Good communication of the interviewer is of paramount importance in spite of latest diagnostic technology. The importance of skill of interview is developed recently because:
- This interview takes the doctor very nearer to patient's mind, so that the patient can trust, can say everything of his own life
- Patient can discuss everything of his personal details of illness
- This can reduce the patient's psychological illness and anxiety, resolves symptoms.
Communication Means Good and Successful Interview
By interview, the interviewer:
- Should get all informations regarding patient's illness
- Should know how he or she gradually develops this illness
- After allowing the patient to narrate the illness from its commencement, the interviewer starts leading questions pointing towards the specific illness
- Should be aware of the patient's social, economic and cultural factors, because anything hidden in these factors may be responsible for the patient's illness
- Should know about the patient's educational status—because, some question may not be understandable to the patient, in that case, interviewer has to narrate the question, so that the patient can understand what the interviewer wants
- Should know about the patient's language, because asking the patient in his own words, he will be gradually nearer to the interviewer and the patient can express everything to him
- Can use some slang words according to the patient's background education and social status
- Can use some phrases or words to gain confidence of the patient.
- Avoid ‘if’, ‘would’, ‘could’, because, these are nonsense language
- Should know, whether the patient is deaf and dumb
- Should know the impact of this illness in his personal, social and marital life
- Should be cheerful, friendly to the patient
- Should allow the patient, at the beginning, to narrate the illness in his own words. Interviewer should not interfere in this, rather he could nod, smile and in few cases, relevant questioning may gain confidence of the patient during narrating the story. From the story, the interviewer may get clue regarding the patient's illness, so interviewer must be keen to the patient's problem—related story
- Should respect the patient's age, sex, educational status, legal status, belief, culture and economic status
- If the patient's story is vague, start some leading questions, like, ‘where’, ‘when’, ‘how’, these are more effective rather than questioning like ‘why’.
When the interviewer does not know the patient's language, he can use interpreter. He:
- Should know the medical terminology
- Should be of same sex and comparable age
- Should share same understanding and belief regarding patient's problem
- Is a bridge between the interviewer and the patient regarding spanning of ideas, emotions and problems
- Must be of patient's choice—because in few cases—family member may be of patient's choice. Because he is most closure to the patient, so that, important problems regarding social, sexual and personal history can be collected by family members of patient's choice—this may be very confidential.
Rule of Five Vowels
Rule of five vowels are important for the interviewer.
- Audition: This corresponds to the careful listening patient's story.
- Evaluation: This corresponds to sorting of important, relevant and useful data, which is corroborating with patient's chief complaint.
- Inquiry: This corresponds to the interviewer's leading questions to the patient to probe the areas of history, which requires more clarification.
- Observation: This corresponds to the patient's behavior during conversation with the interviewer. He also watches the patient's attitude and behavior to answering the leading questions.
- Understanding: This is most important, because, the interviewer must be sympathetic to the patient, he should accept the patient's presenting complaint and situation responsible for the complaint.
The interviewer should be sympathetic to the patient's description regarding antisocial behavior, which may include:
Drug Addiction, Unlawful Action and Aberrant Sexual Behavior
The interviewer should not question such as, ‘why’—it may stop the patient, because he comes to know that the interviewer is unsuitable listener. On the other hand, ‘I understand’—phrase from interviewer may be a good signal to the patient, so that the patient will be keener to describe this nature more vividly.
Patient's body language is also very important during interview, because:
- Patient may frown, when he becomes annoyed to some leading questions produced by the interviewer
- Patient may keep his right palm on the left chest—when he tries to speak something—which is really true
- While asking about his addiction, patient may show his tongue, as if he is ashamed of or frown
- Patient may fist on a table—while he is saying something, which should be emphasized
- Patient may sometimes rub his eyes—when he tries to avoid or refuse the questions, which may harm the patient
- If the patient wants to avoid the particular question during the interview, he may start removing dust from the bed or from his or her clothes
- Patient of Middle East may speak with drooping eyelids; it shows the lack of attentiveness.
Like patient's body language, interviewer's body language is also important, because:
- From interviewer's posture, gesture, eye contact, tone of voice, patient can understand the interest, attention, and understanding of the interviewer
- Interviewer should not be in hurry
- Interviewer's approach, dress, cleanliness, facial appearances are also important to the patient
- The interviewer's room is also very important, because—the patient may not give proper history in a room having several patients, or in waiting room or in busy emergency department.
In that case, interviewer has to take the patient a lonely room or has to draw a curtain around them to maintain the privacy.
During history taking, touching the patient is very useful, because it can grow confidence, attention and understanding between the patient and the interviewer. But touch is varied according to the age and sex.4
In all ages and all sexes, placing the hand on the shoulder of the patient can do no harm. As the patient grows older, touching is more important.
In the age of biomedical advancement, the clinician usually writes costly investigations (both laboratory and radiological) without taking proper history from the patient or without doing proper physical examination—this may help the patient to feel of being neglected, rejected and properly unattended.
Sometimes the patient is advised to be admitted in any hospital wearing hospital dress, keeping his or her dentures, hearing aids and other personal belongings away from him—this may loose the belief of the patient and looses the morale of the patient much more.
Sometimes the clinician may be overworked, tired after days work. In that case, he or she may give less attention to the patient; in that case, he has to depend on investigations.
In other words, history taking is the cognitive skill of the interviewer; it is a powerful diagnostic skill.
Before seeing the patient, interviewer should collect the data from the patient's medical records, like, age, sex, occupational status, address, medication list, details of allergies, any past diagnoses and treatment schedule, if any.
The above collected data may be incomplete or may not match with the data, which you will collect from the patient—but this will help the interviewer to give proper care to the patient.
Symptoms refer to:
- Definite symptoms: What the patient feels, it should be described in detail by the patient
- Constitutional symptoms: This commonly occurs in body systems—such as fever, chill, weight gain or loss, sweating, etc.
Approach to a Patient for History Taking and Examination
- Interviewer should wear white coat with named badge. He should address the patient with Mr/Mrs/Dr/Ms, handshake with him and say his aim
- Bed around the patient and surroundings are properly lighted. The patient's privacy should be assured
- The interviewer must be sure that the patient is not deaf or dumb. Patient should lie in comfortable position or sitting in the chair.
- Interviewer should sit in front of the patient in a chair, 3 to 4 feet from the patient in relaxed position
- In case of bed-ridden patient, elevate the head end of the bed and try to lower the bedside rail, so that it cannot interrupt the interview
- After introduction, interviewer should ask the patient—“For which problem, he has been admitted here?” If the patient tells the interviewer to see his hospital records, he should ask the patient about his previous health, followed by remodeling of first question “he want to hear from the patient's own voice?”
- After interviewer asks the patient to narrate the chief complaint in a specific format, followed by past history, social, personal, drug, dietary history and so on.
Two types of questioning usually should be done:
- Open type questioning: This type of question is required to gather general information. This question is required for opening the interview. Questions are:
- ❖ What about your headache?
- ❖ What about your stomach pain?
- ❖ What about your sensation during headache or stomach pain?
- Direct questioning: This type of question points towards the chief complaint. To elaborate it:
- ❖ Where the pain has been started primarily and where it has been radiated?
- ❖ Whether the chest pain aggravates with respiration?
- ❖ Whether the stomach pain aggravates with intake of food?
Format of the History
There are two types of format:
- Disease-orientated approach: This emphasizes disease process that promotes the patient to seek for medical advice.
- Patient-orientated approach: This is more complete and comprehensive approach, where complete history is needed to know the cause of impact on the chief complaint, e.g. if patient complains of shortness of breath—history of onset, duration, type, frequency, aggravating and relieving factors of that pain has to be gathered to get the vivid picture of the chest pain.
So the format of the patient related history is:
- Patient's details
- Chief complaints/presenting problems
- History of present illness
- History of past illness
- Family history
- Personal history
- Psychological and spiritual history
- Occupational and environmental history
- Sexual, gynecological and reproductive history
- Drug history
- Immunization history
Patient's Details
It includes:
- Name
- Age
- Sex
- Religion
- Address
- Occupation
- Date of admission
- Date of examination
Chief Complaints
- It is brief statement with duration for which he or she has been admitted for in specified institution.
- If the chief complaint is more than one, then they should be arranged in chronological order with respect to duration. For example,
- ❖ Pain in upper abdomen for 4 days
- ❖ Nausea and vomiting for 2 days
- ❖ Loose motion for 1 day.
History of Present Illness
It is important to know that the patient was well before the onset of illness. Patient often does not remember the exact date of onset and duration of illness. In that case, it is necessary for the interviewer to correlate the symptom with any known or memorable event. For example, whether the pain starts during, before or after pooja vacation.
Each principal symptom has to be described in relation to:
OLD CARTS: It means:
O = Onset
L = Location
D = Duration
C = Character
A = Aggravating/relieving factors
R = Radiation
T = Timing
S = Associated factors.
If the patient has more than one complaint, then according to the chronology, they should be described in separate paragraph.
During the present illness, if any medication is taken, it should be described in generic name with specific dosage, route and frequency. If any remedy or aggravation occurred with these medications, this should also be described.7
Any allergy due to intake of recent medication such as, skin rash, nausea, if present or not, it should also be described.
History of Past Illness
It should be divided into two parts:
- Childhood history:
- ❖ Communicable diseases: Chickenpox, measles, rubella, mumps, whooping cough, if occurred, the time of occurrence, course and treatment.
- ❖ Any severe bacterial illness involving lung, gastrointestinal tract, nervous system—should be thoroughly interviewed.
- Adult illness: It should be divided into:
- ❖ Medical history:
- Acute or chronic infection
- Asthma
- Any disease requiring hospitalization.
- ❖ Surgical history: Any type of operation—open, laparoscopic or endoscopic.
- ❖ Gynecological history: Any type of major or minor operation.
Past medical illness composed of three components:
- Diagnosis: Lobar pneumonia
- Evidence: Fever, cough, rusty sputum, breathlessness
- Management: Antibiotics
History of admission in any hospital for medical, surgical, obstretical, gynecological or psychological reasons—the interviewer may ask directly regarding emotional or nervous problem and any counseling therapy was performed or not.
The importance of taking past medical history is to link this with present history of illness, if any.
Any surgical procedure, date, hospital name, if possible, should be obtained.
Family History
It includes the history of:
- Parents
- Grandparents
- Siblings
- Children
- Grandchildren.
The diseases to be enquired are:
- Cardiac—coronary artery disease, hypertension
- Renal—chronic renal disease
- Endocrinological—thyroid disease, diabetes
- Lung—tuberculosis
- Skin—atopic dermatitis
- CNS—convulsion, strokes
- Metabolic—hyperlipidemia.
Personal History
- Educational status: Age of onset of schooling, upto which level the patient is educated
- Occupational status.
- Marital status:
- ❖ Whether the patient is married or not?
- ❖ If married, for how many years he is married?
- ❖ How many issues are present with this patient?
- ❖ Whether the siblings are suffering from any illness?
- ❖ Whether the illness is correlated with the patient's present complaint?
- Dietary history: The following questions are to be asked to the patient:
- ❖ Whether the patient is vegetarian or nonvegetarian?
- ❖ What is his routine diet?
- ❖ Does he take diet with high fiber content, e.g. whole grain, bread, cereal, fresh fruit, vegetables, bran?
- ❖ Does he take extra salt in his diet?
- ❖ How much saturated fat present in his diet?
- ❖ How much and type of fish or meat (chicken, mutton) present in his daily diet?
- ❖ Does he take boiled food or fried food? If so, when?
- ❖ Does he take caffeine containing food daily, if yes, what is the frequency of intake?For example, coffee, tea, cola, chocolate. Caffeine containing foods are responsible for fatigue, palpitation, lightheadedness, headache, irritability.
- ❖ Whether the patient has special or restricted diet?
- ❖ What sort of oils is used during cooking of food?
- ❖ How often the patient uses to take outside food?
- ❖ Occasionally, disease-related questions are to be asked:
- Patient with coronary artery disease should avoid saturated fat, dietary oils, egg yolk, fried food.
- Patient with diabetes mellitus, the following interrogations should be required:
- – Insulin or oral antidiabetic drugs
- – Dietary restriction
- – Any past history of hypoglycemia
- – What type of food exchanges the patient uses to follow?Dietary allergy history: It is necessary to ask the patient about allergy to food. Common foods those are associated with allergy are peanuts, shellfish, eggs, brinjal, soy, milk.The allergic reactions are:
- – Involving respiratory tract: Rhinorrhea, sneezing, wheezing, respiratory distress due to laryngeal edema.
- – Gastrointestinal symptoms: Diarrhea, vomiting, pain abdomen, nausea.
- – Skin: Angioedema, urticaria, erythematous skin eruptions.
- – Food allergy should be differentiated from abdominal bloating. This may be upper abdominal or lower abdominal bloating.
- – Upper abdominal bloating: It is usually acute. Ingestion of gas during swallowing of food or liquid (aerophagia) due to:
- Rapid intake of food
- Smoking
- Talking during intake of food
- Intake of carbonated beverage.
- – Lower abdominal bloating: It is usually chronic.
Loose motion or flatulence, postprandial cramping abdominal pain are usually due ingestion of sugar (xylose, sorbitol), high fibers and lactase deficiency (may be due to intake of yogurt, ice cream, cheese).
The following percent of foods is usual guide for a person:
• Carbohydrate | 45–65% of total calories |
• Fat | 20–35% of total calories |
• Protein | 10–35% of total calories |
• Sodium | = 3.8 gram of salt per day |
• Cholesterol | <300 mg per day |
- Addiction history:
- ❖ Smoking: The question should be:
- For how many years, the patient is taking cigarette?
- How many cigarettes per day he is taking?
- What type of tobacco he is taking, cigarette, cigar, bidi, chewing tobacco?
- Does he change the type of cigarette in recent years?
- Did he try to stop the smoking? If so, what was his feeling?
- Does the smoking relate with bowel movement or cheerfulness?
- ❖ Alcohol history: The question should be:
- What type of alcohol?
- How much alcohol taken by the patient per day?
From the history of alcohol intake, the interviewer can correlate the present illness with the alcohol intake, e.g. if the patient is suffering from jaundice, or severe pain in upper abdomen, it may be due to alcohol related hepatitis, or acute pancreatitis or alcohol related gastritis. It may relate with the patient's emotional reaction.
So heavy alcohol intake may be associated with the following medical problems:
- Coronary artery disease
- Alcohol-related liver disease
- Cardiac arrhythmias
- Hemorrhagic or ischemic strokes
- Hypertension
- Pancreatitis.
CAGE questioning, this is the screening questions for alcohol abuse:
C = Has he ever felt the need to cut down of alcohol drinking?
A = Has the patient ever been annoyed by criticism of his drinking?
G = Has he felt guilty conscious for drinking?
E = Has he ever taken alcohol after rising from the bed (eye opening) in the morning to become steady and get rid of the hang over?
Two or more positive answers to CAGE questionnaire suggest alcohol misuse—sensitivity is 43 to 94 percent, specificity is 70 to 96 percent.
Detection of alcohol misuse can be done by getting history of:
- Syncope
- Convulsion
- Accidents
- Conflict in job
- Relationship with others.
Alcohol intake can be measured in two methods:
- First method: It is inaccurate and underestimate intake.
- Second method: It is the direct calculation of the alcohol content of the drinks.
Method I: One glass of = 1 unit of alcohol.
Method II: 1 unit of alcohol = 10 mL of pure alcohol.
x percent proof = x units of alcohol per liter = 10x mL of pure alcohol.
30 percent proof spirit = 30 units of alcohol per liter = 300 mL of pure alcohol.
1 liter or 1000 mL of spirit contains 40 units of pure alcohol.
1 mL of spirit contains 40/1000 units of pure alcohol.
In case of wine:
If alcohol content of wine is 12 percent, i.e. 1000 mL contains 12 units of pure alcohol.
So, 750 mL contains 12 × 750/1000 mL = 9 units of pure alcohol.
Recommended safe drinking:
21 units per week for men.
14 units per week for women.
Average weekly intake of above 50 units in men and 40 units in women—hazardous drinking.
- ❖ History of drug abuse: In contrast to alcohol abuser, drug abusers are more likely to magnify their use. The following questions should be asked regarding drug abuse:
- What types of drug used?
- How long he has started?
- For how many days, he is taking drug heavily?
- Approximately when he has started drug abuse?
- Why he has started to take the drug heavily?
- At which time, he uses to take the drug?
- What is his feeling after taking the drug?
- Whether he has tried to get rid of the drug?
- What is his feeling after leaving the drug abuse temporarily?
- Is there any convulsion after withdrawal of the drug?
- Does he take the drug in single dose or in divided doses?
- Is he taking only single drug for addiction?Interviewer must be well conversant about the drugs, used for addiction. When cocaine is being used for addiction—orally or intravenously, interviewer should know about the toxicity of the above drugs—whether given orally or intravenously.Normally used drug can be used as a drug of addiction, e.g. propranlol or metoprolol are usually used as antihypertensive, but they can be used to relieve stage fright.
- Sleep history.
Psychosocial and Spiritual History
- Psychosocial history includes:
- ❖ Education
- ❖ Life experience
- ❖ Relationship with other individual
- ❖ Schooling
- ❖ Religious belief
- Spiritual history: Spirituality helps the patient to cope up with chronic disease, debilitation and dying. The spirituality may be in the form of meditation and prayer.
- ❖ This reduces the stress
- ❖ Early recovery from the surgical pain
- ❖ Faster recovery from illness.
Occupational and Environmental History
Occupational history is responsible for 3,50,000 new cases per year in United States. But one may incorrectly describes the illness due to some other cause, because of long latency between exposure and onset of illness. Many occupational diseases have been discovered up till now. Some of these are:
- Bladder carcinoma—in aniline dye worker
- Malignant mesothelioma—person exposed to asbestos
- Malignant neoplasm in nasal cavities—woodworkers
- Hepatic angiosarcoma—person exposed to vinyl chloride
- Pneumoconiosis—coal workers
- Silicosis—sandblasters
- Bassinosis—cotton industry workers
- Ornithosis—bird breeders
- Bronchial asthma—person exposed to dust, pollen
- Khangri cancer—in the inner lip, exposed to tobacco chewers
- Toxic hepatitis—workers of plastic industries
- Friedlander's pneumonia—exposed to pigeon and parrot danders.
Environmental pollution is also responsible for mortality and morbidity of human being world wide, e.g.
- Chernobyl—due to high radiation
- Minamata bay, Japan—due to mercury poisoning
- Hopewell, Virginia—due to poisoning with pesticides chlordecone
- Bhopal, India—due to gas leak methylisocyanate
To recognize the disease as environmental or occupational hazards, the following interrogations are necessary:
- What is his job?
- How long he is in his job?
- In his job, with what material he is working?
- Does he work with proper precaution during his work?
- Description of surroundings around his working place.
- Where is his house? Whether his house is nearer to the coal mine, shipyard, any factories?
- How long he is living in that place?
- What is his hobby? Whether he likes bird or animal?
- If bird, which bird, and if animal, which animal?
- Whether he is working with lead, asbestos, fumes, dust, flower?
Sexual, Gynecological and Reproductive History
This history is most important for complete evaluation of the patient.
Sexual history taking is important for following reasons:
- Sexual drive is sensitive indicator of well-being.
- Sexual dysfunction is responsible for anger, anxiety and depression
- Child's sexual abuse should be identified as early as possible
- Older adult is not sexually inactive, he may enjoy sexual contact.
The following questions may discover the patient's sexual activity:
- Is the patient sexually active?
- If yes, ask about his sexual partner.
- Is he satisfied with his sexual partner? If not, what is the problem? Is it from his side or from her partner's side?
- Has the patient more than one sexual partner?
- If yes, are they of same sex or either male or female sex?
- Whether the patient uses the condom during intercourse?
- In last 6 months, how many sexual partners he had?
- In his life time, how many sexual partners he had?
- Has he ever sexually transmitted disease?
- Whether he has treated or tested for sexually transmitted disease. If so, why?
Menstrual history:
- Age of menarche
- Menstrual flow
- Duration of flow
- Any pain preceding or during menstruation
- If yes, when it subsides?
Obstetric history:
- Number of pregnancies
- Number of abortion
- Number of deliveries
- Age of 1st pregnancy
- Frequency of pregnancies
- Abortion—whether spontaneous or, induced
- Complication of pregnancy
- Postpartum condition of the patient.
Drug History
Any history of intake of drug with dosage, duration, frequency, any history of associated drug allergy should be taken. From drug history, interviewer can think of:14
- Any past medical history
- Any relation of past history with present illness
- If there is drug allergy, avoid the drug throughout the life
- If any flare up of previous disease, which may indicate inadequately treated disease, may be in the form of dosage or duration of treatment
- In case of chronic disease, like, hypertension, diabetes, hyperlipidemia, whether the drugs are continued or not
- If not, the present illness may be the consequences of above chronic disease.
Drug may produce drug and nutrient interactions. This should be interrogated to the patient during interview. So the following questions should be asked to the patient:
- Whether the patient is taking minerals, herbs or dietary supplements for any ailment, if so, why?
- What is the dose of the above drugs?
- Whether the patient experience any side effect during this drug intake?
- Who is the person responsible for the above prescription of the drug?
Drug may influence the nutrients in the following ways:
- Avoiding intake of the food—due to nausea, vomiting or feeling of bad smell of the food.
- Abnormal absorption of the food is due to:
- ❖ Increased intestinal motility
- ❖ Competitive inhibition of the food by the drugs
- ❖ Alteration of the intestinal pH
- ❖ Alteration in excretion.
Drugs | Nutrients affected |
---|---|
• Aluminum hydroxide | Phosphate |
• Sulfasalazine, methotrexate | Folate |
• Neomycin, mineral oil, cholestyramine | Fat soluble vitamins |
• Neomycin | Vitamin B12 |
• Mineral | Water, electrolytes, fat and fat soluble vitamins |
• Isoniazid | Vitamin B6 deficiency |
• Frusemide, thiazides | Potassium, magnesium, calcium |
• Phenobarbital, phenytoin | Calcium, folate, vitamin D |
Immunization History
- From birth to childhood age, whether all immunizations were done or not. If done, the interviewer should see the immunization card
- In adult, yearly influenza vaccination should be done in patient with cardiovascular, pulmonary, renal, hematological disorders.
- Patient with chronic renal disease and older (65 years), should receive pneumococal vaccine once only
- Patient with alcoholism, myeloma, lymphoma, cirrhosis, functional asplenia should receive pneumococcal vaccine
- Only in case of functional asplenia or anatomical asplenia pneumococcal vaccine should be taken in every 6 years.
Hepatitis B vaccination should be given to:
- Intravenous drug users
- Dialysis staff
- Staff of endoscopy unit
- Sexual partner of hepatitis B virus carrier
- Multiple sexual partners
- Hemophiliac patientsHaemophilus influenzae type B vaccine to be given to children.
Live vaccine MMR not to be given:
- To immunocompromised patients
- To patient receiving steroid therapy
- To generalized malignancy
- To pregnant mothers.
History Taking from Different Type of Patients
History Taking from Silent Patient
Patient may be silent due to following causes:
- Due to problem from interviewer's side:
- ❖ When the questions are short and are thrown in rapid succession.
- ❖ When the question makes the patient annoyed.
- ❖ When the question is not understandable to the patient.
- From the patient's side:
- ❖ To remember past events.
- ❖ To recollect past thought serially.
- ❖ Patient thinks whether the interviewer can be trusted to give the details of himself.
- ❖ In case of depressed patient, the interviewer has to question regarding the cause of his depression.
In this case, the interviewer has to gain confidence of the patient, so that patient will give proper informative history.16
During interviewing with this type of silent patients, it is often necessary to watch the facial expression of the patients.
Sometimes, the interviewer should be silent for sometime when the patient starts emotional reactions like, crying, annoying during answering the questions. This allows the patient to release the tension and gives proper history when questioning will be started. So interviewer must be cooperative, attentive and very kind to the patient.
History Taking from the Confused Patient
Sometimes the patient may confuse the interviewer in the following processes:
- When the patient gives affirmative answer to all the direct questions from the interviewer, he has to say the meaning of the questions, so that the patient will answer to the point.
- In some cases, patient's answer is vague, loss of ideas, loss of thought, difficult to understand the meaning of the answer or difficult to understand the language, e.g. patient may give history like:
- ❖ Something crawling over the body
- ❖ Tingling sensation in different parts of the body in different times.
In case of mentally ill patient (depression, anxiety, neurosis, manic depressive psychosis): The history may be inconsistent and may give different types of history of illness having no sequential chronological order.
In this type of patient, the interviewer should not spend time to gather detailed history, rather than giving much time for mental status examination.
History Talking from Talkative Patient
- First, the interviewer should allow the patient to narrate the whole history. Only thing the interviewer has to nod at regular interval and to hear very cautiously the speech and take out the necessary points from the very elaborative history
- The interviewer should listen and think—whether there is any flight of ideas, disorganized thought
- He has to watch, whether the patient is anxious, impatient while talking
- After listening to the elaborative history, the interviewer has to make a structure containing points in the history, and then he has to ask the direct questions to clarify them, e.g. the patient has told regarding the chest pain which is aggravated with exertions. Again he has told that he has retrosternal chest pain exacerbated 17by intake of food. So the interviewer has to know that which pain is earlier
- If possible, the interviewer has to call the patient next day to listen the extra points regarding the history.
History Taking from the Patient Who is Crying
- Crying is the burst of emotion, frustration. Crying is therapeutic. Allowing the patient to cry, the interviewer has to wait, and to provide a tissue paper to rub his or her eyes
- After recovering from the crying episode, most patient starts telling story
- Only the interviewer has to boost at regular intervals during conversation.
History Taking from Angry Patient
- Anger is the outburst of patient who is ill, lack of control in his personal life, feeling of loneliness. But he expresses his anger to the interviewer, if he is late in his chamber or hospital
- In that case, interviewer should not stop him rebuking, rather accepts the angry feelings and accept bad talk without being angry in return in clinic or hospital
- Better the interviewer should avoid the angry patient to join with the other persons in chamber
- After the patient become calm and quiet, the interviewer should tell and confess his guilt and he promises not to do like this in future
- Some angry patients become disruptive. He or she can disturb the atmosphere of the hospital and the clinic.
In this case, the interviewer (clinician) has to call security guard to control the situation by taking the patient in the other room and makes him or her to understand the cause.
When the rapport will be established between the patient and the interviewer, the patient will be calm and quiet and starts giving history.
History Taking from the Patient with Low Literacy
Firstly, the interviewer has to know whether the patient has:
- Language barrier
- Diminished vision
- Learning disorder
- Lack of education.
If the patient is not blind, there is no language barrier, lack of education or low literacy is the prime cause. This can be tested by the following methods:18
- Can the patient read the question given by the interviewer?
- Can he fill in the blanks in a form given?
- The interviewer gives any book or text in up side down to the patient and asks him to read.
History Taking from the Patient with Impaired Hearing
Firstly, the interviewer has to know about:
- Language of communication
- Level of education
- Level of schooling
- If the patient is blind unilaterally, the interviewer has to sit on the side in which ear he is not blind
- The room must be calm and quiet, the sound of television, radio or any if present, should be stopped
- If deaf person can read the lips of the interviewer, he can understand what the interviewer wants to say.
History Taking from Psychotic Patient
This patient usually suffers from hallucination, delusion, flight of ideas, feeling of persecution. So the interviewer has to calm, quiet, understand the patient as much as possible. Some patient is not floridly psychotic. So there are several clues, which are very helpful for the interviewer to diagnose the patient as psychotic:
- Speech pattern
- Speech organization
- Flight of ideas
- Distraction from the questions
- Patient cannot complete answer, the question, rather he unnecessarily asks questions.
History Taking from the Demented and Delirious Patient
- Demented patient has lost his intellectual memory, becomes confused from their surroundings
- Delirious patient has altered level of consciousness—as a result of which he behaves incorrectly with his surroundingsBoth types of patients suffer from fear. Hence, during questionnaire to these patients, the interviewer must be calm, quiet and beware of that type of questions, which may be harmful to the patients
- Patient with organic mental syndrome is lucid, occasionally becomes disorientated, has defect in attention, memory and thought.
In this type of patient, record the questions and answers. After few minutes, the interviewer asks similar questions and he should 19check whether the patient gives similar answer or not. This proves that the patient is suffering from inattention.
History Taking from Acutely Ill Patient
It is better to take relevant questions during rapid physical examination, because there is no time to ask the patient the detailed history and perform detailed examination as it may defer the urgent management.
As the patient becomes stabilized, the interviewer can take detailed history and will do accordingly.
History Taking from Patient Suffering from Cancer
Patient with cancer has five major concerns:
- Loss of control makes the patient helpless.
- Alienation—this feelings arising from reaction of the people around him.
- Perception of pain—patient has intense fear of having pain.
- Fear of mutilation—women with mastectomy may suffer from a fear of rejection by the community as no longer being a complete woman.
- Patient always thinks of his inevitable mortality very soon, because the pathologic process always progresses very fast.
Physician is always afraid of the patient, because he may ask the progress of the disease. But physician must be sympathetic to his emotional reaction.
History Taking from Aphasic Patient
- If the patient is aphasic, it may be motor or sensory
- If it is sensory, then it is not possible for the interviewer to get the history from the patients, so in that case, he has to depend upon the patient's party
- If the patient's aphasia is of motor type, it must be confirmed by giving a pen and a paper and ask him to write ‘yes’ or ‘no’ to the simple questions like, ‘are you male’, or ‘have you married?’ If the patient comprehend the question, then the interviewer ask the patient a series of questions and allow him to give answer in the form of nodding of head, or ‘yes’ or ‘no’ in writing.
History Taking from Alcoholic Patient
Alcoholic patient is physically handicapped, because:
- He may suffer from various diseases related to gastroenterological system and liver, cardiovascular system and respiratory system
- He is sexually inadequate
Alcoholic patient is psychologically handicapped, because:
- He feels alone
- He is abandoned by his family members and friends.Alcohol is his day and night friend.
In this case, interviewer should be particular in asking history, because, it may make the patient annoyed, explosive.
Approach to a Patient for Physical Examination
Make-up of the Patient's Mind
- Give your identification as a medical student
- Give proper security to the patient
- You must be calm and quiet in spite of occasional irritable behavior of the patient
- Give assurance to the patient that you will examine the whole body keeping privacy. Because he has to examine the whole body in spite of no abnormality in any system other than the involved system for which he has been admitted in this hospital
- Draping of the patient is very essential for keeping the privacy of the patient. You should examine the areas one after another, e.g. when you want to examine abdomen, cover the other parts of the body. Again you want to examine the left breast, cover the rest of the body. This helps in the following ways:
- ❖ This helps to concentrate the examination area
- ❖ This draws confidence of the patient
- ❖ This draws respect from the patient.
- You should be gentle, systematic and professional while doing physical examination
- After examination is over, you should not interpret the findings with the friends or with the teacher in front of the patient, because the patient may wrongly interpret your discussion
- Again, you should not react badly by seeing any foul smelling lesion
- Take permission from the patient before examining the private parts of the patient, e.g. pubic area, femoral pulse
- During physical examination, you must watch the facial expression of the patient—whether he is angry, sensitive or cooperative.
Proper Lighting in the Examination Area
- Proper lighting should be in your examination room, so that both of you are comfortable
- Room should be calm and quiet, so that heart sounds and lung sounds can be heard easily
- Two types of lighting are useful during physical examination:
- Tangential light is required for seeing:
- Jugular venous pulsation
- Thyroid gland
- Apical impulse.
Because, it can shadow on the surface—so that contour, elevation, depression, pulsations may be noticed. - Direct lighting.
Details of Instruments used in Examination
- Blood pressure instrument
- Torch light
- Thermometer
- Watch
- Stethoscope, having earpiece, fits strongly without pain, and bell and diaphragm should be good and interchangeable
- Tape
- Tuning fork
- Cotton
- Pin
- Hammer
- Two glasses containing cold and warm water respectively
- Pencil and paper
- Gloves for rectal examination
- Ophthalmoscope
- If required, otoscope.
Postexamination
- Patient should be comfortable in his previous position
- If the patient is bedridden, bed should be down. Side rails should be raised, so that the patient will not fell down.
Primary position of the patient and the examiner:
- Patient should be examined from his right side. This position is important for having following advantages:
- ❖ It is reliable to see jugular venous pulse from right
- ❖ Placement of hand for palpation of apical impulse is comfortable
- ❖ Palpation of abdominal organs, such as liver, spleen, and kidney is easier and comfortable
- ❖ The examiner can move for examination of the extremities to the foot end or left hand side.
- Patient should be examined from head to toe—sequentially, because if you jump from one part to another part, leaving area in between, there is every chance of missing some important finding in that area.
- In case of bedridden patient:
- ❖ The examiner should examine head, neck and anterior chest in supine position
- ❖ The examiner should examine posterior chest, back of the head in right or left lateral position
- ❖ Roll the patient to supine or patient's comfortable position.
- In case of mobile patient:
- ❖ Sitting position:
- General survey
- Examination of head
- Examination of neck
- Thyroid gland
- Cervical lymph node
- Anterior and posterior part of chest
- Breast
- Few parts of nervous system examination—mental status, orientation, cranial nerves, cerebellar function, upper extremities
- Palpation of aortic and pulmonary area.
- ❖ Lying supine with head end of the body raised to 45 degree position—Jugular venous wave, carotid artery, tricuspid area
- ❖ Supine position with 30° elevation of the head end and rotation slightly towards left—mitral area for murmur and other abnormal sound
- ❖ In sitting position with leaning forward—tricuspid and aortic area.
- ❖ Lying in supine position in flat bed:
- Face
- Anterior neck
- Anterior thorax
- Breast
- Abdomen
- Axillae
- Pubic area
- Genital area
- Upper and lower extremities
- Plantar response.
- ❖ Supine with flexed, abducted and externally rotated hip and knee flexed position:
- Pelvic examination
- Rectal examination.
- ❖ Lying on left lateral position:
- Rectal examination
- Prostate examination.
The following techniques of examination are usually done:
- Inspection: It means close observation of:
- ❖ Skin
- ❖ Facial expression
- ❖ Body habitus
- ❖ Eye movements
- ❖ Any thoracic asymmetry, deformity, fullness, abnormal movement
- ❖ Abdomen—size, shape, lesion, venous prominence
- ❖ Cardiovascular system—jugular venous pulsation, abnormal precordial pulsation, aortic and pulmonary area
- ❖ Height
- ❖ Weight
- ❖ Body mass index.
- Palpation: Pressure by the palm of the hands assess:
- ❖ Skin elevation
- ❖ Temperature
- ❖ Pulse
- ❖ Lymph nodes
- ❖ Size of the organs and tenderness
- ❖ Any mass any where in the body
- ❖ Abnormal palpable cardiac sounds, thrill
- ❖ Palpable pleural rub, rhonchi.
- Percussion:
- ❖ Chest percussion for evaluation of different notes
- ❖ Abdominal percussion for any fluid in the abdomen.
- Auscultation:
- ❖ Lung sounds
- ❖ Heart sounds
- ❖ Peristaltic sound
- ❖ Any bruit in the abdomen
- ❖ Venous hum.
- Auscultopercussion:
- ❖ To delineate stomach size
- ❖ To diagnose hydropneumothorax.
Analysis of Data
- Data collected from history—subjective data
- Data collected from physical examination—objective data
Now compilation of subjective and objective data can be done in the following ways. If patient complains of chest pain, it may arise from:
- Heart and associated great vessels
- Lung and pleura
- Esophagus
- Musculoskeletal structure:
- ❖ If pain is associated with exertion—think of cardiovascular disease
- ❖ If pain alters with respiration—think of respiratory (pleural), and musculoskeletal structure
- ❖ If pain arises during carrying heavy bag—think of musculoskeletal structure
- ❖ If pain arises during swallowing and in retrosternal area—think of esophagus
- ❖ If there is fever, weight loss, anorexia, then there is no definite history of structure or area involvement.
Detection of Processes or Causes from History of Present Illness
- The following processes or causes are:
- ❖ Congenital
- ❖ Inflammatory
- ❖ Vascular
- ❖ Trauma
- ❖ Infection
- ❖ Nutritional
- ❖ Metabolic
- ❖ Neoplastic
- ❖ Degenerative
- ❖ Toxic.If a patient complains of headache, then it may signify:
- ❖ Infection
- ❖ Vascular
- ❖ Trauma
- ❖ Metabolic
- ❖ Neoplastic
- ❖ Nutritional.If there is associated vomiting and neck rigidity, then it may suggest:
- ❖ Infection
- ❖ Vascular—subarachnoid hemorrhage
- ❖ Degenerative process—cervical spondylosis.If associated loss of consciousness it may suggest:
- ❖ Vascular
- ❖ Traumatic
- ❖ Associated cerebral involvement in case of meningitis.
- Pathophysiological process:
- ❖ Congestive cardiac failure
- ❖ Migraine.
- Psychological:
- ❖ Anxiety
- ❖ Depression.
Working Out to Establish the Diagnosis
- After getting history of present illness, relevant other history and findings of physical examination, it is necessary to perform necessary hematological, biochemical, serological (both routine and special), invasive and noninvasive radiological investigations for clinching the proper diagnosis or narrowing the differential diagnoses.
- These depend upon the nature of symptom:
- ❖ If it is vague, a large number of investigations are necessary to come to a diagnosis.
- ❖ If the complaints are projected towards:
- Specific structure or structures
- A specific process
- A specific cause.
Then a limited number of investigations may be necessary to come to a diagnosis. - So a plan of future events like, investigations for confirmation of structural diagnosis and management are necessary having a specific cause and process. This should be discussed with patient or patient's party for:
- ❖ Seeking his or her opinion
- ❖ Willingness to perform future investigations, whichever and whenever these are necessary.
If the patient, his or her party are knowledgeable or understand the problem, then he or she will proceed.
Clustering of Data and its Challenges
- Problem: After clustering of data, it may fit into one or several problems.
- ❖ Age of the patient:
- If the patient is young, the patient probably is suffering from one disease.
- If the patient is older, he or she may suffer from multiple diseases.
- ❖ Timing of illness:
- If the patient suffers from pharyngitis 1 month ago, recent history of fever, cough, chest pain may not be related to previous pharyngitis.
- If the patient now presents with discharge from penis followed by penile ulcer after 3 weeks—think of primary syphilis or gonorrhea.
- If similar patient develops lymphadenopathy and skin rash after 2 months—think of secondary syphilis.
- Involvement of different systems due to complaints, which relate to different systems:
- ❖ Symptoms related to one body system.
- ❖ Symptoms related to more than one body systems, e.g. patient may complains of chest pain, palpitation—which may relate to cardiovascular system, but if this patient also develops loose motions—it may relate to gastrointestinal system.
- Occasionally, single disease may explain involvement of different systems: An alcoholic patient present with jaundice, ascites, previously diagnosed as cirrhosis of liver, present with decreased micturition and unconsciousness. In this case, it may be due to:
- ❖ Involvement of brain due to increase blood ammonia level
- ❖ Decreased micturition due to hepatorenal syndrome unless proved otherwise.
After collection of data—both subjective and objective, the interviewer should compose the data with proper interpretation.
By asking several relevant questions, he should exclude some of the differential diagnoses before doing investigations.
A clear well-organized clinical data is very necessary for patient's future care.