The Skills of History Taking (for Medical Students and Practitioners) Rahul Tanwani
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fm1The Skills of History Taking For Medical Students and Practitionersfm2
fm3The Skills of History Taking For Medical Students and Practitioners
Second Edition
Rahul Tanwani MBBS MS (Surgery) MCh (Pediatric Surgery) Assistant Professor (Surgery) Index Medical College Hospital & Research Centre Indore, Madhya Pradesh, India Foreword DP Lokwani
fm4
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The Skills of History Taking
First Edition: 2014 (Published by Author)
Second Edition: 2016
9789385999444
Printed atfm5
Dedicated to
my family
and
my studentsfm6
fm7Foreword
An appropriate communication with his patients is a key to success of any practicing doctor. In clinical practice, most of the diagnoses can be made on the basis of history taking alone and excessive clinging to investigations may ruin and atrophy both clinical skills and practice.
It is my privilege to present a foreword for this excellent piece of work. The most desired and untouched subject of ‘history taking’ has been addressed thoughtfully and meticulously. The proper way of history taking and its presentation, local terminologies and the art of dealing with special cases are few of the impressive features. The tailor-made approach for interacting with patients is unique and will definitely help the students and practitioners in a long way. Perhaps, the interaction of a student with a patient before, during and after history taking cannot be explained in a more precise and apt form.
The affection of this book to answer the most frequently faced problem, how to ask, is quite appreciable. In this regard, the concepts of western world cannot be replicated for the developing countries, and the author has meticulously framed the methodology, which is quite suitable for our country.
I am sure that his hard work of all these years will be used by medical science in the years to come.
My best wishes for the success and meaningful utility of this book!
DP Lokwani
Former Vice Chancellor
Madhya Pradesh Medical Science University
Jabalpur, Madhya Pradesh, Indiafm8
fm9Preface to the Second Edition
It is now nearing two years since the first edition of this book The Skills of History Taking has been released. It was encouraging for me to see a positive response from the medical students and physicians from all around the country. I thank them all, especially for their precious suggestions, which have helped and motivated me to bring several positive modifications in the second edition of this book.
All the chapters have been thoroughly revised and updated. Some new chapters have been added, like the chapters focusing on communication skills during internship and postgraduation, and communication skills in clinical practice. Many new sections have been added at multiple places in several chapters, like on communication with emergency cases, common mistakes during presentation, etc. With an intention of making them more perspicuous and interesting, all the messages and suggestions for the students are supported by some illustrated cases, which are inspired by some real-life incidents. Also, several photographs showing interaction of students with the patients have been added in this edition.
The contents of this book are based on my personal observations as well as on the ideas and suggestions generated by interacting with faculties of various departments, private practitioners, multiple students, patients and their relatives. As with the previous edition, I have tried my best to avoid any controversies in the text. Still I apologize for any disagreement if it perhaps finds its way in.
As before, I welcome constructive criticisms and suggestions from the readers for further improvement of the book.
I hope this book will prove itself beneficial for the students in improving their communication skills with the patients both in their present as well as future life.
Rahul Tanwanifm10
fm11Preface to the First Edition
Proper communication with patients is an art and every doctor keeps on learning and improving it throughout his life.
A patient visits a doctor with a diseased body, a pile of complaints and a hope to get a remedy from him. By his skills of ‘history taking and clinical examination’, the doctor is able to diagnose what is troubling the patient and subsequently prescribes medications for the same. Improperly elicited history may mislead to a wrong diagnosis, and hence, to an ineffective treatment. So, a proper communication with the patient is the key to success for medical therapy.
The art of history taking and physical examination is taught to a doctor right from his student life in a medical college. Most of the literature available in our country has emphasized on the examination of the patients, and the practical aspects of ‘history taking’ have been summarized only in the few initial pages. Though, this part has been extensively covered in foreign literature, but because of the significant difference in culture and lifestyle, it cannot be blindly replicated for the students and patients of our country.
The skill of history taking is based on three basic questions: ‘What to ask?’, ‘Why to ask?’ and ‘How to ask?’. This book is pretty much intended to the most undercovered of these three: ‘How to ask?’, as the remaining two have been adequately covered by other available literatures, both by the Indian as well as foreign authors.
Detailed description of proper history taking has been presented. To make it more interesting and perceptible for the students, almost every point is supported by suitable illustrations. In fact, these are the cases which I actually came across as a student, a doctor and a teacher. Most of them are surgical cases, but this book should not be considered as a book of history taking of only surgical patients. This book should be considered as a supplementary manual for general communication with patients and is based on my observation of the commonly encountered problems by the students, while communicating with different fm12patients. These observations have been confirmed and augmented by interacting with consultants of various clinical departments, multiple students, patients and their relatives.
Besides, there are many instructions which may not be very useful for the students at present, but will play an important role in their future life as practicing doctors. Though this book primarily caters to the needs of medical students, it may be consulted by medical practitioners as well to improve their interaction with the patients in their clinical practice.
I acknowledge my gratitude to all my colleagues in the de-partment, who gave me unstinted support, especially to Dr GV Vivekanandan, Head, Department of Surgery, Index Medical College, Indore, Madhya Pradesh, India for encouraging me throughout the process of writing this book. I also express my thanks to all the consultants from different clinical and paraclinical departments for their valuable contributions.
I pay my sincere regards to Dr BR Parekh (Director Professor, Pediatric Surgery, Sri Aurobindo Medical College and Postgraduate Institute, Indore) for blessing the contents of this textbook by his valuable suggestions and appropriate modifications. I acknowledge my gratitude to Dr DP Lokwani (Vice-Chancellor, Madhya Pradesh Medical Science University, Jabalpur) for blessing me by adding his foreword letter to the textbook.
I thank Dr VP Gupta of Avichal Publishing Company for printing my thoughts in a presentable form. Last but not the least, I take this opportunity to thank Ms Akanksha Gupta (MBBS final-year student, Index Medical College) for her painstaking efforts to give finishing touches to the literary part of the contents of this textbook.
I have tried my best to be cautious enough to avoid any controversies in the text. I, however, apologize for any, if they perhaps find their way in. I welcome comments concerning omissions and errors, reviews regarding content and critical suggestions for further editions. They may be e-mailed to me at dr.tanwani.rahul@gmail.com.
I hope this book will prove itself beneficial for the students in improvising their communication skills with patients, as a medical student at present and as a practicing doctor in future.
Rahul Tanwanifm13
Acknowledgments
I must begin with thanking my parents and teachers for making me what I am today.
I heartily thank the readers of the first edition (medical students, teaching faculties and practicing doctors), who gave me a positive feedback and precious suggestions through personal meetings, e-mails and social media.
I am thankful to Mr Suresh Singh Bhadauria, Chairman, Index Group of Institutions, Indore, Madhya Pradesh, India for giving me the permission and desired help to work in the field of communication skills in his institute. I express my sincere gratitude to the faculties of various departments of my college for their precious suggestions and contributions to this edition. I specially thank the head of my department, Dr GV Vivekanandan for his constant support and motivation during my work.
I pay my sincere regards to Dr BR Parekh (former professor and head of pediatric surgery, MGM Medical College, Indore) for his blessings and precious suggestions for improving the content of this book.
I am thankful to Dr DP Lokwani (Former Vice Chancellor, Madhya Pradesh Medical Science University, Jabalpur, Madhya Pradesh, India) for blessing this book with his foreword letter, and for constantly encouraging me to move ahead in this field.
I pay my regards to Dr (Mrs) Sukhwant Bose (Director–Professor of Physiology and Convener, MCI Regional Training Centre in Medical Education Technology, Sri Aurobindo Institute of Medical Sciences, Indore) for her blessings, guidance and appreciations right from the beginning of my academic career.
I thank Dr Jayant Vagha (Professor and Head, Department of Pediatrics and Convener, Communication Attitude and Phonetics Lab, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India) for motivating me to start a systematic ‘communication skills lab’ in my institute, which has immensely helped me in bringing several modifications and expansion in this edition of the bookfm14.
I heartily thank Shri Jitendar P Vij (Group Chairman, Jaypee Brothers Medical Publishers (P) Ltd, New Delhi) for accepting my thoughts for printing in a presentable form.
I thank my friends Dr Amit Arora (Mohali, Chandigarh, India) and Dr Yatin Talwar (Delhi, India) for helping me in the promotion of the first edition of this book amongst the students. I express my thanks to Mr Shashi Shekhar Sharma (Delhi, India) for providing me his support and encouragement whenever I was in need. My special thanks to my student, Ms Mehul Srivastava for her diligent efforts and opinions in improving the literary part of this book.
I am thankful to Dr HS Bhargava (M/s Scientific Literature Co., Indore) for his support and expert suggestions in the marketing of this book right from the beginning.
Last but not the least, I thank all the students of my college for their enthusiasm and positive response towards the subject of ‘communication skills’, which has encouraged me to do more work in this field.
Disclaimer fm15Abstract of the Chapters
Chapter 1: An Approach to the Diagnosis
The most important task of any physician is to make an accurate diagnosis of his patient's disease. Proper theoretical and clinical knowledge of the disease helps him in extracting out the signs and symptoms, which is further supported by appropriate investigations. This chapter is intended to enlighten the knowledge of medical students on the proper method of approaching the diagnosis of the disease.
Chapter 2: Student-Patient Communication
During his learning period, a medical student comes in close contact with various types of patients. The success of the outcome of interaction between a student and a patient depends very much on the knowledge, attitude and communication skills of the student. A detailed description of this interaction has been presented in this chapter.
Chapter 3: Format of Case History
A standard set of questions is taught to the medical students which should be asked to each and every patient during their learning period. Later on, during clinical practice, a physician focuses only on the questions that seem relevant with the suspected disease of the patient. This chapter includes the format of a typical case history, which has been used for the description in the subsequent chapters.
Chapter 4: Patient's Profile
The recording of any medical history begins with the general information about a patient, like his age, occupation, religion, residence, etc. In many cases, some of these basic informations may provide an important clue to the diagnosis of the disease.
Chapter 5: Presenting Complaints
The most important information in the case history of any patient is about the complaints which have brought him to the physician along with their duration. They also guide him to set the relevant fm16questions for subsequent conversation with the patient. This chapter highlights the common as well as unusual methods of presentation of complaints by different types of patients along with the suggestions for overcoming the commonly encountered problems by the students.
Chapter 6: History of Presenting Complaints
The description of individual complaints, along with the course of the disease from its onset till present time helps the physician in formulating a provisional diagnosis of a patient's disease. Technically, it is one of the most difficult sections of case history which can be learnt by the students only by interacting with various types of patients. Through this chapter, an attempt has been made to covey the students the maximum possible information related to the section of history of presenting complaints of any disease.
Chapter 7: Past History
The information of any significant disease or event (like surgery, hospitalization, etc.) in the past life of the patient may be valuable in making a provisional diagnosis and planning the management of some diseases. A detailed description of enquiry related to the past life of a patient has been presented in this chapter.
Chapter 8: Personal History
The lifestyle of a patient may be the cause of his disease and, at the same time, the diseases of a patient may affect his lifestyle. In many diseases, the information about the features related to a patient's routine life (like sleep, dietary habits, appetite, addiction, etc.) may help the physician in formulating a diagnosis of his disease. This chapter will enlighten the medical students about the proper method of enquiring and interpreting various informations related to the personal life of their patients.
Chapter 9: Family History
Some diseases are well-known for their familial inheritance. The information about the health status of the other members of the patient's family may be helpful in suspecting the diagnosis of such diseases. The same information is valuable in making the diagnoses of contagious diseases also.
Chapter 10: Menstrual and Obstetric History
Menstruation is a physiological phenomenon associated with the females. Its information is valuable in clinching the diagnosis of fm17many gynecological as well as some nongynecological diseases. Similarly, information about the previous pregnancies and deliveries of females may be important in making diagnosis and planning the management of some diseases. This chapter is focused on the minimum information related to menstrual and obstetric history of any patient, which should be asked by the undergraduate medical students during interaction with the female patients in any department.
Chapter 11: Drug History
It is essential for a physician to know about the medicines which have been taken by his patient for the same or any other significant illness. It helps in diagnosing some diseases and, more importantly, for planning a suitable prescription for the treatment of a patient's present illness.
Chapter 12: Allergy History
Before prescribing any medicine to his patient, a physician must ask about the history of any major or minor allergic reaction to any drug in the past life of the patient. This section differs from the other sections of medical history in the fact that its major role is in the planning and management of the disease and not in making its diagnosis.
Chapter 13: Elicitation of Pediatric History
A child should not be considered as a miniature adult. A different format is required for taking the history of a pediatric patient, emphasizing on some special points (like antenatal history, birth history, immunization history, etc.) and excluding some others. This chapter is an attempt to present a description of the same format in a proper sequence.
Chapter 14: Special Cases
During his clinical practice, a physician meets the patients of different types of personalities and intellectual levels in a rapid succession. All of them should be dealt in different ways. This chapter is based on the common problems faced during communication with patients of different age, gender and personalities (like elderly, pediatric, female, talkative, reticent, irritated, educated, etc.). Besides, it also includes some suggestions for interaction with patients presenting with acute and emergency conditions, especially for the interns and postgraduate studentsfm18.
Chapter 15: Presentation of a Case History
Proper presentation of a case history is an essential responsibility of medical students both during the clinical posting and the practical examinations. This chapter includes the basic difference between communications with the patients at these two places. Also, there are multiple suggestions for the students to improve their presentations in front of their teachers and examiners.
Chapter 16: Communication Skills During Internship and Postgraduation
Internship and postgraduation are two brief but important periods of student life which need a different type of communication with the patients. This chapter focuses on the life of the students during internship and postgraduation period and includes some suggestions to improve their communication with the patients as well as with their colleagues, consultants, nursing and paramedical staff.
Chapter 17: Communication Skills in Clinical Practice
The one who is a medical student today is going to be a medical practitioner tomorrow. The practicing life of a doctor needs a special type of communication with the patient which differs from what he has practiced during his student life. This chapter covers a description of communication of a physician with his patients both at his clinic and in the hospital. It will help the students learn about proper methods of communication at early stages, especially during internship and postgraduation.
Chapter 18: An Illustration of History Taking and Presentation
During history taking and presentation, a student has to interact with both the patient and the teacher or examiner. This chapter includes a verbatim presentation of a conversation of an undergraduate medical student with a hypothetical patient during his clinical posting in the department of surgery. It is followed by presentation of a case history of the same patient in the form of a speech.fm21
Figure 1: Descent and well-dressed appearance of the students is impressive for the patients as well as the teachers.
Figure 2: Simultaneous questioning from several students may confuse and irritate the patient.
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Figure 3: The leading student is conversing with the patient, while the other students are listening attentively.
Figure 4: Activities of the other students may distract patient's mind away from the conversation with the leading student.
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Figure 5: Standing in front of the patient for a long period may bring discomfort to the student as well as the patient.
Figure 6: Student sitting on a chair: The most comfortable position for communication with the patient.
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Figure 7: Presence of too many relatives may interfere with proper communication with the patient.
Figure 8: Communication skills lab at Index Medical College Hospital & Research Centre, Indore.