The history

The doctor has four basic tasks to perform during the history-taking phase of the consultation. These are to determine:

• the patient's stated reason for attending

• why the patient is attending today, or at this particular time in the course of this illness

• a list of problems or supplementary symptoms

• any other initially unspoken or hidden reason for attending, e.g. the fear of cancer

The old medical cliché: that 'a good history is the basis of the clinical examination' is as relevant as always. The art of history taking, which is based on good communication, is the most fundamental skill in general practice and requires a disciplined approach. Guidelines include: 3

• Commence by eliciting the presenting complaint.

• Permit an uninterrupted history.

• Use appropriate language—keep the questions simple.

• Use specific questions to clarify the presenting complaint.

• Write notes or use the keyboard to record information but maintain as much eye contact as possible.

• Enquire about general symptoms such as fatigue, weight changes, fever, headache, sleep and coping ability.

• Undertake a relevant systems review.

• A historical checklist includes past medical history, complete medication history, drug habits and sensitivities, family history, psychosocial history and preventive care history.

• Give feedback to the patient about your understanding of the problems and agenda, and correct any misconceptions.

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