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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, June 20, 2016

History Taking - Revisited

From the moment we start interacting with patients as medical students, we are always taught that a good history and physical is of paramount importance to clinch a diagnosis. Faculty from medical schools across the globe, emphasise on this point over and over in an attempt to mould the thought process of students. But in modern day scenario, most of you would agree that the pendulum has swung way too far towards labs and imaging. Sometimes, history and physical is cut short or even completely skipped due to over-reliance on labs. 

I think labs certainly form an important component while evaluating patients, but a balance needs to attained between labs and history/physical. Work up needs to individualised based on presentation, order of differentials i.e every chest pain does not need D-Dimers, CT Pulmonary Angiogram, Cardiac Cath and Endoscopy!

Let us remind ourselves the key components of history taking. This of course, comes in addition to communication skills which are learned over time. Read more on Medical Interview communication skills here.

If done fluently, this elaborated history take anywhere between 10-15 minutes. However, in the ED we rarely need to ask all this questions to all the patients. ED history is focused depending on the chief complaint and also due to time constraints. So this format needs to be gauged based on every individuals chief complaint. For instance, don't dig into getting a detailed sexual history in a 75/M with acute chest pain but do a thorough sexual history in a 24/F with lower abdominal pain or vaginal discharge.

The key is starting with the Chief Complaint, if there are a couple of them then ask the patient which one makes him more concerned. Following this do the Past History (Medical, Surgical, Sexual, Family, OBGYN, Social, Sexual and Allergies) and then ask YES/NO type of questions in the Review of Systems (ROS). One you are through this, do a quick and focussed examination. Now, when you probably have a few differential diagnosis in your mind, order the tests  based on ruling in or ruling out (to a certain extent) these differentials. 

Also remember that while working in the ED, you often treat the symptoms and a suspected diagnosis (awaiting labs). 

Take Home:
  • No lab test/imaging can replace history and physical examination 
  • Follow the sequence (History-->Physical-->Differentials-->Labs)
  • ED history is focussed, based on the chief complaint


     Lakshay Chanana


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