Effective History Taking

A reliable history is always the best source of clinical information but is also the area most vulnerable to corruption or
misinterpretation
Skilful history taking is cheaper and more effective than a battery of tests.
A badly taken history may lead to unnecessary investigation, inappropriate treatment, wasteful consumption of
resources - at worst, harm to the patient
Although there are defined components in the history taking, the clinical interview is far from 'routine' or mechanical. It
should be taken intelligently and thoughtfully.
From the moment the patient utters the first sentence, a series of mental processes should immediately begin to
interpret and synthesise the information provided.
There are real questions behind the questions that you ask:
Profile
Does the age, sex, ethnicity and place of birth or residence give clues about the spectrum of common problems
usually seen
e.g. the likely cause for a fever is will be different between a returned traveller from Western Africa from a young baby
from Metropolitan Adelaide
Presenting complaint

What is the differential diagnosis of common or important conditions based on their presenting complaint?

What further questions do I need to confirm or exclude the diagnoses?

History of presenting complaint

Are the pattern of symptoms consistent with the diagnosis? e.g. poorly localised colicky abdominal pain with
vomiting and abdominal distension.

Are there are other symptoms consistent with a known cause or chain of causes? e.g. recurrent groin swelling
which has now become irreducible and tender, worsening angina leading to increased GTN use and an
episode of syncope

Do the symptoms provide an indication of severity? e.g. fevers and vomiting of faeculent material

Past medical history

Is the previous diagnosis correct? Was the diagnosis arrived at by sound diagnostic criteria or adequate
investigation?

Are the symptoms similar to a previous episode of an existing condition? e.g. chest pain similar to previous
anginal symptoms or reflux symptoms?

How serious is their illness? Associated with complications or recurrent problems? Life threatening episodes
or hospitalisations?

How well managed are their existing conditions? Are they on complex or advanced medical therapy?
Requires frequent escalations of treatment?

e.g.

a. Poorly controlled non-compliant Type I diabetes with early diabetic nephropathy. Currently on insulin
infusion pump. Frequent admissions with either DKA or recurrent hypoglycaemia.
b. Mild asthma maintained well on steroid inhalers and infrequent of bronchodilators. Regularly
reviewed by GP. No admissions to hospital and required one course of oral steroids for exacerbation
in the last 5 years.

Do current conditions predispose the patient to other problems e.g. Dyspnoea in a patient with rheumatoid
arthritis = ?Pulmonary fibrosis

Are there proposed treatments which might be contraindicated e.g. Prescribing a beta-blocker for a patient
with hypertension with a past history of asthma?

Are there other treatments that may be considered but are excluded because of a problems with a previous
trial?

Medications

Does the therapeutic regime provide clues about the nature of the condition and its severity? e.g. frusemide
alone vs ACE-I, spirinolactone, beta-blocker

Are there any side effects or drug interactions which are related to the presenting complaint? e.g. syncope
episodes from combined B-blocker and Ca-channel blocker

Is the medication regime too complicated for the patient? Is inadequate response due to wrong treatment or
poor compliance?

Is the patient compliant? How much will this affect treatment?

Does the regime require special monitoring e.g. drug levels, side effects, organ damage?

Will they interact with other medications or other medical conditions? e.g. warfarin and amiodarone, steroids
and diabetes

Has there been a recent change in regime that might either lead to worsening control of the disease or
increased likelihood of side-effects?

Is a proposed treatment likely to fail due to previous lack of patient acceptance, physical/mental limitations,
non-compliance or side-effects?

Adverse drug reactions

Are there any contraindications to medications which I am likely to prescribe?

Are previous reactions likely to recur or be of significant concern?

Smoking / Alcohol / Recreational drugs

Will this level of usage put them at significant risk of complications?

Is there an underlying psychosocial reason for this use? e.g. marijuana use to manage psychotic symptoms

Has abstinence been in response to a significant medical illness? e.g. smoking after a myocardial infarction

Review of symptoms

Are there any other separate issues which need further assessment or investigation?

Are there undiagnosed medical problems that may cause or interact with the presenting complaint? e.g.
Recurrent black stools + Dyspnoea = Symptomatic anaemia from chronic upper GI bleeding.

Psycho-social history

Are there any psycho-social circumstances that will make it difficult for the patient to manage their conditions?

Are there any dependents who are reliant on the health and wellbeing of the patient?

Are there any available resources that can supplement any deficiencies in the patient's situation?

Does the patient require assistance to comply with treatment?

Functional history / ADLS

Will a minor medical condition significantly impact on their usual level of function?

Is the patient physically or mentally capable to comply with medical instructions?

The Short Case

What is the short case?

The candidate is given approximately 8-12 mins to examine a body system or anatomical area

No history is taken

Verbal communication is only allowed to get the patient to follow a set of instructions or if the patient's speech
is being formally tested

Following the examination the candidate must give a 3-5 minute summary of
1. The examination findings
2. The likely differential diagnosis based on the finding
3. The probable causes and severity of the condition
4. General discussion related to the above

A smooth and confident technique reassures the examiner that you have a systematic manner of examining
the patient and eliciting signs and defining the findings

A gentle, kind and friendly manner indicates that you are an experienced and professional clinician.

Why is the short case so weird and stressful.

No rapport established with the patient (usually a history breaks the ice before physically touching the
patient)

The patient may need to be involved in a lot of physical tasks rather than just answering some questions

There are no initial clues about the likely diagnosis (problem formulation based purely on signs)

Its an artificial method of assessment (usually the diagnosis comes from the history and the examination
findings confirm the hypothesis)

The assessment is very brief

You dont have a lot of time to think about the problem.

How to make the short case less weird and stressful..

Rehearse the examination until it is smooth and polished. In the lead up to the exam get in the habit of using
a disciplined and orderly technique on all the patients that you see.

If you can do most things automatically (e.g. do the examination, and provide instructions) then you have
more time to think on your feet

Show the examiner that you are already thinking ahead. Dont stop/start the routine as if you are thinking
about what to do or say next.

Dont start the exam until the patient is in the best position or standard position you are accustomed to e.g.
sitting 45 degrees, lying flat, sitting over bed with hands on a pillow (occasionally it will be impossible to do this
let the examiner at the end how this limited the assessment and your preferred method)

Have all your equipment ready before you start the exam. Dont fumble and search for items in your pockets
and bag as you go along.

Anticipate that you may not be required to elicit some signs i.e. vital signs, corneal reflex, fundoscopy, PR, gait
in a spinal patient e.g. While you are examining the hands announce to the examiner I am going to measure
the BP next.....If no response then immediately proceed. Dont finish looking at the hands, then look at the
arm, stall for a few seconds in a perplexed fashion then ask if you can take the BP

Pre-empt the next phase of the exam e.g. reach for your tongue depressor and torch just before you move
from cranial nerve V and VII to IX and X

Have a standard strategy for how you respond to an abnormal sign e.g. murmur > radiation and dynamic
manoeuvres, III n palsy > exclude concurrent IV n palsy, ascites > ask examiner to help you to do fluid thrill

It is generally impossible to conduct the whole thing in silence without any comment. An intermittent friendly
comment helps break the ice and reduce the awkwardness of the situation. Even a take a deep breath, good
work, thank you is helpful. After a gruelling neurological exam you might apologise 'that was a little workout
wasn't it?'

Be nice to the patient I would like to have a look at your abdomen, tell me if I cause you any discomfort.

Let the patient know what you are going to do nextI will like to look at your handsI will like to a closer look
at your neckI am just going to press on your tummy.Can I look at your eyesI would like to test the
strength in your armsCan I just check your co-ordinationI am going to test the feeling in your legsI
would like to look at how you walk.

Remember the neurological examination has a lot of talking and requires patient co-operation have a set
of pre-rehearsed clear and ambiguous instructions so you arent struggling to get the patient to understand or
comply (also have alternative instructions if the first ones dont work) e.g. 'I would let to test your reflexes one
more time. Now I am going to ask you to clasp you fingers like this <demonstrate to patient> and pull. We
will practise this together once more time <repeat manoeuvre>. Now relax again. I a moment I am going to
ask you to please repeat this movement. Now, 'pull' <immediately test reflexes>. That's good. Thank you'

Dont be afraid to ask the examiner to assist your with certain manoeuvres 'would you mind helping
me.....' e.g. sit the patient up, stand by assistance for gait testing, check for fluid thrill.

If you see a large collection of abnormal signs but having trouble dissecting them dont slog away silently
trying to unravel them without making an initial comment e.g. it seems there are a quite few things going on
there, I might need to spend a bit more time on this part of the examination, sounds like you have more than
one murmur going on there, I am going to try a few more things to sort this out, you seem to have more than
one problem with your eye movements, can I try these tests.This reassures the examiner that you know what
the issue is and not making random gestures to delineate the problem.

Some parts of the exam e.g. testing power can be quite exhausting. Don't forget to let the frail patient take a
breather if they look like they are tiring.

If a patient cant achieve a task, just say looks like you are having difficulty/struggling with that...lets try
this. Dont get thrown off by things not working out. Smoothly proceed to the next task. The fact the patient
is struggling or frustrated can be a diagnostic clue and definitely worth mentioning in the formulation.

Don't be frustrated that there are not a lot signs to find. The absence of signs can be just as important as the
presence of signs e.g. 'I was asked to examine Mrs. X respiratory system, it was notable that she was not
attached to pulse oximetry, appeared comfortable, in no respiratory distress, not cyanotic and not on
supplemental oxygen.'

How to begin (the general inspection)

This initial interaction will help relax you, the patient and the examiner: It is a critical point of the short case. It should
appear deliberate and purposeful (even if it is only for a brief period of time).
1. Hello, my name is Dr. X, before I examine you (or your child) closely I would like to take a general look at you
or look at your breathing.
2. Stand back in a relaxed but studied approach hand on chin, head cocked to one side like Sherlock Holmes
investigating a crime scene. Move you head/eyes in deliberate way from head to torso. Step around or behind
the bed as necessary, look deliberately at oxygen flow rates, infusions, sputum pots walking aids and other
visual clues.
3. Good, now I would like to have a closer look, May I have both of your hands..

Make a brief statement (but dont prattle on) if there is a startling clue on initial inspection (otherwise proceed quickly
to the examination) e.g.
Point to a visual cue e.g. set of calipers and say I presume these belong to you'
"Mmm, I notice your face looks a bit flushed or your lips look a little dusky"
Oh, thats an interesting sound, it seems to be coming from your heart. I would like to listen to than in a
moment..
You look like you are a little out of breath, Is it OK for me to examine you"
My you seem to be covered with quite a few bruises"
"That tremor must be really bothering you.
"Looks like you are having some trouble with your breathing"
Make your commentary in a rhetorical way rather actually expecting the patient to answer
This reassures the examiner that your general inspection is already giving you important information and you are
confident with your signs. It is also a good icebreaker with the patients, builds rapport and makes it easier to
progress.

Further examination (after the hands)

Examples:
Examine this patients cardiovascular system

I would now like to take your pulse

Examine this patients abdomen

let me have a good look at your

tummywhile I am doing that can you
cough for me.

Examine this patients limbs/joints

let me have a closer look at your

hands/feet/knee/hip. I would like
to feelthem, let me know if I cause you
discomfort. Can show what you can do
with them. I would now like to
now movethem for you.

Examine this patients cranial nerves

.I would like to take a closer look at your

face and do some tests

Examine this patients eyes/vision

.let me have a closer look at your eyes

I would now like to test your eyesight

Examine this patients speech

.I would to evaluate your speech a bit

futher

Key into major symptoms

It is worth briefly commenting about a clearly obvious sign then proceed quietly through the rest of the
examination".thats an interesting clicking coming from your chest...I will to need to listen carefully"".that liver
certainly feels enlarged.I will like to feel a bit more closely, tell me if it becomes uncomfortable""..looks like you
have a bit of squint.I will need to have a better look at your eyes.""..those joints look at bit swollen/sore. I will
like to examine them a little more closely, tell me if it becomes uncomfortable"
Questions about style

Some candidates find in certain situation that narrating (all or some) of the positive physical findings during
the examination is helpful. This is more of a question of style. Whatever method is chosen, it should appear
logical and well integrated into the process. If it causes the examination to appear fragmented or confusing
then a review of the process is required. Usually a few carefully chosen comments on key signs is adequate
to let the examiners know what you are thinking.

When eliciting signs be aware of where the examiners are standing so that you are not obscuring positive
findings. Make eye contact with the examiner to catch their attention to an abnormal finding e.g. clonus,
shifting dullness

When asked to formulate the case, be prepared to immediately respond. Remember what was asked of
you. 'I was asked to see Mr. Jones and examine his knee. He was lying comfortably in bed with a notable
fixed flexion deformity'