Medical history taking: Difference between revisions
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In health care, the '''medical history taking''' is a systematic and thorough interview of the patient for symptoms and risk factors of disease or abnormality as well as relevant psychosocial factors that might affect the expression of treatment of disease.<ref>{{MeSH}}</ref> | In health care, the '''medical history taking''' is a systematic and thorough interview of the patient for symptoms and risk factors of disease or abnormality as well as relevant psychosocial factors that might affect the expression of treatment of disease.<ref>{{MeSH}}</ref> | ||
The medical history taking complements information gathered in the [[physical examination]] and is an important part of the [[physician-patient relationship]]. The medical history contributes more to diagnosis than does the [[physical examination]].<ref name="pmid1536065">{{cite journal |author=Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV |title=Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses |journal=West. J. Med. |volume=156 |issue=2 |pages=163–5 |year=1992 |month=February |pmid=1536065 |pmc=1003190 |doi= |url= |issn=}}</ref><ref name="pmid1148666">{{cite journal |author=Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C |title=Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients |journal=Br Med J |volume=2 |issue=5969 |pages=486–9 |year=1975 |month=May |pmid=1148666 |pmc=1673456 |doi= |url= |issn=}}</ref><ref name="pmid466256">{{cite journal |author=Sandler G |title=Costs of unnecessary tests |journal=Br Med J |volume=2 |issue=6181 |pages=21–4 |year=1979 |month=July |pmid=466256 |pmc=1595755 |doi= |url= |issn=}}</ref> | The medical history taking complements information gathered in the [[physical examination]] and is an important part of the [[physician-patient relationship]]. The medical history contributes more to diagnosis than does the [[physical examination]].<ref name="pmid1536065">{{cite journal |author=Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV |title=Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses |journal=West. J. Med. |volume=156 |issue=2 |pages=163–5 |year=1992 |month=February |pmid=1536065 |pmc=1003190 |doi= |url= |issn=}}</ref><ref name="pmid1148666">{{cite journal |author=Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C |title=Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients |journal=Br Med J |volume=2 |issue=5969 |pages=486–9 |year=1975 |month=May |pmid=1148666 |pmc=1673456 |doi= |url= |issn=}}</ref><ref name="pmid466256">{{cite journal |author=Sandler G |title=Costs of unnecessary tests |journal=Br Med J |volume=2 |issue=6181 |pages=21–4 |year=1979 |month=July |pmid=466256 |pmc=1595755 |doi= |url= |issn=}}</ref><ref name="pmid16323069">{{cite journal| author=Leuppi JD, Dieterle T, Koch G, Martina B, Tamm M, Perruchoud AP et al.| title=Diagnostic value of lung auscultation in an emergency room setting. | journal=Swiss Med Wkly | year= 2005 | volume= 135 | issue= 35-36 | pages= 520-4 | pmid=16323069 | doi=2005/35/smw-10886 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16323069 }} </ref> | ||
Collaborative agenda setting may reduce, "oh by the way," requests by patients at the end of the visit.<ref name="pmid21735348">{{cite journal| author=Brock DM, Mauksch LB, Witteborn S, Hummel J, Nagasawa P, Robins LS| title=Effectiveness of intensive physician training in upfront agenda setting. | journal=J Gen Intern Med | year= 2011 | volume= 26 | issue= 11 | pages= 1317-23 | pmid=21735348 | doi=10.1007/s11606-011-1773-y | pmc= | url= }} </ref> | |||
Soliciting the patient's narrative may be more effective than asking closed ended questions.<ref name="pmid12767949">{{cite journal |author=Haidet P, Paterniti DA |title="Building" a history rather than "taking" one: a perspective on information sharing during the medical interview |journal=Arch. Intern. Med. |volume=163 |issue=10 |pages=1134–40 |year=2003 |month=May |pmid=12767949 |doi=10.1001/archinte.163.10.1134 |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=12767949 |issn=}}</ref> | Soliciting the patient's narrative may be more effective than asking closed ended questions.<ref name="pmid12767949">{{cite journal |author=Haidet P, Paterniti DA |title="Building" a history rather than "taking" one: a perspective on information sharing during the medical interview |journal=Arch. Intern. Med. |volume=163 |issue=10 |pages=1134–40 |year=2003 |month=May |pmid=12767949 |doi=10.1001/archinte.163.10.1134 |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=12767949 |issn=}}</ref> | ||
The accuracy of diagnoses reported by patients may be low for diseases such as sinusitis.<ref name="pmid15364670">{{cite journal| author=Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, Powers C| title=Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache. | journal=Arch Intern Med | year= 2004 | volume= 164 | issue= 16 | pages= 1769-72 | pmid=15364670 | doi=10.1001/archinte.164.16.1769 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15364670 }} </ref> | |||
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==External links== | ==External links== | ||
* [http:// | * The Rational Clinical Examination Series. This is a series of [[systematic review]]s published in the [http://jama.ama-assn.org/ Journal of the American Medical Association] of topics in medical history taking and [[physical examination]]. | ||
** [http://jama.ama-assn.org/cgi/collection/rational_clinical_exam Browse] | |||
** [http://jama.ama-assn.org/search.dtl?tocsectionid=The+Rational+Clinical+Examination Search][[Category:Suggestion Bot Tag]] | |||
Latest revision as of 11:00, 17 September 2024
In health care, the medical history taking is a systematic and thorough interview of the patient for symptoms and risk factors of disease or abnormality as well as relevant psychosocial factors that might affect the expression of treatment of disease.[1]
The medical history taking complements information gathered in the physical examination and is an important part of the physician-patient relationship. The medical history contributes more to diagnosis than does the physical examination.[2][3][4][5]
Collaborative agenda setting may reduce, "oh by the way," requests by patients at the end of the visit.[6]
Soliciting the patient's narrative may be more effective than asking closed ended questions.[7]
The accuracy of diagnoses reported by patients may be low for diseases such as sinusitis.[8]
References
- ↑ Anonymous (2024), Medical history taking (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV (February 1992). "Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses". West. J. Med. 156 (2): 163–5. PMID 1536065. PMC 1003190. [e]
- ↑ Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C (May 1975). "Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients". Br Med J 2 (5969): 486–9. PMID 1148666. PMC 1673456. [e]
- ↑ Sandler G (July 1979). "Costs of unnecessary tests". Br Med J 2 (6181): 21–4. PMID 466256. PMC 1595755. [e]
- ↑ Leuppi JD, Dieterle T, Koch G, Martina B, Tamm M, Perruchoud AP et al. (2005). "Diagnostic value of lung auscultation in an emergency room setting.". Swiss Med Wkly 135 (35-36): 520-4. DOI:2005/35/smw-10886. PMID 16323069. Research Blogging.
- ↑ Brock DM, Mauksch LB, Witteborn S, Hummel J, Nagasawa P, Robins LS (2011). "Effectiveness of intensive physician training in upfront agenda setting.". J Gen Intern Med 26 (11): 1317-23. DOI:10.1007/s11606-011-1773-y. PMID 21735348. Research Blogging.
- ↑ Haidet P, Paterniti DA (May 2003). ""Building" a history rather than "taking" one: a perspective on information sharing during the medical interview". Arch. Intern. Med. 163 (10): 1134–40. DOI:10.1001/archinte.163.10.1134. PMID 12767949. Research Blogging.
- ↑ Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, Powers C (2004). "Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache.". Arch Intern Med 164 (16): 1769-72. DOI:10.1001/archinte.164.16.1769. PMID 15364670. Research Blogging.
External links
- The Rational Clinical Examination Series. This is a series of systematic reviews published in the Journal of the American Medical Association of topics in medical history taking and physical examination.