim SH, Lee YM, Park JT.Patients' perspectives on sexual history taking in Korea.Patient EducCouns. 2008 Mar;70(3):370-5. Epub 2007 Dec 20

[27] Mazer M, Deroos F, Hollander JE, McCusker C, Peacock N, Perrone J. Medication history taking in emergency department triage is inaccurate and incomplete.AcadEmerg Med. 2011 Jan;18(1):102-4. doi: 10.1111/j.1553-2712.2010.00959.x. Epub 2010 Dec 22


Writings of Professor Omar Hasan Kasule, Sr

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