1.1 The consultation
Most consultations between a clinician and a patient follow a very structured pattern: an introduction is followed by a thorough history, which explores the patient's ideas, concerns and expectations (ICE). The patient is examined and a differential diagnosis formulated. Investigations are then organised, when necessary, and a treatment plan is put in place. Over 80% of diagnoses in general medical clinics are based on the medical history, so it is of paramount importance to focus time and energy on becoming a good history taker.
At the beginning
Taking a history is not only the key to clinical diagnosis but also the start of the ‘doctor–patient’ relationship. Every consultation should start the same way:
- Wash your hands
- Always come to the door to greet the patient. Never greet a patient sitting down, unless you are unable to stand
- Introduce yourself, your role and designation (in lay terms)
- Find out who the patient is (biographical details): the mnemonic DNA SORAN (Table 1.1) can be used. These elements don't all have to be taken immediately (name and age are a minimum), but it is appropriate to take them during the social history. You may ask the patient how he or she wishes to be addressed
Open and closed questions
Doctors generally interrupt their patients after 18 seconds. This may be necessary in order to guide the consultation, but 2usually it is out of impatience and can significantly reduce the chances of identifying the correct diagnosis. This is difficult because, if allowed to, some patients continue talking for excessive periods with too much detail. You will soon learn key phrases to try to bring them back to the task in hand, e.g. ‘Coming back to your chest pain, have you noticed…’
Questions can be classified as either open or closed:
- An open question is non-directive and allows the patient to give information freely, e.g. ‘Why don't you tell me what's been going on?’. Patients can report information that is most important to them and also give their own version of events, in their own words. Open questions work only if you are ready to take the time to listen. Use active listening (see below) to encourage the patient to keep speaking
- A closed question elicits an answer such as ‘yes’, ‘no’ or something else factual, e.g. ‘Does the pain move from your chest into your neck?’.
Use a funnelled approach to your consultation, starting with open questions and leading into closed questions.
Active listening
Active listening is a way to show patients that you are taking a genuine interest in what they are saying. This not only makes them feel valued, and improve the doctor–patient relationship, but also encourages them to be honest and forthcoming. Here are a few key ways of listening actively:
- Lean forward
- Make eye contact
- Nod
1.2 General principles of history taking
Over time you will develop your own style for taking a history. There are, however, key areas that must be covered, these include (Table 1.1):
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- History of presenting complaint (HPC)
- Past medical and surgical history (PMH/PSH)
- Drug history (DH)
- Family history (FH)
- Social history (SH)
- The patient's knowledge, feelings, ideas, concerns and effects or expectations
- Review of systems
Taking a history is an inexact process. Two histories from the same patient on two different occasions will not necessarily be the same. For example, after a history has been taken, a patient may report new or completely different symptoms when a colleague joins the consultation.
Environment
Most consultations occur in outpatient or family medicine clinics. Wherever they occur, the environment should be made comfortable and secure.
On a ward, curtains offer little confidentiality and this should be taken into consideration when taking the patient's history, because he or she will be unlikely to disclose embarrassing or intimate information.
Position yourself in an open and non-threatening position. Standing over a patient can be intimidating. Try not to position desks or beds between you and the patient. Use space in a way that makes the patient the centre of your attention. If consulting a threatening patient, never position yourself so the patient is between you and the exit.
Cultural differences
People from different cultures have different ideas surrounding healthcare and different ways of explaining their illness. For example, a patient without anatomical or health literacy may say, ‘I have all-over body pain’ but in reality mean that they have a dull pain and stiffness in their joints. These are not classic symptoms described in textbooks and as a result can be confusing, frustrating and time consuming for the clinician. An 5in-depth exploration may clarify these misunderstandings; use narrow ended questions and ask the patient to show you what they mean or give you specific examples.
A patient's ideas surrounding healthcare influences their understanding of the cause of their illness, and what treatments they believe will work (see Ideas, concerns and expectations, page 16). If the patient does not agree with or understand your model of healthcare delivery, they may not accept the investigations or treatments you recommend. In order to overcome these challenges it is helpful to show understanding of the patient's beliefs, educate them on alternative diagnoses and treatment plans, and be flexible in one's own idea of treatment plans.
Using an interpreter
It is your responsibility to determine whether an interpreter is needed. An interpreter may be needed if English is the patient's second language; the patient relies on family members for interpretation; or if the patient gives inappropriate response to questions. It is ideal if the interpreter is present in the clinic, however alternative telephone or video interpreter devices can be used.
- Take time to prepare; it may help to give the interpreter a brief explanation about the patient's medical condition prior to the patient's visit
- Ensure that the interpreter and patient do not know each other (this is common in small communities with unusual languages) and that the patient is comfortable with their interpreter (for example, a woman may not be happy having a man interpret for her in a gynaecology consultation)
- Speak directly to the patient (i.e. ‘how long have you had a cough?’) rather than the interpreter (‘ask the patient how long they have had a cough’)
- Look at the patient when you are speaking to them, not the interpreter
- Use short, simple sentences and avoid jargon and acronyms
- Pause for interpretation. Even if you are busy, don't speak over the interpreter because they cannot listen and speak at the same time
Presenting complaint
The PC is the problem – or set of problems – that caused the patient to seek help from a doctor. Patients often have more than one problem and each of these should be listed one by one. A good opening question might be ‘What seems to be the main problem today?’.
History of the presenting complaint
Take your time to elicit details on each of the presenting problems. As you take more histories you will become skilled at directing the consultation based on the information the patient gives you. Initially it may be worth memorising a useful mnemonic such as OPERATES+ to ensure that key points are 7not missed (Table 1.2). Obtain details for each of the presenting problems. As you progress through the history, further problems may be identified that the patient did not initially report or identify as problematic. When a patient has several problems, it can be helpful to say that you will go through each problem in turn. That way each issue can be explored systematically and thoroughly without missing anything. A useful mnemonic for taking a pain history is SOCRATES (Table 1.3); this identifies all areas related to pain, but miss key features in alternative presentations.
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Past medical history and past surgical history
Some clinicians prefer to take the PMH before the HPC. This enables them to develop a clear sense of what are current and what are past problems. If you choose to do so, explain to the patient: ‘Before we discuss why you came today, I wanted to ask you some background questions. Would that be okay?’.
Start by asking an open question such as ‘Have you had any serious illness in the past?’. Patients often omit or forget important information. This is often because of the way in which a question is posed. Use several different questions to ensure that the patient understands. Similarly, use several different questions to elicit the past surgical history, e.g. ‘Have you ever seen a surgeon?’, ‘Have you had any operations?’ and/or ‘Have you ever had an anaesthetic?’.
Specific past medical history
To finish, it is worthwhile asking a series of closed questions to identify any common or significant problems. A useful mnemonic is JADE CAT MARCH (Table 1.4).9
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Drug history, allergies and immunisations
Drug history
It can be useful to start this section with the questions ‘Do you have your medications with you’ or ‘Do you have a copy of your prescription?’. Patients often find it difficult to remember the medications they are taking or have taken in the past. Taking a drug history can therefore be one of the most difficult parts of the history.
It is essential to know:
- Which medication(s) they are currently taking
- Which medication(s) they have previously taken
- Why each medication was started
- At what dose it/they have been prescribed
- In what preparation(s) it is given
- The effect that the medication(s) has had
In addition, identify use of:
- Inhaler, cream, patch or suppository
- Over-the-counter medications
- Herbal and complementary medications
- Medications prescribed for somebody else but taken by the patient
- Contraception – including implants and injections (patients don't often think of these as medications)
Use this opportunity to check for compliance by asking patients if they take their medications as prescribed, e.g. ‘How often do you forget to take your medicines?’. This is important for medications that may have been stopped by the patient because they have had ‘no effect’. This can become evident for the first time in a patient who is admitted to a ward and has supervised medication administration, e.g. an elderly patient who becomes hypotensive because he is given the high-dose beta-blocker that he had not been taking at home.
Patients may be taking several different medications, each with its own side-effect profile. This can add to the symptoms that they have and also cloud your differential diagnosis.10
Allergies
Reactions to drugs can range from life-threatening anaphylaxis through to mild side effects that have been misinterpreted by the patient. Ask the patient several questions to clarify this part of the history:
- ‘Do you have any allergies?’
- ‘Have you ever had a reaction to a medicine that you have taken?’
- ‘What happens to you when you take this medicine?’
Immunisations
An immunisation history should be taken if it is relevant to the case. This is particularly important in children. For an elderly patient or anyone with chronic disease, ask if he or she has had the influenza (flu) immunisation. The World Health Organization recommends a minimum schedule of immunisations in all countries, with extended schedules for country-specific diseases.
Family history
Ask questions such as: ‘Are there any illnesses that run in your family?’ or ‘Has anyone in your family had a similar problem?’. Taking a family history can also help identify any concerns that the patient may have.
How to draw a family tree
If necessary, draw a family tree (Figure 1.1) to help map the possible inheritance of the disease.
Social history
Determine:
- Employment (past and present)
- Housing type and with whom the patient lives
- Social support
- Restrictive or unusual diets
- Stresses at home and/or work
- Restrictions on activities
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A good understanding of the patient's background helps to form a diagnosis and an appropriate management plan.
Basic activities of daily living and instrumental activities of daily living
Basic activities of daily living (BADLs) (Table 1.5) are used to describe a patient's functionality in self-care tasks. Instrumental activities of daily living (IADLs) describe the ability to maintain an independent household. If a patient is unable to perform any of these tasks, identify what factors are limiting their ability to do so. These assessments are not only good 12measures of how a disease is impacting on a patient, but also of the support he or she needs in order to return home independently.
Faith or spiritual history
Taking a faith history requires permission, sensitivity and respect. Not only does it help us to know more about our patients, but it also guides decision-making during the practice of evidence-based medicine (e.g. a Muslim may wish to be offered low-molecular-weight heparin that is non-porcine in origin).
How to take a faith or spiritual history Here are some examples of appropriate questions to ask patients about their spiritual ‘health’:
- ‘It would help me to treat your medical problem better if I knew more about you.’
- ‘Do you have a personal faith that helps you (in a time like this)? How does it affect your life?’
- ‘Do you belong to a faith community? Some people find it helpful to meet with someone. Would you like us to arrange this for you?’
Smoking, alcohol and illicit substance use
Smoking – what is a pack-year?
Quantify smoking in terms of pack-years: 20 cigarettes per day for 1 year equates to 1 pack-year (e.g. 15 cigarettes per day for 4 years is equivalent to 3 pack-years). Also ask about other tobacco products.13
Alcohol
The effects of alcohol on health are enormous, including acute intoxication and chronic disease (e.g. liver disease and psychiatric problems such as addiction and depression). Alcohol also leads to social problems such as reduced productivity, violent crimes and antisocial behaviour. Many patients who are alcohol dependent will enter a stage of withdrawal in hospital if this area is not appropriately investigated. Ask questions such as:
- ‘How much do you drink each week?’
- ‘Have you ever been a heavy drinker?’
- ‘What is the most that you drink in one go?
When documenting the history, report alcohol use in units per week and state if evidence of bingeing is present. One unit of alcohol is equivalent to 10 mL of pure alcohol, so:
Units = alcohol by volume (%) × volume of alcohol (mL) ÷ 1000
Therefore 125 mL glass of 14% white wine is equivalent to 1.75 units alcohol. Be sure to clarify how much a patient means; for example when a patient says ‘a whisky a night’, is this a standard 25 mL measure or a larger shot poured by the patient? A simple and non-judgmental way of asking this is ‘How quickly do you finish a 75 cL sized bottle of whisky?’.
There are several quick and easy scoring systems for assessing possible alcohol dependence:
- The Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization and comprising 10 simple questions, each scored on a 0- to 4-point scale
- The Fast Alcohol Screening Test (FAST), developed from AUDIT and having four questions scored according to how often a prespecified alcohol-related event occurs (e.g. memory loss about the previous night)
- CAGE, developed at the North Caroline Memorial Hospital in the USA and containing just four questions, mainly covering the patient's emotions in relation to drinking, requiring yes or no answers
Binge drinking (heavy episodic drinking) is drinking heavily in a short space of time in order to get drunk or feel the effects of alcohol. UK researchers commonly define binge drinking as consuming more than 6 units of alcohol in a single session for men and women.
Illicit drugs
Reassure patients that any information they give you is confidential. Asking direct questions often leads to an immediate denial, so indirect questioning can be useful e.g. ‘What drugs have your friends tried?’, ‘… and you?’. Once you have gained the patient's confidence, establish:
- Which illicit drugs have been used
- When and for how long
- How much and how often
- How they were taken (i.e. orally, smoked, injected venously, injected subcutaneously)
- What the impact has been on his or her health and life
Nutrition
There is a clear association between nutrition and health. A nutrition history may be necessary if a patient is undernourished or overweight. A good nutrition history is important for giving lifestyle advice as part of preventive medicine.
Nutrition history
- How many meals and snacks do you eat each day?
- How many times a week do you eat away from home? What do you eat?
- On average, how many pieces of fruit or glasses of juice do you eat or drink each day?
- On average, how many servings of vegetables do you eat each day?
- How much fibre do you eat?
- How many hours of television do you watch each day? Do you snack during viewing?
- How many times a week do you eat desserts and/or sweets?
- What types of beverages do you drink, how much and how often?
- How much alcohol do you drink?
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Review of systems
Start with a statement such as: ‘I am now going to ask you some specific questions’. A comprehensive list of symptoms is given in Table 1.6. It would be almost impossible to go through the entire list with all patients. As you start learning to take histories try to be as comprehensive as possible. With time your ability to focus your review of systems, dependent upon the HPC, will improve. Use lay terms when questioning the patient.
Ideas, concerns and expectations (ICE)
Explore the patient's ICEs. Although this is part of the history, some clinicians ask about ICEs at the end of the consultation, once they have examined the patient and before discussing the management. This is a matter of discretion.
Ideas
- ‘Do you have any thoughts about what could be causing your symptoms?’
Concerns
- ‘Is there anything in particular that you had in mind when you came to the clinic today?’
- ‘Is there anything in particular that is worrying you about your symptoms?’
Expectations
- ‘Was there anything that you were hoping we might be able to do for you today?’
Common pitfalls in history taking
There are many pitfalls that can reduce your chances of obtaining an accurate history. There are three common pitfalls made by clinicians when taking a history.
1. Anchoring
This is a mistaken latching on to an early piece of information. For example, if the nurse says ‘Can you see the patient with asthma in room 4’, there is a danger of focusing on the history around this early suspicion of asthma. Closed questions may confirm early suspicion of asthma and minimise other symptoms or signs that suggest that the diagnosis is something different.
2. Availability
You may have recently seen a case that is particularly dramatic, or lots of cases of a particular diagnosis, so may fall into the pitfall of availability, e.g. having recently seen several cases of oesophagitis, you may falsely diagnose your next patient with chest pain as having oesophagitis.18
3. Attribution
You may immediately make judgements about a patient on first encounter, e.g. if a 22-year-old student presents with vaginal discharge, you may falsely assume that she has a sexually transmitted infection.
Clinical examination
Examination of the patient is covered in Chapters 2–14. Before progressing to the examination, it is worthwhile summarising the history back to the patient. This gives him or her the opportunity to confirm whether your version of events is correct and provides reassurance that you have listened to all of the problems.
1.3 Forming a differential diagnosis
The differential diagnosis
The aim of the history and examination is to formulate a diagnosis while also planning possible investigations and treatments. A differential diagnosis is a systematic approach used to identify the true diagnosis among many other alternatives, known as the ‘differential diagnoses’ or ‘differentials’.
There are a series of steps in formulating and acting on a list of differential diagnoses:
- Gather all the information from the history and examination to form a list (mental or written) of symptoms and signs
- List all the possible causes for these symptoms and signs
- Prioritise this list based on the most urgent or life threatening and those that are statistically the most likely
- List investigations and treatments that should be drawn up, which will either confirm or rule out diagnoses, while treating any active or life-threatening symptoms
This is a complex process of mental reasoning and takes clinicians years to perfect. Using a mnemonic (‘surgical sieve’) can be useful in helping to draw up a list of differential diagnoses.
An easy mnemonic for remembering a surgical sieve is VITAMIN CDE:
- Vascular
- Inflammatory (infectious and non-infectious)
- Autoimmune
- Metabolic
- Idiopathic
- Neoplastic
- Congenital
- Degenerative
- Environmental
Multiple causation
Symptoms and signs rarely give a single clear diagnosis that immediately responds to a single treatment. Often symptoms can be multi-factorial in nature, e.g. a patient may have lower back pain due to a strained muscle and depression. The depression causes an exacerbation of the symptoms of the back pain, in turn exacerbating the depression because the patient may stop leaving the house because of the pain.
Management
The term ‘management’ is used to describe a combination of the investigations and treatments that are offered to the patient. Document which investigations you would like to perform and what treatments you would like to start immediately.
Planning investigations
Investigations are tests that can be used to define and measure the extent of a diagnosis and/or measure the progress of a disease and the response to treatment. Investigations should be ordered carefully based on the differentials. Patients should not receive a ‘blanket’ series of tests in the hope of unearthing something. Rather the investigations ordered should be rationalised and justified. When deciding which investigations to order, one should consider the following:
- How will the results affect the management of the patient?
- Are there any risks to the test?
- What specimens need to be taken and is it possible in this patient?
- Does the cost of the test warrant its use?
1.4 After the consultation
At the end of any consultation explain to the patient:
- What you have found during the history and examination
- What the likely diagnosis is and any possible alternatives (differentials)
- What tests, if any, are required, what they involve and how accurate they are
- What treatments can be started, how these work, how they are taken and what side effects may be seen
Documenting in medical notes
Writing good notes that are contemporaneous (Figure 1.2) helps process your thoughts and plans, records what has been done and aids communication with your colleagues.
During the first consultation, often referred to as ‘the clerking’, the documentation follows the same structure as the consultation, i.e. PC, HPC PMH, DH, FH, SH, examination, differentials, management. Documentation is said to be contemporaneous if it is made at the time of, or as soon as possible after, the consultation (Figure 1.2).
Presenting patients to colleagues
Presenting a case to a colleague or senior improves not only your own learning but also patient care. Presenting a case should follow the same structure as the consultation (Figure 1.3).
1.5 Evidence-based medicine
Definition and clinical relevance
Evidence-based medicine (EBM) is the integration of the current best research evidence (e.g. journal articles) with our own clinical expertise, along with the values that are unique to our patients. A common misconception is that EBM is a process of substituting our clinical expertise with research. In reality EBM is a process that combines three key principles:
- Clinical expertise
- Patient values, circumstances, expectations and beliefs
- Best available research evidence
Key principles of EBM
Clinical expertise
Clinical skills are enhanced by the experience of seeing patients. Underpinned by good communication skills, a thorough history and examination not only assist with differential diagnosis but also allow you to ascertain the patient's personal values and expectations (Figure 1.3). It is impossible to practise EBM without good clinical skills, e.g. without a correct clinical diagnosis, a clinician will search the wrong research evidence.
Patient values, circumstances, expectations and beliefs
Patient values are the unique preferences, concerns and expectations that each patient brings to each clinical encounter. These must be woven into clinical decisions to best serve the patient, e.g. the patient with hypertension in Figure 1.4 may have osteoarthritis and find an exercise ECG painful and stressful.
Best research evidence
This is clinically relevant research that has been evaluated to assess whether it is of high quality and that it is directly relevant to the patient. It could give you information about diagnostic tests, prognosis or therapy.23
Five steps for practising EBM
There are five steps in practising EBM (Figure 1.4):
Step 1 – Ask: convert information needs into questions
24Step 2 – Acquire: identify the best evidence to answer the questions (whether from the clinical examination, diagnostic laboratory, published literature or other sources)
Step 3 – Appraise: critically appraise this evidence for its validity (closeness to the truth) and usefulness (clinical applicability)
Step 4 – Apply: apply the results of this appraisal in our clinical practice
Step 5 – Assess: evaluate our performance
1.6 Ethicolegal considerations
As a clinician you are expected to adhere to a certain code of practice. This involves the following principles:
- Keep your knowledge and skills up to date, always working within the limits of your competence
- If you think that patient safety or dignity is being compromised, take prompt action
- Always treat patients as individuals and maintain confidentiality
- Work in partnership with the patients, enabling them to make decisions about their care
- Finally, never discriminate unfairly against patients or colleagues, or abuse a patient's trust
In the UK this is outlined by the General Medical Council's Duties of a Doctor.
Four pillars of medical ethics
There are four pillars of medical ethics: autonomy, beneficence, non-maleficence and justice. Doctors should also reflect on the scope of application of these principles.
Autonomy
Autonomy is the capacity for self-determination. It is the right to choose what you want, for yourself, in an unbiased environment. A decision made by an individual may not appear rational but this does not mean that the individual is therefore incapable of acting autonomously or that he or she does not have capacity.25
Beneficence
Beneficence is the concept of acting to benefit an individual or a population. In treating a patient autonomously consider that one patient's beneficence may be another patient's maleficence.
Non-maleficence
Non-maleficence is the concept of ‘doing no harm’, e.g. stopping a medication that has no benefit but has side effects. Whenever doctors try to benefit a patient (beneficence) there is always the possibility that they may harm them (maleficence); there should always be a ‘net benefit’ for the patient.
Justice
Practise in a manner that is fair to all. This should include distributive justice (the fair distribution of resources), respect for people's rights and respect for morally acceptable laws.
Other ethical principles
Best interests
Work with colleagues in ways that best serve patients’ interests.
Confidentiality
All parts of the medical consultation are confidential. There are few cases when confidentiality can be relaxed (see Clinical insight box).
Capacity
In order to have capacity, a patient must be able to:
- Understand the information relevant to the decision
- Retain the information
- Use that information as part of the decision-making process
Key legal concepts
Legal standards vary in different countries. The concepts here describe the general principles that are held to be true in the UK.
Consent
Consent is the process of gaining approval or permission after thoughtful consideration. Consent can be implied, verbal or written. Consent is valid if: (1) the patient has capacity, (2) the patient was sufficiently informed, and (3) the consent was voluntary and not coerced. Consent is often regarded as a legal expression of autonomy.
Decisions relating to cardiopulmonary resuscitation
Respect the desires of well-informed patients who do not wish to undergo cardiopulmonary resuscitation. This may appear to be a difficult consultation, but most patients who are near the end of life have a desire to discuss the pertinent issues. It also opens a door to a discussion between a patient and their loved ones about their current clinical condition. Clinicians should assist their patients in this discussion.
Treat patients with respect
In order to treat a patient autonomously, you must treat patients with respect regardless of their religion, sexual orientation and life choices. You must not unfairly discriminate against them by allowing your personal views to adversely affect your professional relationship with them or the treatment that you provide or arrange.
Probity
Probity means being honest and trustworthy and acting with integrity; this is at the heart of medical professionalism be courteous. Let people talk, and show them that you are listening to them carefully:27
- Give unbiased advise
- Encourage patients to participate actively in all decisions related to their health and support these decisions even if you disagree with them
- Accept death as a part of life and help people make the best possible arrangements when death is close
- Work cooperatively with other members of the healthcare team
- Live a balanced life and care for yourself and your family as well as your colleagues