Tuesday, 7 October 2008

History Taking is a Continuous Process

Dear Bloggers

Today I would like to revisit history taking. In fact, one of the main purposes of this blog is to discuss various elements of the history taking process.

Once the patient has been admitted to the hospital it is often necessary to obtain further history in order to understand the current patient problems plus existing co-morbidity to thereby construction a diagnosis which can then be tested.

Taking a thorough history on admission and doing it quickly is an art and something that experienced doctors are adept at doing. However, junior doctors through a lack of experience and perhaps a lack of sufficient training, take time to develop such skills that are the essential elements of any physician.

Hence, a patient who is admitted to the hospital will often not have a thorough enough history taken and therefore, it is up to the senior doctors to identify the areas that the junior doctor has failed to recognise and to then go back to the bedside and speak to the patient to obtain the salient information through appropriate questioning.

This is the best opportunity for the junior doctor to learn i.e. by seeing the senior doctor's style, methodology and purpose of questioning. This is part of the bedside teaching process.

By obtaining more detailed information can lead to the uncovering of information that guides the physician in a different direction or it may merely confirm what the junior doctor already thought. Taking further history is essential to fill in the gaps.

I often say, and even more so in these times of world financial collapse, 'if you were buying a house, you would read all the details and fine print before signing your savings over to the bank and obtaining a mortgage, which is only money. But, if you were a patient admitted into hospital wouldn't you want to be asked the finite details to help the doctors understand your symptoms on which your life might depend?'

In the days of CT, MRI, SPECT, PET etc, aren't we becoming complacent in our own confidence of being able to make a diagnosis with these tools at the neglect of history taking plus physical examination?

For example, in another hospital some time ago, a patient with COPD was admitted with a chest infection for which he was not getting better despite the use of a 3rd generation cephalosporin antibiotic. The junior doctor was concerned because of the continued fever and dyspnoea. A senior doctor went to the bedside and took more history whilst the patient was eating his food. It soon became clear that the patient was coughing when trying to swallow his food. The senior doctor obtained a classic history consistent with aspiration i.e. coughing when eating and when lying flat.

These symptoms had not been posed to the patient on admission, but as easily as asking an open question of how he was, he offered up the information of potential aspiration. Such important information was able to redirect the focus of investigation and treatment with obvious benefit to the patient.

However, junior doctors should not simply rely on the admitting history and stick rigidly to it and bypass asking any further questions. History taking is an ongoing process throughout the inpatient stay and beyond into the post-discharge outpatient follow-up.

By not asking questions to our patients, we are doing them a disservice.

Please consider.

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