The Art of History Taking Kashinath Padhiary
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General Considerations1

 
 
Reaching at the Diagnosis
It is an age old saying that diagnosis should precede treatment. To decide that somebody is suffering from a disease or not, it needs evaluations of all aspects of diagnostic principles. These principles are:
  1. History taking
  2. General physical examination
  3. Systemic examination
  4. Investigations.
Each step has got significance. In some cases history alone may be enough, in some cases systemic examination may yield the maximum information and in the other cases it may be required to ask for a series of investigations. As one proceeds from history onwards, one should assess how nearer 2he has come to the diagnosis at the end of every step. By proceeding this way one can narrow down the differential diagnosis; hence, one can logically plan the line of investigations. Proper planning of investigations is very much required as some of the investigations are costly and some are risky. Over the years clinical diagnosis has been found to be the most cost-effective step in reaching at the diagnosis and it can be utilized anywhere, can be repeated several times. Investigations are not always productive. At times unreliable, at times ambiguous, as there are very few standardized laboratories in a country like India. Whether to accept a report or not, needs detail knowledge of the clinical situation. So one should always try to acquire as much clinical skill as possible. In fact, it has been advised that “no doctor should request any special investigation unless he knows what information relevant to the problem it is likely to provide, and has some idea of its cost and of its possible danger to the patient” (Hutchison, 18th edn, Page 4)
 
Importance of History Taking
With the progress of time, diagnosis of human disease has become easier due to availability of several investigative facilities like X-ray, ultrasound, echocardiography, CT scan, MRI scan and others. However, the value of clinical diagnosis has not decreased. All the investigations are supplementary to the clinical diagnosis only. History contributes the major part to the clinical diagnosis.
In the history taking we evaluate the feelings of a person. There is no machine to measure or assess the feeling of a 3man. At times it becomes difficult for a person to express his feelings in words, sometimes he expresses in gestures and these gestures often give important clues to diagnosis.
The physical examination and the investigations reveal the changes present at the time of examination, does not tell anything about the temporal profile of the illness. But, it is the temporal profile of the illness which is most often required to clinch the diagnosis. This is only brought out by a thorough history taking. Even a probable diagnosis can be known about an illness which occurred years back by detail analysis of symptoms. This importance of history in clinical diagnosis must have been realized by all physicians in their lifetime. However, I want to quote one statement from a leading book on clinical method, Hutchison's clinical method, 20th edition:
“Remember that the examination can only reveal abnormalities present at the time of the examination. The history, on the other hand can reveal aspects of the temporal development of the illness. The history and examinations are thus complementary, but often the history is more important.”
In a neurological case one should be able to give three-fourth of the diagnosis at the end of the history taking. If this has not been achieved, history taking is told to be inadequate (Bickerstaff, 6th edn, 1996; Page 8). The same author has also stated: ‘No one can expect to go through his career and to be right all the time, but most error arise from inadequate taking of history and inadequate physical examination—particularly the inadequate history.’4
It is equally important in a respiratory case also. I have felt that history gives more information in a respiratory case than in a neurological case. Physical findings are often confusing and unreliable. In relation to history in respiratory case, Hutchison states: As with every aspect of diagnosis in medicine, the key to success is a clear and carefully recorded history (20th edn, 1995; Page 141). Another leading author on respiratory diseases, GK Crofton states. ‘In many instances careful history taking is more important than elicitation of elegant, but possibly misleading physical signs’(The respiratory system, Macleod's clinical examination, 9th edn, 1995; page 136). The clinical history and examination are fundamental to assessment of respiratory health even in the epoch of computer-assisted tomography and broncho-alveolar lavage. In deed too great an emphasis on the technology of medicine may lead to atrophy of clinical study and thus a loss of judgment in the assessment of an individual's health (The clinical manifestations of respiratory diseases, Crofton and Douglas's Respiratory Diseases; A Seaton, D Seaton, AG Leitech, 4th edn, 1989; Page104).
In diseases of the Gastrointestinal system too history is equally important. Little information will be obtained by examination of these patients. Pain is a common symptom of intra-abdominal diseases. In patient with abdominal pain, detail interrogation and clinical judgment is essential before investigations are performed. If this is neglected, unnecessary tests may result in the discovery of asymptomatic abnormalities, such as hiatus hernia or gallstones, leading to inappropriate management and even unnecessary surgery. 5(The alimentary and genitourinary systems, MJ Ford, DW Haner Hodges; Macleod's clinical Examination, 9th edn, 1995; Page 162).
From these Quotes from different renowned authors and from the experiences of my colleagues and from my own, I can conclude that in every case history taking is of utmost importance to reach at a diagnosis and for proper planning of investigation and treatment. I shall again re-emphasize the value of history taking in individual chapters.
 
History Taking—An Art
History taking is basically a process of understanding the feeling of an individual. These feelings are nothing but the symptoms of different diseases. Feelings cannot be quantitated, so cannot be always expressed in scientific terms, nor can be satisfactorily expressed in words. Scientific understanding of a disease is nothing but understanding the bodily changes in terms of changes in anatomy and physiology. History taking not only tries to assess the bodily changes but also its affect on mind. So, while taking history, look for the affect of the illness on the mind in addition to its affect on the body. This can be done by looking for the nonverbal communications and the body language. In fact, there may not be any physical ailment at all, yet the patient becomes symptomatic and the significance of these symptoms can be known from the body language. How to study the body language and the emotional aspect of an illness cannot be taught theoretically, hence, this has to be learnt by seeing patients under guidance; so this becomes an art.6
To take a good history, one has to go down to the level of the thinking of the patient. The words the lay man uses, one has to understand clearly what he means by that. One has to know the exact nature of the work of the patient and how the illness affects his day-to-day work. Understanding the language of the patient is mandatory for correct assessment of the history. This is particularly true for a country like India, where people use several languages. Even in the same language there are several colloquial words and terms which are also to be understood clearly. Whenever required the help of a good interpreter should be taken.
Because history taking is basically a mode of conversation, so the doctor should encourage the patient to speak freely without any reservation. An environment for free talk should be created. You have to ensure him that you also feel for his illness and you are there to help him. Remember that while you are taking history the patient also marks how attentively you are listening to him. If you show dissatisfaction or displeasure repeatedly, he does not feel like talking and may give a confusing history. Similarly if your attention is diverted frequently to other things while listening to the patient's complaints, he feels that you are neither interested nor attentive to his problem. Due to this type of attitude, patients lose faith in the doctor even if he has diagnosed and treated correctly. I remember a father took his young son to a renowned physician. The consultant wrote the age of the child to be one and half years instead of one and half months and accordingly prescribed the drugs. This was noted by the father after coming out of the consultation chamber. 7He returned back and pointed it to the doctor, but the doctor did not take it seriously. The father lost faith in the doctor and did not follow the prescription. The father had also marked that while the doctor was taking history of his child he was often talking to others. This example speaks that patients do notice how attentive you are to them. So, while consultation is being done too many outsiders should not be allowed. This will make the patient nervous, likely to divert the attention of the doctor and the patient will not feel free to speak, particularly matters related to sex and personal life.
Like any other art, practice makes a man perfect, so also in the art of history taking one has to practice daily to improve. More one feels for the patient, more one gets involved with the patient and more one can extract the information from the patient.
Often people do not know what to tell before a doctor and do not understand which part of the history is to be elaborated. This is either due to illiteracy or due to nervousness. Whatever may be the reason it is the duty of the doctor to collect a reliable history. To eradicate the initial anxiety and nervousness from the patient's mind try to greet the patient by name whenever possible. Try to discuss topics unrelated to his ailment. Like commenting on the dress, asking about his children in case of elderly people, school and education in case of school-going children. At times these discussions can reveal key points. If the patient is giving the unnecessary details of a minor point, instead of getting irritated on him, listen to him patiently and simultaneously ask the details of the points which you feel to be important. Often 8patients try to speak medical terms without knowing their significance and meaning. They should be dissuaded from this. At times patients tell more about their treatment than about their illness. This should be discouraged also. Also there are patients who show several consultation papers without telling much about their illness. Tell them to show the papers at the end of the consultation, because these papers are likely to misguide the examiner. However, these papers have their own importance which will be discussed later. I always recommend students to evaluate the cases independently so that they can assess themselves after going through the papers of experienced consultants.
Never show dissatisfaction or displeasure in words or in action while listening to the patient. For example, if a patient passes urine or vomits before you, remain quite, ask the attendant to clean the patient and the room, ask the patient to relax on a bed for some time and then discuss or examine him later. Similarly, if there is a foul smelling ulcer or foul breath, do not sniff or spit before the patient. These cases are often discarded by the family members and friends; their only hope is the doctor, that he will be able to do something to get rid of his problem, so that he will be able to go back to social life. Instead, if he feels that the doctor also dislikes him, he may not feel like living and may attempt to commit suicide.
The doctor is in an advantageous position; rather he is in a better position than other relatives including parents to know the facts about the patient. The facts which are not told to the relatives may be revealed to the doctor. Grown up children will not like to undress before their parents, but 9will not hesitate to do so before the doctor. That the doctor is in an advantageous position, he should not take its undue advantage. One has to maintain the privacy of every patient and the secrecy of facts revealed to him should be maintained. It is a common experience that often doctors become good friends of many patients, particularly elderly people. These people often express unnecessary details of their family matters.
 
Sequence of History Taking
Traditionally after collecting biodata, which includes age, sex, religion, address, occupation; the chief complain, history of present illness, history of past illness, family history, personal history, menstrual and obstetrics history and treatment history are to be taken. However, this scheme need not be strictly followed while applying on an individual case. In fact, some authors recommend taking past history and family history earlier than the present illness. This helps to understand the person and his illness more completely and more clearly. I personally agree with this recommendation. I am giving two examples here how this is helpful.
Suppose, a case of rheumatic heart disease complains of fever for fifteen days and gives history of dental extraction twenty days back. Here fever is the present illness and tooth extraction comes under the past illness. If this case is presented in a sequence like – a case of known rheumatic heart disease had tooth extraction twenty days back and having fever for fifteen days, it appears that this patient is suffering from infective endocarditis.10
Similarly, if a woman comes with unconsciousness and is pregnant also, it is better to tell from the beginning that ‘a pregnant lady coming with loss of consciousness for so many days duration’. Here one need not wait for obstetric history to mention about her being pregnant. Presenting this way will make the clinical situation clearer.
It is not important in what order history is collected provided one does not miss any point and the examiner has been able to understand every aspect of the history. In fact, in nervous patients it is wiser to discuss his personal life earlier than about his illness, so that the patient gains confidence and tells the history clearly. However, for beginners it is better to stick to the sequence, so that they will not miss any point. Similarly in critically ill patients few points from history should be collected and no delay should be made to institute the first aid to save the life of the patient. Once the condition of the patient is stabilized details of the history can be collected. One should not waste time in getting unnecessary details of the history when the patient is in a gasping state. Here are the situations where treatment precedes the diagnosis, though in most other situations diagnosis should precede treatment. I have seen students taking history from the relatives while the patient is already dead.
 
The Leading Question
Ideally patients should be asked to narrate their story in their own words. Leading questions are not to be asked. Leading question is that which suggests its answer, usually as yes or no. But many patients do not give a cohesive history. These 11patients require asking some direct questions, often as leading questions. The physician has to be very careful in accepting the answers to leading questions. These answers should be cross verified, about their reliability. Because, often the patient replies in yes, to emphasize his complaints and replies in no if he wants to hide some points. In fact, some authors say that the best physician is he who can interpret the leading questions.
 
From whom History to be Collected
Under ordinary situations patient himself should be asked to tell the history. Often relatives of the patient try to interfere in history collection. This should be discouraged. Even the most uneducated patient can tell about his illness with a little guidance from the doctor.
In case of a child, history should be collected from the parents, preferably from the mother. If detail of the illnesses of childhood is required, this can be collected from the parents or from any other senior family member who knows about his childhood.
In unconscious patients history should be collected from the persons who were present during the onset of the illness (often this gives clue points to diagnosis). He may be family member, room mate, class mate, colleague or teacher.
Similarly in patients with transient loss of consciousness like epilepsy or transient ischemic attack history should be collected from an eyewitness. Mentally retarded, deaf and dumb person's history should be collected from the people who ordinarily take their care. Because, they can notice the 12slightest changes in their activity or notice the symptoms of illness at the earliest.
 
Observing for Nonverbal Communications
While the patient is telling the story, observe the patient closely. The words he uses, the emotional attachment to the words, movement of hands and other body parts, etc. should be marked.
For example, while describing the anginal pain the patient may start weeping, which signifies the severity of pain. Simultaneously if he is moving his hands over the sternum, implying that the pain is retrosternal in site. If the patient is moving his hand over a wide area on the abdominal wall while describing abdominal pain, it is likely that the pain is not localized. If he points the site of pain with a finger, it is a localized pain as seen in pleurisy. If a patient is groaning with abdominal pain likely that it is a colicky pain. If a patient comes with a cloth tied over the head or on the abdomen very likely he is having headache or colicky abdominal pain respectively. If a patient is talking in a loud voice he is either nervous or deaf. If a patient is talking in a low voice, often looking at this side or the other, probably wants to speak something about sexual problem. If a patient is wearing a warm dress in summer season likely that he is having a chilly sensation (possibly due to fever). If a patient is not able to complete a sentence in one breath his vital capacity is low. If the patient is giving extensive details of his illness and treatment is likely to be a hypochondriac. At times patients produce a list of complaints often as many as ten to fifteen 13of them. It may be so that, none is genuine, suggesting that they are hypochondriac too. A patient of polyuria may come with a bucket of water with him because excessive thirst and non-availability of safe drinking water on the way. If a patient comes with a stick, it is likely that he is not sure of his stance or gait (either due to weakness or due to ataxia).
Chronic bodily illness often puts its impact on the mind. These patients move from doctor to doctor and if still don't get relief; they get depressed (thinking that they are suffering from an incurable disease). The depressed mood can be noted from their face and from their mode of talk. Likewise there are many more things which can be observed while taking history.