Tricks and Helpful Hints for Students in Taking and Presenting a History:
Daniel Sexton, M.D., Duke University Medical Center
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Tell a story that has an introduction, a temporal sequence and a conclusion
that has a summary
Group pertinent negatives and positives together as a series (e.g. “The
following important symptoms were absent (or present): dyspnea, leg edema,
nocturia, cough, and chest pain”
Be sure that time is emphasized (e.g. 1 month ago . . 1 week ago . . 3 days
ago…)
Inform the listener before the start where you are going (e.g. “Mr. Jones was
admitted with cough, fever, and confusion. The story of his illness began 30
… or 10 . . . or 3 days ago).
Different histories require different techniques. Sometimes you must divide
the problem into separate and distinct parts. [e.g. “Mr. Jones has two
problems: (a) Longstanding diabetes; and (b) recent ulceration of his foot.
First I am going to tell you about his diabetes, and then I am going to tell you
about his foot.] At other times you must string together an array of
problems in a coherent sequence. (e.g. “Mr. Jones has had an illness that has
two phases. First longstanding abdominal and leg swelling attributed to his
biopsy-proven cirrhosis of the liver and a more recent phase characterized
by tense abdominal swelling, confusion, vomiting and nausea.”)
Always begin with a patient profile. Make it interesting and aim to explain
first WHO has the disease or problem. Try to make this portion of the
presentation interesting. For example:
Mr. Jones is a retired truck driver and former WWII tailgunner
Mrs. Jones is an 80-year old seamstress with 17 grandchildren
Mr. Jones is a lawyer, avid golfer, and Elvis Presley fan
Mrs. Jones is a former New York schoolteacher and political activist
who now lives in a retirement home.
Include information pertinent to the DDx in the HPI. If a patient has chest
pain, include risk factors for CAD in HPI. It is often best to group them
together as pertinent positives and/or negatives. For example, if a patient has
a DVT, include risk factors for clot formation such as use of OCP, prior
DVTs, malignancy in the HPI.
When presenting or writing the review of systems, there is no need to repeat
pertinent positives and negatives already mentioned in the HPI. For example,
it is OK to write: Pertinent review of systems per HPI with these additions.
An important key to making oral presentations is knowing what to include and
exclude.
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Time is of the essence. The length of your presentation should be a maximum
of 5 minutes. The key here is to learn what is important and to present it in a
logical, organized, and sequential fashion. You also must keep the attention
of your audience throughout your presentation. They are more likely to stay
focused if you are organized, tell a story logically and anticipate their
questions and differential diagnosis. For example if you are presenting a case
of chest pain you must anticipate that the reader or listener will want you to
cover the classic differential diagnosis of chest pain in your presentation.
You can modify when/how you present the past medical history, medications,
and review of systems depending on the nature of the problem. (e.g.
sometimes the meds and past medical history are included in the HPI. When
this is the case, do not repeat yourself mindlessly and give the same
information twice).
In general, repetition is boring and bad, but it can be helpful in the
summary. (e.g.” to summarize: Mrs. Jones is a lady with 3 prior admissions
for pneumonia, known bronchiectasis, a recent increase in her chronic
cough, coupled with a two-day history of hemopytsis, fever and dyspnea.”)
Try to commit yourself in the summary to a conclusion and present the case
and the summary in such a way that the audience will easily understand your
conclusion and the reasons for it. For example, if you told a story of cardiac
chest pain, it should be clear to the listeners why you think reflux is unlikely.
Or if you told the story of a patient with vertigo, you should have included
enough pertinent positive and negative information to inform everyone why
you think the cause is most likely a stroke (or alternately benign positional
vertigo).
It is sometimes helpful to quantify symptoms (e.g. Mrs. Jones could climb
two flights of stairs in January but by February she was fatigued and winded
walking from her bed to the bathroom).
Use imagination to tell your story. There are easy ways to keep the listener’s
attention just like there are easy ways to take the history from the patient. A
few simple clues among many include: be enthusiastic, keep it simple, keep it
logical, and make it personal and relate the illness to the person with the
disease. (The latter is a special and very important skill)
Including lab data in the HPI or past medical history is sometimes important
but summarize the results and group them as normal or abnormal and avoid
a long recitation of numbers. This is boring, hard to follow, and usually
demonstrates that you are long on facts and short on synthesis. (e.g. rather
than giving a long list of hemoglobin and blood count results, you could say
“Mrs. Jones was discovered to be anemic in January and one week prior to
admission her anemia had worsened to the point she was severely fatigued.
At that point her hemoglobin was measured at 7 and she was transfused.” Or
say, “During her admission last month laboratory abnormalities included
azotemia, anemia, and thrombocytopenia.”
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Avoid talking about endless visits to Dr. A, then more visits to Dr. B who
gave medicine A and then medicine B. When such information is necessary
and important, edit it tightly and summarize the BIG PICTURE rather than
boring the listener with tiny insignificant details. (e.g. “Prior to admission
Mrs. Jones saw her personal physician three times in a 10 day period, and
she sequentially received an oral cephalosporin, a quinolone and then a
macrolide -- all without benefit.”)
Common errors:
-Lack of a clear-cut chief complaint
-No patient profile
-Jumbled time sequences
-Focusing on the details of prior Rx without discussing symptoms
-Irritating repetition
-Not separating problems into components
-Not preparing the listener where you are going
-Including information that is not pertinent
-Omitting pertinent information
-Making the presentation too long
-Not editing the presentation
-“Spewing facts” about lab tests, CT scans, xrays, doctor visits
without talking about signs and symptoms