A student while posted in medicine has to learn the clinical medicine with following aims:
- One should learn the art of taking a detailed informative history. History taking is an important aspect of medicine.
- One has to know the method of detailed physical examination to be carried out. Both the important positive and negative physical signs are to be noted so as to reach some conclusion at the end of examination.
- The exact terminology used in medicine has to be followed. Terminology based on science is the foundation for the solution to many clinical problems.
- The practice of medicine combines both science and art. The dazzling advances in biochemical methodology and in biophysical imaging techniques that allow access to the remotest recesses of the body are the products of science. So, too are the therapeutic manoeuvres which increasingly are major products of medical science. One has to learn the skill in the most sophisticated application of laboratory technology or use of the latest therapeutic modality.
- The ability to extract items of crucial significance from a mass of contradictory physical signs and from the printouts of laboratory data, when a clinical sign is worth pursuing or when to dismiss it as ‘red herring’ and to estimate in any given patient whether a proposed treatment entails a greater risk than the disease are all involved in the ‘decision-making’. This combination of medical knowledge, intuition and judgement is termed the art of medicine, which one has to learn.
- The patient-doctor relationship: It may be emphasised that students/physicians need to approach patients not as ‘cases’ or ‘diseases’ but as ‘individuals’ whose problems/symptoms are to be heard sympathetically. Most patients are anxious and frightened. Often, they go to extreme ends to convince themselves that illness does not exist or unconsciously develop false belief or perception about benign disease as life threatening illness. Some patients may use illness to gain attention, or to serve as a crutch to extricate themselves from an emotionally stressful situation; some even feign physical illness. Without this knowledge, it is difficult for the physicians to gain rapport with the patient or to develop insight into the patient's illness. The patient-doctor relationship must be based on thorough knowledge of the patient and on the mutual trust and the ability to communicate with one another. A strong personal relationship with the patient is essential in order to sustain the patient during stressful situation.
The written history of a patient should contain all the facts of medical significance in the life of the patient. The history should be recorded in a chronological order. The recent events should be given most attention. A problem-oriented approach should be adopted while recording the history; the problems that are clinically dominant should be listed first. Ideally, patient should be allowed to narrate his/her history in his/her own way and language without any interruption. However, few patients have sufficient power of observation or recall to give a history without some guidance from the physician. A physician/student must be careful not to suggest the answers to the questions being posed. A physician/student should hear the history with patience, often a symptom which has concerned a patient most may have little significance, while an apparently minor complaint may be of considerable importance. Therefore, the physician must be constantly alert to the possibility that any event narrated by the patient, however, trivial or apparently remote, may be the key to the solution of the medical problem.
An informative history is more significant than orderly recorded symptoms. Something is always gained by listening to the patient and noting the way in which he/she expresses the symptoms. Inflictions of voice, facial expression and attitude may betray important clues to the meaning of the symptoms to the patients. In listening to the history, physician/student discovers not only something about the disease but also something about the patient.
Unless patient is known, clinicians should introduce themselves by name and explain their position. If appropriate, the patient identity must be confirmed along with that of any accompanying person. The patient may be interviewed alone or in the presence of an accompanying person. This may allay anxiety and may be necessary in some situations such as memory impairment and language difficulty or an unconscious patient. The accompanying person or third person or a family member may be involved during discussion after the clinical examination as this may improve patient's subsequent understanding of the information given by the doctor.
- What to ask about? It is useful to think about questions to be asked which are multilayered. A positive response leads to further questioning; whereas negative response moves the clinician on to the next question.
- How to ask? The patient needs to understand what is being said. Generally speaking, technical words should be avoided. The public is becoming increasingly aware of medical terms or medical matters through the internet and mass media, but this does not necessarily mean they understand the terms, therefore, certain terms having different meanings may be clarified if used by the patient.
There are two main types of enquires—open (how, what and why type of questions) and closed (who, when, where types of questions). Examples of inquiries and there purpose is depicted in the Box 1.
Pitfalls in History Taking
With experience, the following pitfalls in history—taking have become apparent.
- What the patients relate for the most part consists of subjective phenomenon and they obviously differ widely in their responses to the same stimuli and in their interpretation. Their attitude is variably influenced by fear of disability and death and by concern over the consequence of their illness to their families.
- Accuracy of the history is affected by language or sociological barriers.
- History is also influenced by intellectual powers which interfere with recall. This is the reason that, sometimes narration by the patient may be difficult due to failing intellectual powers, hence, in such a situation it is narrated by the accompanying person which, in itself, may not be true representation of patient's symptoms.
- History taking in unconscious patient is difficult. It is difficult to collect factual data and physician is forced to proceed with objective evidence of the disease.
It is in obtaining the history that the physician's skill, knowledge and experience are most helpful.
Parts of History Taking/Recording
It consists of the following parts:
- Name, age, sex, father's name, marital status, full address, occupation, socio-economic status.
- Chief complaints.
- History of present illness.
- Past history of illness.
- Treatment (drug) history.
- Family history.
- Personal history:
- – Occupational or socio-economic history.
- – Dietary history.
- – Menstrual history in females.
Ask the patient regarding the main complaint for which he/she is seeking medical consultation. Most of the patients have mainly one or two complaints which are recorded in chronological order easily (see Box 2) but sometimes because of nervousness, anxiety, apprehension and fear, they may exaggerate the symptoms to gain sympathy and make a list of complaints that are recorded in an order in which the most troubling complaint becomes the presenting complaint.
The question of duration of a complaint is difficult especially in old people and in uneducated people. Majority of patients do not remember the exact duration of complaints. In such a situation, approximate duration may be asked. The duration of complaints gives a rough idea of duration of disease whether acute, subacute or chronic and its progression. The onset of complaints may help to make the diagnosis in the absence of objective evidence. For example, to satisfy the definition of chronic bronchitis, history of intermittent cough for three months in a year for two years is sufficient for diagnosis.
How to Write the Chief Complaints?
The format is to ask the patient “what is your main complaint”? And then “when were you last in your usual state of health”. This leads to the request; please tell me what has happened to you since then. The format of chief complaint(s) in chronological order is given in the Box 2.
The History of Present Illness
Ask the patient to tell the detailed story of his/her illness from the day it started till today, giving the details of treatment, if taken. Ideally, patient should not be interrupted while narrating the history. During history, patient may tell the things or statements which are of no consequence; these should be ignored. Sometimes, patient may describe the complaints in medical terms such as they may use rheumatism for joint pains and migraine for headache. The patient here will be asked to tell what actually happens during these complaints or he/she should give full details of the symptoms. While listening to the history, a student/physician can ask the patient to give more details about that specific symptom. Sometimes, symptoms and signs appear and disappear spontaneously and one should try to confirm whether they are related to relapse or remission of the disease.
When a student/doctor has understood the story of illness, he should proceed with each main complaint turn by turn and examine it in details. The first step in history is to make sure that you and patient are talking about the same thing. Sometimes, patient may use certain words which may have many meanings or may have different interpretation. In such a situation, one should clearly ask what does it mean actually. For example, a patient may say wind in the abdomen that moves from abdomen upwards into the brain and causes headache. Ask the patient directly whether he/she means that wind does not pass down and instead it goes up and causes discomfort.
Aims of Present History
- To keep history flowing by asking so what happened next?
- To identify those aspects of history which are incomplete and require further questioning.
- To pick up clues about the patient's reaction to the complaints, emotional and mental state of the patient.
Analysis of a Symptom
Perhaps the most common complaint is a pain which brings the patient to a doctor. The way in which a symptom is to be analysed is illustrated with the example of pain. Ask about the following points.
- Site: Where is the pain? Note the way by which the patient illustrates the site, either he/she will use his/her finger or spreads his/her hand over the chest.
- Radiation: Is it static or moves from one place to another?
- Severity: How severe is it? Is it variable in severity from time to time? It depends on an individual's perception of pain. Patient may use exaggerated terms such as agonising or tearing to seek sympathy of the doctor or to overcome socio-psychological distress.
- Timing: Note the time or any diurnal variation of symptom.
- Occurrence or its exaggeration: Note what brings the pain. How does it get relieved? Are there any precipitating factors? Is it related to exertion? Does it occur at rest? Is there any relation to food, etc.?
- Relief: What makes it better? Does it get relieved with the change in position? Is it relieved by food, by defaecation or by passage of wind? Cardiac pain is brought by exertion and is relieved by rest.
- Effect of treatment: The effect of drugs may have diagnostic value.
It is, however, possible to explore other symptoms, for example, thirst, by asking the relevant questions. The enquiries to be made for thirst are given in the Box 3. This is an urge to drink water. It occurs in variety of disorders.
Similarly, other symptoms analysis may be done according to the systemic symptoms discussed under the symptoms of systemic disorders. Towards the end of present illness, besides positive complaints of the patient, one must ask certain relevant questions about symptoms which the patient has not complained. This is important from following points of view:
- Patient may not like to include it as main complaint but that may be important for diagnosis.
- Presence and absence of symptoms not told by the patient may help in making the diagnosis and to exclude other similar conditions.
- Other information relevant to the symptoms may be necessary such as risk factors for coronary artery disease in a patient with chest pain or current medications in patients with syncope.
There are two important points about history-taking which must be mentioned here:
- Under each system, the absence of the most important symptoms, i.e. dyspnoea and cough in case of respiratory system, dyspnoea on exertion or cardiac pain in case of the cardiovascular system and paralysis or headache or fits in the case of nervous system must be recorded. Their absence influences the diagnosis. The positive symptoms and important negative symptoms on history may give indication of specific involvement of a system.
- Secondly, the history does not end with the first examination. Continuous notes should be made regarding the disappearance of symptoms or the appearance of new ones, or any other relevant fact.
Course of the illness must be ascertained whether it is acute or insidious onset. How did it progress, i.e. worsened quickly or slowly? Whether there have been relapses or remissions of illness, which would give the intermittent nature of the disease. Sudden events are due to trauma or vascular accidents, etc. Painful disorders and fever indicate infections and neoplasms. Progressive or chronic nature of the disorders points to degenerative origin of the disease. Exaggeration and chronicity of symptoms without any ill effect may be due to psychological reasons.
History of Past Illness
The previous or past history should include all events since infancy. Patient may give ready-made diagnosis of his/her illness that occurred in the past. In that eventuality, it must be verified by asking what actually happened during that illness so as to conclude whether diagnosis is likely or less likely. At times, it may be necessary to communicate with doctors or hospitals that have treated the patient in the past.
Patients are usually not interested to tell the past events. They may or may not remember minor events of the past. The relevant past history pertaining to the present symptoms is to be asked by the physician and recorded. For example, history of acute rheumatic fever in cases with rheumatic heart disease is quite relevant. Jaundice in the past, in case of liver disease, may point to the aetiopathogenesis of symptoms of liver disease in the present history.
To ask past history of diabetes in a patient, who is suffering from diabetes mellitus, is not relevant because it is incurable disease and once it manifests, it continues. Therefore, in such a situation, past history should be asked about the age of onset, its progression and any complications during the past. Some relevant past history to be asked and recorded is as follows:
- Childhood illnesses, e.g. measles, rubella, mumps, whopping cough, chicken pox, rheumatic fever and polio and history of immunisation such as DPT, polio, tetanus, hepatitis B, measles must be asked.
- Adult medical illnesses, e.g. diabetes, hypertension, tuberculosis, asthma, hepatitis, HIV disease must be asked.
- In a patient with rheumatic valvular disease, past history of acute rheumatic fever, joints pain, sore throat is helpful, while history of hypertension is to be recorded in a patient with ischaemic heart disease.
- History of jaundice, haematemesis, malena, disturbed consciousness are to be asked in a case with liver disease. Drug treatment is to be asked if jaundice is present. Past history of amoebic dysentery in a case with liver abscess is important.
- Past history of chronic bronchitis (cough occurring 3 months in a year for two consecutive years) is relevant to COPD (chronic obstructive pulmonary disease). Similarly, history of episodes of acute breathlessness with wheeze is important in a case with bronchial asthma. Past history of exanthematous fever, respiratory sinus infection, sore throat are important points to be asked in a respiratory case. Long history of fever with cough, haemoptysis is important for tuberculosis of lung.
- Prolonged history of diarrhoea is relevant to a patient with an intestinal disorder. Episodic pain in abdomen in the past related to meals is relevant to peptic ulcer.
- Past history of trauma head is significant in a case with neurological disorder.
Importance of Past History
Certain illnesses in the past may produce complications in the present, for example, childhood infectious illness may produce pulmonary complications in adulthood. Similarly adult illness in the past may have important bearing on the symptoms of present illness. Obstetric/gynaecological past history (menstrual history, birth control, and sexual function) carry significance in a female presenting with gynaecological complaints. The past history relevant to various systems is depicted in the Table 1.1.
Difficulties in History Taking
Taking a history from a patient may pose problem for a number of reasons discussed below. Patient may not at all be at fault. The difficulty is created by circumstances, hence, one should bear this in mind and remain objective (rely on signs) and professional throughout. The circumstances that lead to difficulty and their remedial measures given in the Box 4.
Note the patient's position in the family, the ages of the children and record of their health, important illnesses and cause of death of immediate relatives. If, however, there is question of hereditary disorder, one should enquire about all the relatives and attempt to construct a family tree showing those affected and those who are not affected (Fig. 1.1). The family history serves several functions. First, in rare single gene defects, a positive family history of a similarly affected individual or a history of consanguinous marriage may have important diagnostic implications. Second, in diseases of multifactorial aetiology that have a family aggregation, it may be possible to identify the patients at risk for the disease and to intervene prior to development of overt manifestations. For example, a recent history of weight gain is a more ominous development in a woman who has a family history of diabetes than in one who does not. Ask the family history of each of the following conditions and record if they are present or absent in the family; hypertension, coronary artery disease, hyperlipidaemia, stroke, diabetes, thyroid or renal disease, cancer (specify type), arthritis, asthma, tuberculosis, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction and allergies.
The symbols used in construction of a family tree (pedigree chart) are illustrated in Figure 1.1. The genetic basis is most striking in certain autosomal dominant (Huntington's disease) or X-linked disorders (haemophilia, myopathy). The pattern of inheritance is less apparent in autosomal recessive disorders as sublings just have a 1 in 4 (25%) chance of developing the disorder.
In many common disorders such as hypertension or coronary artery disease, the mode of inheritance is complex and variable under the environmental influences such as diet and smoking. Apparently a common pathological process such as atheroma may present in unrelated manner in a family for example one relative may present with a heart attack and another with stroke. Therefore, environmental factors may emerge through family proximity. For example, a life-long non-smoking woman with a bronchogenic carcinoma may have had a smoker husband who died due to smoke-related illness.
The Social, Personal and Occupational History
This history actually deals with the patient's physical and emotional environment, the surroundings both at home and at work, habits, mental attitude to life and to work. Therefore, ask about the followings:
- Exact nature of work/occupation: Ask the type and nature of work being done by the patient. You can ask him about former occupations, if any. One should also ask about the attitude towards work, employer and fellow-workers. Try to find out financial worries.
- Domestic and marital relations: Ask about the marital status. In men, particularly if unmarried, remember the possibility of homosexuality. Both in males and females, homosexuality is frequently associated with personal and social stresses.Try to find out his/her relation with other family members/friends. The life study of the patient should be explored by asking his/her hobbies, interests, fear, hopes, games played or other source of entertainment, etc.
- Home surroundings: Ask about his house whether it is made of mud (kuccha house) or bricks and cemented (pucca). Ask about the sanitary conditions, any possibility of overcrowding or loneliness. What pets are kept?
Smoking, alcohol drinking and abusing drugs contribute to the disease, hence, inquiries into these habits is often necessary. Patient may be defensive and may deny or minimise their substance use, in such a situation questioning should be tactful, firm and persistent to get the full information either from him or from a relative.
- Determine status of smoking of the patient, e.g. smoker, an ex-smoker or a life-long non-smoker.
- If patient is smoker, then determine;
- – Form of smoking (cigarettes, bidi, cigars, pipe), quantity (number of cigarettes/bidi/cigar smoked/day) and duration of smoking.
- If the patient is ex-smoker, note the length of time since the patient stopped smoking.
In smoker, the possibility of tobacco related disease should be considered (Fig. 1.2). It must be remembered that tobacco related diseases are common in both active as well as passive smokers (who just inhale smoke).
FIGURE 1.1: Symbols used for construction of a pedigree charts. First of all draw up a family tree with affected person first found to have trait. Thereafter, relevant informations regarding siblings and all maternal and paternal relatives are included
- Ask whether the patient is tea-totallar or drinks alcohol, with the approximate weekly amount (quantity in units).
- A past or recent history of an alcohol related problem must be noted. Repeated hospital admissions or consultations must be noted.
- The quantity of alcohol consumed in an week should be calculated. Normally in Indian setting, a small pack of alcohol means 20–30 mL and large back consists of 40–60 mL.
There are two ways of calculating the units of alcohol consumed.
Standard measure = one glass of wine, one half pint of beer, one shot of spirits = 1 unit of alcohol.
Calculation of accurate alcohol strength, i.e. 1 unit = 10 mL of pure alcohol × percent proof = units of alcohol/L. For example, 40 percent proof contains 400 mL pure alcohol or 40 units/L so one standard bottle of 750 mL contains 30 units of alcohol. For beer, 4 percent beer contains 40 mL of pure alcohol or 4 units/L, so one large 500 mL bottle can contain 20 units of alcohol.
The detailed history of alcohol intake becomes important;
- When a man drinks heavily in a binge and could be a suspect of alcohol-induced problem.
- When excessive drinking is suspected either currently or in the recent past.
- When an alcohol dependence syndrome exhibiting withdrawal symptoms such as “Shakes” develop.
- When symptoms are suggestive of alcohol-related disorder. A further questioning relate to assessing the presence of different aspects of alcoholism (Box 5).
Illicit Drug Use
The significance of alcohol intake and its related disorder are depicted in Box 6.
In modern era where illicit drug consumption is rising rapidly, one should not hesitate to ask about it if there is any doubt. However, enquiries should be made in a tactful manner with no adverse effect on patient-doctor relationship.
If illicit drugs are being suspected or have been used; the followings should be noted:
- The type(s) of drug involved
- The frequency and duration of use
- Intravenous use and whether needle-sharing occurred. The needle-related disorders are depicted in Figure 1.3
- Whether drug dependence developed
- Any mental, physical or social problem arising from drug use (e.g. indulging in other illegal activities).
While asking about substance misuse, it is necessary to advise the patient that medical confidentiality affords protection of patient and even if he/she refuses to disclose details of illicit drug-taking, this should be noted.
The social history and its relevance is depicted in Table 1.2.
REVIEW OF SYSTEMS/PRESENTING SYMPTOMS
While taking/recording the history, the doctor/student has to ask certain questions pertaining to his/her presenting complaints. What sorts of questions are to be asked is most challenging task for the students. In fact, the review of systems covers the questions pertaining to symptoms, but on occasions, some physicians also include diseases like tuberculosis, pneumonia, epilepsy, diabetes in the present or past history (if the patient is intelligent, educated and remember important illnesses as you ask questions within the Review of Systems, you can record or present such illnesses as a part of present illness or past history).
The details of questions varies according to state of the patient, nature and severity of illness and relevance of the information sought to the problem/illness under consideration. Always begin with general questions pertaining to various systems in easy understandable language. These focusses the patient attention and enable you to gain confidence of the patient so that you can shift to more specific questions about the system in question.
Under Review of Systems questions may uncover certain problems that the patient has overlooked, particularly in areas unrelated to present illness.
Some physicians do the “Review of Systems” during the physical examination, asking about questions as they examine them. If the patient has only a few symptoms, this combination can be efficient, but if there are multiple symptoms, then the flow of both history and the examination is disrupted and necessary note-taking becomes awkward.
A standard series of review-of-system questions are listed in the Table 1.3.