Advanced history taking

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Chapter 2 Advanced history taking

‘First the doctor told me the good news: I was going to have a disease named after me.’

Steve Martin

Most complaints about doctors relate to the failure of adequate communication.1,2 Encouraging patients to discuss their major concerns without interruption enhances satisfaction and yet takes little time (on average 90 seconds).3,4 Giving premature advice or reassurance, or inappropriate use of closed questions, badly affects the interview.

Taking a good history

Communication and history taking skills can be learnt but require constant practice. Factors that improve communication include use of appropriate open-ended questions, giving frequent summaries, and the use of clarification and negotiation.3,4 See Table 2.1.

Table 2.1 Taking a better history

1 Ask open questions to start with (and resist the urge to interrupt), but finish with specific questions to narrow the differential diagnosis.
2 Do not hurry (or at least do not appear to be in a hurry, even if you have only limited time).
3 Ask the patient ‘What else?’ after he or she has finished speaking, to ensure that all problems have been identified. Repeat the ‘What else?’ question as often as required.
4 Maintain comfortable eye contact and an open posture.
5 Use the head nod appropriately, and use silences to encourage the patient to express him- or herself.
6 When there are breaks in the narrative, provide a summary for the patient by briefly re-stating the facts or feelings identified, to maximise accuracy and demonstrate active listening.
7 Clarify the list of chief or presenting complaints with the patient, rather than assuming that you know them.
8 If you are confused about the chronology of events or other issues, admit it and ask the patient to clarify.
9 Make sure the patient’s story is internally consistent and, if not, ask more questions to verify the facts.
10 If emotions are uncovered, name the patient’s emotion and indicate that you understand (e.g. ‘You seem sad’). Show respect and express your support (e.g. ‘It’s understandable that you would feel upset’).
11 Ask about any other concerns the patient may have, and address specific fears.
12 Express your support and willingness to cooperate with the patient to help solve the problems together.

The differential diagnosis

As the interview proceeds, the clinician will need to begin to consider the possible diagnosis or diagnoses – the differential diagnosis. This usually starts as a long and ill-defined mental list in the mind of the doctor. As more detail of the symptoms emerges, the list becomes more defined. This mental list must be used as a guide to further questioning in the later part of the interview. Specific questions should then be used to help confirm or eliminate various possibilities. The physical examination and investigations may then be directed to help further narrow the differential. At the end of the history and examination, a likely diagnosis and list of differential diagnoses should be drawn up. This will often be modified as results of tests emerge.

This method of history taking is called, rather grandly, the hyopthetico-deductive approach. It is in fact used by most experienced clinicians. History taking does not mean asking a series of set questions of every patient, but rather knowing what questions to ask as the differential diagnosis begins to become clearer.

Fundamental considerations when taking the history

As any medical interview proceeds, the clinician should keep in mind four underlying principles:

1. What is the probable diagnosis so far?

This is a basic differential diagnosis. As you complete the history of the presenting illness, ask yourself: ‘For this patient based on these symptoms and what I know so far, what are the most likely diagnoses?’ Then direct additional questions accordingly.

2. Could any of these symptoms represent an urgent or dangerous diagnosis – red-flag (alarm) symptoms?

Such diagnoses may have to be considered and acted upon even though they are not the most likely diagnosis for this patient. For example, the sudden occurrence of breathlessness in an asthmatic who has had surgery this week is more likely to be due to a worsening of asthma than to a pulmonary embolism, but an embolism must be considered because of its urgent seriousness. Ask yourself: ‘What diagnoses must not be missed?’

3. Could these symptoms be due to one of the mimicking diseases which can present with a great variety of symptoms in different parts of the body?

Tuberculosis used to be the great example of this, but HIV infection, syphilis and sarcoidosis are also important disease ‘mimickers’. Anxiety and depression commonly present with many somatic symptoms.

4. Is the patient trying to tell me about something more than these symptoms alone?

Apparently trivial symptoms may be worrying to the patient because of an underlying anxiety about something else. Asking ‘What is it that has made you concerned about these problems now?’ or ‘Is there anything else you want to talk about?’ may help to clarify this aspect. Ask the patient ‘What else?’ as natural breaks occur in the conversation.

Personal history taking

Certain aspects of history taking go beyond routine questioning about symptoms. This part of the art needs to be learnt by taking lots of histories; practice is absolutely essential. With time you will gain confidence in dealing with patients whose medical, psychiatric or cultural situation makes standard questioning difficult or impossible.5,6

Most illnesses are upsetting, and can induce feelings of anxiety or depression. On the other hand, patients with primary psychiatric illnesses often present with physical rather than psychological symptoms. This brain–body interaction is bidirectional, and this must be understood as you obtain the story.

Discussion of sensitive issues may actually be therapeutic in some cases. ‘Sympathetic confrontation’ can be helpful in some situations. For example, if the patient appears sad, angry or frightened, referring to this in a tactful way may lead to the volunteering of appropriate information.

If an emotional response is obtained, use emotion-handling skills (NURS) to deal with this during the interview (see Table 2.2). Name the emotion, show Understanding, deal with the issue with great Respect, and show Support (e.g. ‘It makes sense you were angry after you husband left you. This must have been very difficult to deal with. Can I be of any help to you now?’).

Table 2.2 Emotion-handling skills—NURS

• Name the emotion
• Show Understanding
• Deal with the issue with Respect
• Show Support

There may be reluctance or initial inability on the part of the patient to discuss sensitive problems with a stranger. Here, gaining the patient’s confidence is critical. Although this type of history taking can be difficult, it can also be the most satisfying of all interviews, since interviewing can be directly therapeutic for the patient.

Any medical illness may affect the psychological status of a patient. Moreover, pre-existing psychological factors may influence the way a medical problem presents. Psychiatric disease can also present with medical symptoms. Therefore, an essential part of the history-taking process is to obtain information about psychological distress and the mental state. A sympathetic, unhurried approach using open-ended questions will provide much information that can then be systematically recorded after the interview.

It is important for the history taker to maintain an objective demeanour, particularly when asking about delicate subjects such as sexual problems, grief reactions or abuse. It is not the clinician’s role to appear judgmental about patients or their lives.

The formal psychological or psychiatric interview differs from general medical history taking. It takes considerable time for patients to develop rapport with, and confidence in, the interviewer. There are certain standard questions that may give valuable insights into the patient’s state of mind (see Questions boxes 2.1–2.3). It may be important to obtain much more detailed information about each of these problems, depending on the clinical circumstances (see Chapter 12).

Questions box 2.1

Personal questions to consider asking a patient

1. Where do you live (e.g. a house, flat or hostel)?
2. What work do you do now, and what have you done in the past?
3. Do you get on well with people at home?
4. Do you get on well with people at work?
5. Do you have any money problems?
6. Are you married or have you been married?
7. Could you tell me about your close relationships?
8. Would you describe your marriage (or living arrangements) as happy?
9. Have you been hit, kicked or physically hurt by someone (physical abuse)?
10. Have you been forced to have sex (sexual abuse)?
11. Would you say you have a large number of friends?
12. Are you religious?
13. Do you feel you are too fat or too thin?
14. Has anyone in the family had problems with psychiatric illness?
15. Have you ever had a nervous breakdown?
16. Have you ever had any psychiatric problem?

Questions box 2.2

Questions to ask the patient who may have depression

1. Have you been feeling sad, down or blue?
2. Have you felt depressed or lost interest in things daily for 2 or more weeks in the past?
3. Have you ever felt like taking your own life?—Risk of self-harm
4. Do you find you wake very early in the morning?
5. Has your appetite been poor recently?
6. Have you lost weight recently?
7. How do you feel about the future?
8. Have you had trouble concentrating on things?
9. Have you had guilty thoughts?
10. Have you lost interest in things you usually enjoy?

Questions box 2.3

Questions to ask the patient who may have anxiety

1. Do you worry excessively about things?
2. Do you have trouble relaxing?
3. Do you have problems getting to sleep at night?
4. Do you feel uncomfortable in crowded places?
5. Do you worry excessively about minor things?
6. Do you feel suddenly frightened, or anxious or panicky, for no reason in situations in which most people would not be afraid?
7. Do you find you have to do things repetitively, such as washing your hands multiple times?
8. Do you have any rituals (such as checking things) that you feel you have to do, even though you know it may be silly?
9. Do you have recurrent thoughts that you have trouble controlling?

The sexual history

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