Hanging in one of my exam rooms are these framed Ten Commandments of effective history taking, as told to a former student of mine in the summer of 2013. Patients have often commented favorably, and I thought it appropriate to present it to you now. Accurate history taking is the most fundamental aspect of clinical medicine, and when done correctly is most likely to result in obtaining the correct diagnosis, as well as avoiding errors and pitfalls on the way. This process is as old as medicine itself, and to be performed correctly takes time and effort. In the current medical climate in which speed is part of the reality, the maximum benefit is derived when the patient answers the questions posed by the medical provider as accurately and succinctly as possible. We cannot stress this enough. The benefit of an accurate medical history is achieved when patients answer the questions posed to them directly and to the point. It actually requires that patients have the confidence in their providers asking the correct questions, and of course it is up to the providers to pose them. There is nothing more fundamentally important. Often, patients believe they know more than they actually do, including their own diagnosis. This thwarts accurate history taking, and creates an undue burden on the history taker. So remember; answer the questions that your provides asks, this will benefit you and your provider. This information in conjunction with the article in June, “Primary Care: The ‘Sinew’ of Medicine (Healthcare)”, provides some of the fundamentals of clinical medicine to better utilize the Health Care system.
- Health Care providers are really looking for changes, which can be either feelings (symptoms), or observable (signs). Any new or worsening of these need to be addressed with your Health Care practitioners.
- Always be skeptical of any and all information until proven.
- Obtain the entire history. Details matter.
- Never assume anything. Never, it will only get you into trouble.
- Clinicians can live comfortably in a world of uncertainty, until the correct diagnosis is made, there is no need for premature diagnosis.
- Identify whether a problem is new, recurrent, or a relapse.
- Just like real estate, when it comes to a complaint referable to a body part it’s all about location, location, location.
- Every medical problem has a beginning, middle, and end. It is imperative to determine exactly when the problem began.
- Medications have unintended and negative consequences. Know every medication and dose taken by the patient.
- Analyze all data available to answer the question at hand. Always review the entire medical record. (No matter how cumbersome it may be!)
And remember, care must be taken not to over prescribe or overuse antibiotics for fear of their side effects. Never treat a viral infection with an antibiotic, these are only for bacterial infections.