General ConsiderationsCHAPTER 1

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 he has come to the diagnosis at the end of every step. In fact one can narrow down the differential diagnosis from the chief complaints alone. For example, if the first complaint is fever so many probabilities are there. But, if it is associated with cough with expectoration (second complaint) the probability is infection in the lower respiratory tract. If the fever is of short duration it could be pneumonia, if the fever is of long duration it could be tuberculosis. So every case should be assessed after history taking, after general physical examination and systemic examination. By proceeding in this way one can narrow down the differential diagnosis to a great extent. This will help to plan the investigations properly and logically. This will also improve one's clinical skill. Proper planning of investigations is very much required as some of the investigations are costly and some are risky. The mentioned order has also to be maintained. One should not first examine the case without taking a thorough history. 3Similarly, if you are dealing with a case which has already been treated/evaluated by some other doctor you are likely to be carried away by his opinion or by his investigations. In such cases also one should go step by step in stead of skipping any step. It is required to be remembered that the value of clinical evaluation of cases has not declined over the years even if so many investigative facilities have come up. The merits of clinical evaluation are:

For all these reasons no doctor should leave any scope to improve his clinical skill.

On the other hand, investigations are not always productive. At times unreliable, at times ambiguous, at times the patient may not be able to afford for costly tests. As there are very few standardized laboratories in a country like 4India, depending too much on the investigations might prove harmful for the patient at times. 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 Edition, Page: 4)

In the history taking we not only collect data about the physical illness but also evaluate the feelings of a person. How much impact the disease has put on the mind of the person is known from history and this is required to give total care to the patient. There is no machine to measure or assess the feeling of a man. The patient might be suffering from a fatal ailment, yet he might be happy; may be due to ignorance. Similarly. patient might be too much worried even if his illness is too trivial (out of fear). At times, it becomes difficult for a person to express his feelings in words and expresses in gestures. These gestures often give important clues to diagnosis.5

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 life time. 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.

History taking is important in cases of all systems. 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 be inadequate. (Bickerstaff:6th Edition, 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.’

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 6case, Hutchison states—As with every aspect of diagnosis in medicine the key to success is a clear and carefully recorded history(20th Edition,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 Edition, 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 Edition,1989; Page-104).

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. (The alimentary and genetourinary systems, MJ Ford, DW Haner Hodges; Macleod's clinical Examination (9th Edition) 1995; Page-162).

From these quotes from different renowned authors and from the experiences of my colleagues and from my own, 7I 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 discuss later in respective system how history taking is important.

To take a good history, one has to go down to the level of the thinking of the patient. It is required to understand clearly the terms and words a lay man uses. One has to know the exact nature of the work of the patient and how 8the 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 clearly understood. 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, he does not feel like talking and might 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. For this type of attitude, patients lose faith in the doctor even if he has diagnosed and treated correctly. I shall give an example—“A father took his young son to a renowned physician. The consultant wrote the age of the child to be one and half years in stead of one and half months and accordingly prescribed the drugs. This was noticed by the father after coming out of the consultation chamber. He returned back and pointed it out to the doctor, but the doctor did not take it seriously. The father lost faith in the doctor and did not follow the prescription and went to another doctor. The father had also marked that while the doctor was taking 9history of his child he was often talking to others.” This speaks that patients do notice how attentive you are to them. So, during the time of consultation too many outsiders should not be allowed to be present. This will make the patient nervous; likely to divert the attention of the doctor and the patient will not feel free to speak. This is more so if the matter is 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 one can extract more information form 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 ignorance or due to nervousness. What ever 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. One can comment on the dress, can ask about his children in case of elderly people, about his school and education in case of school going children. At times these discussions can reveal key points too. If the patient is giving unnecessary details of a minor point, in stead of getting irritated on him, listen to him patiently and simultaneously ask the details of those points which you feel to be important. Often patients try to speak medical terms without knowing their significance and meaning. They should be dissuaded from that. At times patients tell more about their treatment than about their illness. This 10should 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 and assess themselves after going through the papers of experienced consultants. This will help to develop their own thought process.

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. They feel that the doctor will be able to do something to get rid of his problem and he will be able to go back to his social life. In stead, if he feels that the doctor also dislikes him, he may not feel like living and might attempt suicide.

Grown up children will not like to undress before their parents, but will not hesitate to do so before the doctor. This speaks that the doctor is in an advantageous position; rather he is in a better position than other relatives of the patients including parents to know the facts about the patient. The facts which are not told to the relatives may be revealed to the doctor. However the doctor should not take its undue 11advantage. He 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. It is wiser to listen to them patiently.

Suppose, a case of rheumatic heart disease complains of fever for fifteen days and also 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 (past history) had tooth extraction twenty days back and now having fever for fifteen days (present illness), it appears that this patient is suffering from infective endocarditis.12

Similarly, if a woman comes with unconsciousness and she 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 pregnancy. Presenting this way makes 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.

Chronic bodily illnesses often put their impact on the mind. These patients move from doctor to doctor and if still don't get relief; they get depressed. They feel that they are suffering from an incurable disease. The depressed mood can be marked from their facial expression and from their mode of talk. Likewise there are many more things which can be observed while taking history.

I tell them as obvious, means even a common man will be able to see them. One should not miss these obvious findings while collecting the history. To an observant eye many things are obvious. So, like practicing history taking one should try to improve his power of observation.