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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