History Taking1

Proper history taking helps a clinician to come to 60-70 percent of the diagnosis of a clinical illness/problem.

Most of the medical introductions or consultations between the patients and the clinicians occur in the out-patient setting. The achievement of confidence and the assessment of personality and social skills of each patient can be done here. Either the doctor must himself go to fetch the patient from the waiting room or the patient may be brought into the consultation room by the nurse or receptionist (which is usually seen). This creates a friendly atmosphere and the patients too feel assured of being at the right place. Introduce yourself and greet the patient gently. Try to observe his response. Does the patient smile or look frightened or anxious? Does he make good eye contact? Is he depressed or normal? Do you find any signs of breathlessness? You may try to feel his body temperature when you give him a handshake. Always handshake by using both the hands of yours. By this, the patient gets a feeling of being at your concern and care (and your main purpose of feeling the temperature is also solved). Pleasant surroundings are very important. Both, the consultant and the patient, should feel at ease with each other. Always try to make the patient to sit to your left. This makes your observation more accurate and even better.

The process of observing the patient must begin right from the moment he walks into your chamber. While communi-cating with him, try to make judgments about the patient’s general demeanour. Does he present himself in a clean, well-spoken, intelligent manner? Do you find any signs of disability, whether mental or physical? What does the gestural language of the patient says? Is the patient confident, knowledgeable or perhaps depressed and miserable? Does he or she describe his/her problem in a relevant manner? Is there any embarrassment about something that is not spoken of ? Is the patient talking about the things that really bothers him? Have a look over the patient’s clothes and belong-ings. This tells a lot about your patient’s language, interests and educational level. Try to explore the patient’s knowledge about his own illness or disease.

A good clinician always likes to spend some time during the initial exchange of greetings to know and identify who is present and to get some idea of the persons accompanying the patient. Identify the seniormost person present. Try to know the expectations of this consultation. Inquire whether the patient has taken medical care of any other physician. Assure him that it is only to make his treatment better and successful. Make sure why the accompanying persons wish to be present, and, certainly, whether this is also the patient’s wish. Sometimes the information obtained from a concerned and observant relatives may be of great importance to you. But avoid unnecessary interpretation by them.

Never try to start the interview immediately. It is better to engage in certain preliminary exchange of ideas. This way, the patient will be at ease and this will also lend you the way to go confidently. At times, you may try to create some humor (of course, after judging the mood and condition of the patient).

A word of caution—always check that you have the right patient—there may be many patients of same name or same surname (for example, there may be many Mr Sharma or Mrs Shrivastava waiting for you). Check the address, date of birth as well as name. Also, have a look at the patient’s papers and hear what the patient has to say. Let communi-cation be a two-way process.

Always try to tell your patient that you expect him to talk freely. Assure the patient that you will be able to reach to the correct diagnosis only if he narrates to you the complete and detailed facts. Assure him that his secrets will not be disclosed to anybody and he/she is in the safe hands.

From the patient’s perspective, the most important compo-nent in the process of history taking and clinical examination is “the explanation.” The clinicians who are gentle, patient, interested and kind to the patient, those who encourage the patient and relatives to ask questions and who spend the time explaining the situation in a way it is understood are regarded as “good doctors”. A clinician, who readily accepts his mistakes instead of trying to hide it, is more respectable in the eyes of the patients and his relatives. He should assure them that still many “good things” can be done for the patient. He should well explain the patient and his relatives about the illness of the patient.

Every medical student should try to make his best efforts at good history taking and thorough and complete clinical examination. If the students are asked by a patient to give a medical opinion, they should gently remind the patient of their status and suggest them to undergo a more useful consultation with the doctor. Alwaysremember that an undergraduate medical student is not there togive opinions or medication to the patients. He is supposedto examine the patients, to observe them,and then finallyreport to a senior doctor about the findings in thepatients and learning more about the cases.

Try to keep eye contact with the patient while making notes. Do not be in a hurry to make notes. First listen carefully to the patient, make up your mind what is being said and record enough (in the form of the points) to help you remember the important points narrated by your patient. Later, you can make a detail out of these points. Always use the words narrated bythe patient. Never try to use medical terminology for thecomplaints described by the patient until and unless you arevery much sure about that. For example, never use the words like vertigo for “chakkar” or dyspnea for “difficulty in breathing.” The same is to be applied while talkingto the patient.

You will always find time and place for direct questions in history taking. Direct questions are indeed an essential component of relevant history taking. A good physician always stores up the direct questions until the patient has finished talking. If you are not sure of something, ask for more details. If you have noticed an abnormality not mentioned by the patient (for instance, a swelling, a rash, an abnormal posture, a visible scar mark, etc.), ask about it directly. Now if you think that you have a clear understanding of the patient’s complaints, you should take each main symptom in turn and have a detailed examination. Some examples of direct questions are:

Have you ever coughed blood?

A vigilant doctor will always try to look for non-verbal clues. Look at the facial expressions of the patient. Whether it shows any signs of grief, tiredness, stress or anxiety. Does the patient catch his breath, appears confused, has abnormal breathing pattern, looks pale or flushed, is restless or shows any abnormal body posture or body movements? Does he catch hold his head while speaking or takes along pause to narrate the next point to you? Always behave peacefully with such patients. Be sympathetic to them. Try to know the causes of his worries; and if possible at your level, try to solve his problem. You should put your pen down and listen carefully to the patient and you should give an eye-contact to the patient. Many a times, it may happen that the points which the patient is narrating to you may not be useful for 3 you or for your process of history taking. In such a case, you should be at your norm and should peacefully try to explain him what you expect him to tell to you. Many patients have the habit of telling about their complaints in an exaggerated manner in order to gain your attention. They may complain of “all the time” pain or headache or they may complain of having anorexia or abdominal discomfort for last few weeks. Indeed, in spite of his exaggeration, the complaint is real (no doubt, it may be of mild degree), but you should definitely pay your full attention to it.

Many a times, the patient may be so frustrated and worried about his problems, or he may be waiting for his turn since long, that he may burst open on you. In such a situation, you should handle the patient very gently. After the day’s tiring work, itmay seem difficult for you, but remember it is notimpossible. Always try to have a soothing attitude. After all, you are there for the same. If at all the patient is so angry that he tries to dominate you, it is good for both of you “to end up the consultation”, to have the consultation on some other occasion or some other day/date, or you may even refer the patient to some other doctor also.

This stands for six utmost important questions to be asked while taking the history. They are as follows:

The summary is the main crux of the matter that you have discussed with the patient. In this process the history narrated by the patient is read in front of him within a very short time (say, one or two minutes). For example, “Let’s have a quick look at what we have discussed so far and please correct me wherever I go wrong. You were absolutely alright till last evening when you suddenly developed crushing pain in the middle of your chest while you were watching the television. You turned sweaty and started vomiting and were breathless also. Then you turned restless and could not sleep the whole night. And this morning you are here. Am I right?”

Name: Asking the name is an opening question in an interview. It is good to use the patient’s name or the surname (depending upon his age). This way the patient feels himself to be at your concern; and no doubt, it helps to go on with the discussion. For example, “Mr Paul, please come in,” Or, “Hello Ram, how are you?”

Age and sex: Certain diseases are more common at certain age groups. For example, atherosclerosis and certain degene-rative disorders occur at a later age, whereas certain congenital anomalies manifest themselves at younger age except for a few disorders like valvular heart disease with a mild degree of abnormality or syringomyelia that manifests at a later age.

Address: The place where the patient lives, i.e. the area, the locality, the state or the country holds certain significance. For instance, endemic goiter is mostly seen in the foothills of the Himalayas. Lathyrism caused by the long-term consumption of khesri dal is commoner in the North Indian states. Skin diseases and respiratory disorders like pulmonary tuberculosis is more common in people of lower socio-economic groups and those living in slums and crowded, ill-ventilated environment.

Occupation: The occupation and the working conditions of a patient can provide direct clues towards the etiological factors of the disease. For example, bladder cancer—paints and dye industries; scrotal cancer—chimney sweeps; pneu-moconiosis, silicosis and anthracosis—mining, sand blasting and coal industries; lead poisoning—lead using industries and plumbers; cirrhosis of liver—chemical industries; surgeons, traffic police and housewives—varicose veins. Thus, the list goes on and on. Questions that you should ask to the patient are:

Occupational diseases are defined as the diseases arising out of or in the course of employment. They are grouped as in Table 1.1.

Religion, caste and race: Although the patient may feel it awkward and may also find it useless when you ask him about his caste or religion; but you should try to explain him that in some cases, it may provide important clues in the diagnosis of the disease. Some of the diseases are more common in particular groups or communities. For example, the largest concentration of thalassemia patients is seen in South-East Asia, Sri Lanka, Bangladesh, North-West India, Pakistan, Middle East countries, North Africa, Greece and Italy. Its prevalence in India is high among Gujaratis, Punjabis, Sindhis, Lohanas, etc. Over 30 million people are carriers of thalassemia gene in our country. Ten thousand thalassemic children are born every year in India. Sickle cell disease is common in Africa and in American Blacks and in aboriginal tribes in Central India (Mahars, Kunbi and Telis) inhabiting areas around Chhota Nagpur, in Maharashtra, in MP and extending to Orissa. Nearly 20 million people are affected in India. Hemoglobin D disease (also called hemoglobin Punjab) is seen in 10 percent of Punjabis and Gujaratis in India. Hemoglobin D thalassemia is a very mild clinical syndrome like thalassemia minor. It has been seen in Punjabis. Hemoglobin E thalassemia is common in West Bengal, Assam and in Bangladesh. Hemoglobin C thalassemia is seen in Italians (severe form) and in Blacks (relatively milder).

Social history: You should ask the patient about:

(When you have recorded the chief complaints, you should ask about each and every symptom in detail. This is because6 a single (same) symptom may be due to the involvement of two or more systems. For example, dyspnea (breathlessness) may be due to respiratory or cardiovascular system involvement. As a medical person, you should be familiar with etiology of dyspnea.

History of any previous illness or past history: Try to make detailed inquiry about all the illnesses right from the patient’s childhood, especially about those diseases/symptoms that are related to the presenting complaints and also their duration and severity.

Medical history and treatment history: A detailed inquiry should be made about significant illnesses which the patient had suffered in his life and whether he was ever admitted for that. What was the outcome of that illness? Is it still continuing? Did the patient took any medications to cure the disease? What were they? (If he still remembers the names of those medicines?) How long did he do so? Was the complete treatment taken with proper dosages? And few other questions which you find significant. Was there any recurrence of the illness? Were there any side effects of the therapy and if yes, what were they?

Surgical history: Whether the patient was operated anytime for some illness? What was the case? What was the outcome of the surgery? Was there any recurrence of the illness? Were there any serious complications of the surgical procedure?

History of drug allergy (allergic reactions due to certain drugs): Has the patient ever shown allergic manifestations due to any specific drug? What were they like? Also, inquire about their severity and duration. What did the patient do to get rid of these signs and symptoms?

*Alchol intake:

(Similarly, the questions about tobacco chewing or smoking can also be asked to the patient.)

Tobacco-related disorders: (You should inquire about the form in which the tobacco is consumed that is—smoking cigarettes or beedis, or chewing simply in betel leaf (paan)).

Pack years (PYs): Duration of smoking in years × Number of packets of cigarettes (or beedis) smoked per day. For example, one pack of cigarettes smoked per day for thirty years constitutes thirty PYs (Risk of bronchogenic carcinoma increases when PYs exceed 40).

Smoking index (SI):Number of cigarettes or beedis smoked per day and its duration. For example, a person smoking 20 cigarettes or beedis per day for the last 30 years has the SI of 600. (Risk of bronchogenic carcinoma increases when SI exceeds 300.)

The following questions are to be asked:

The following questions are to be asked:

Family history: