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

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:

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

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).

Cross-cultural history taking

If the patient’s first language is not the same as yours, he or she may find the medical interview very difficult. Maintain eye contact (unless this is considered rude in the cultural context) and be attentive as you ask questions.¹⁰

If language is an issue, an interpreter who is not a relative should be used to assist these patients. Some patients may be embarrassed to discuss medical problems in front of a relative, and relatives are often tempted to explain (or change) the patient’s answers instead of just translating them. Professional translators are trained to avoid this and can often provide simultaneous and accurate translation, but not all patients feel comfortable with a third person present. It is important to continue to make eye contact with the patient while asking questions, even though it will be the interpreter who responds; otherwise the patient may feel left out of the discussion. Questions should be directed as if going straight to the patient: ‘Have you had any problems with shortness of breath?’ rather than ‘Has he had any breathlessness?’ It always takes longer to interview a patient using an interpreter, and more time should be allowed for the consultation.

It is alarmingly common for relatives who accompany patients to interrupt and contradict the patient’s version of events even when they are not acting as translators. The interposition of a relative between the clinician and the patient always makes the history taking less direct and the patient’s symptoms more subject to ‘filtering’ or interpretation before the information reaches the clinician. Try tactfully to direct relatives to let the patient answer in his or her own words.

Attitudes to illness and disease vary in different cultures. Problems considered shameful by the patient may be very difficult for him or her to discuss. In some cultures (and increasingly in Australia), women may object to being questioned or examined by male doctors or students. Male students may need to be accompanied by a female chaperone for even the interview with sensitive female patients, and certainly should have one during the physical examination of the patient. It is most important that cultural sensitivities on either side are not allowed to prevent a thorough medical assessment.

Aboriginal patients may have a large extended family. These relatives may be able to provide invaluable support to the patient, but their own medical or social problems may interfere with the patient’s ability to manage his or her own health. Commitments to family members may make it difficult for the patient to come to medical appointments or to travel for specialist treatment. Detailed questioning about family contacts and responsibilities may help with the planning of the patient’s treatment.

Recent concepts in indigenous health care include the notions of cultural awareness, cultural sensitivity and cultural safety.^11,12 Cultural awareness can be thought of as the first step towards understanding the rituals, beliefs, customs and practices of a culture. Cultural sensitivity means accepting the importance and roles of these differences. Cultural safety means using this knowledge to protect patients and communities from danger, and making sure that there is a genuine partnership between the health workers and their indigenous patients. These skills have general application for all cultural groups but vary in detail from one to another.

All of these problems require an especially sensitive approach. You as a clinician need to be impartial and objective. Students may need to discuss specific problems with members of the medical faculty and find out what the university and hospital policies are on these matters.

The ‘uncooperative’ or ‘difficult’ patient and the history

Most clinical encounters are a cooperative effort on the part of the patient and clinician. The patient wants help to find out what is wrong and to get better. This should make the meeting satisfying and friendly for both parties. However, interviews do not always run smoothly.¹³ Resentment may occur on both sides if the patient seems not to be taking the doctor’s advice seriously, or will not cooperate with attempts at history taking or examination. Unless there is a serious psychiatric or neurological problem that impairs the patient’s judgment, taking or not taking advice remains his or her prerogative. The clinician’s role is to give advice and explanation, not to dictate. Indeed, it must be realised that the advice may not always be correct. Keeping this in mind will help prevent that most unsatisfactory and unprofessional of outcomes—becoming angry with the patient.

This approach, however, must not be an excuse for not providing a proper, sympathetic and thorough explanation of the problem and the consequences of ignoring medical advice, to the extent that the patient will allow. A clinician whose advice is rarely accepted should begin to wonder about his or her clinical acumen.

Patients who are aggressive and uncooperative may have a medical reason for their behaviour. The possibilities to be considered include alcohol or drug withdrawal, an intracranial lesion such as a tumour or subdural haematoma, or a psychiatric disease such as paranoid schizophrenia. In other cases, resentment at the occurrence of illness may be the problem.

Some patients may seem difficult because they are too cooperative. The patient concerned about his blood pressure may have brought printouts of his own blood pressure measurements at half-hour intervals for several weeks. It is important to show restrained interest in these recordings, without encouraging excessive enthusiasm in the patient. Other patients may bring with them information about their symptoms or a diagnosis obtained from the internet. It is important to remember, and perhaps point out, that information obtained in this way may not have been subjected to any form of peer review. People with chronic illnesses, on the other hand, may know more about their conditions than their medical attendants.

Sometimes the interests of the patient and the doctor are not the same. This is especially so in cases where there is the possibility of compensation for an illness or injury. These patients may, consciously or unconsciously, attempt to manipulate the encounter. This is a very difficult situation and can be approached only by rigorous application of clinical methods.

Occasionally, attempted manipulation takes the form of flattery or inappropriate personal interest directed at the clinician. This should be dealt with by carefully maintaining professional detachment. The clinician and the patient must be conscious that their meeting is a professional and not a social one.

History taking for the maintenance of good health

There has never been more public awareness of the influence the way people live has on their health. Most people have some understanding of the dangers of smoking, excessive alcohol consumption and obesity. People have more varied views on what constitutes a healthy diet and exercise regime, and many are ignorant of what constitutes risky sexual activity.

Part of the thorough assessment of patients includes obtaining and conveying some idea of what measures may help them maintain good health (Questions box 2.4). This includes a comprehensive approach to the combination of risk factors for various diseases, which is much more important than each individual risk factor. For example, advising a patient about the risk of premature cardiovascular disease will involve knowing about the family history, smoking history, previous and current blood pressure, current and historical cholesterol levels, dietary history, assessment for diabetes mellitus and how much exercise the patient undertakes.

Ask about screening tests being done for any serious illnesses, such as mammograms for breast cancer, Pap smears for cervical cancer or colonoscopy for colon cancer.

The first interview with a patient is an opportunity to make an assessment of the known risk factors for a number of important medical conditions. Even when the patient has come about an unconnected problem, there is often the opportunity for a quick review. Constant matter-of-fact reminding about these can make a great difference to the way people protect themselves from ill-health.

The patient’s awareness and understanding of these basic measures for maintaining good health can be assessed throughout the interview. Even when they are unrelated to the presenting problem, serious examples of risky behaviour should be pointed out. This should not be done in an aggressive way. For example, you might say: ‘This might be a good time to make a big effort to give up smoking, because it’s especially unwise for someone like you with a family history of heart disease.’

Certain questions can be helpful in making a diagnosis of alcoholism; these are referred to as the CAGE questions (see Chapter 1). Another approach is to ask, ‘Have you ever had a drinking problem?’ and ‘Did you have your last drink within the last 24 hours?’ The patient who answers ‘yes’ to both questions is likely to be a high-risk drinker.

The patient’s vaccination record should be reviewed regularly and brought up to date when indicated. The dead virus vaccines include influenza and polio (injectable); hepatitis A and B vaccines are recombinant vaccines. Dead bacteria vaccines include the pneumococcal, meningococcal and H. influenzae vaccines; tetanus, diphtheria and pertussis are bacterial toxins modified to be non-toxic. The attenuated live-virus vaccines include measles-mumps-rubella (MMR), herpes zoster and influenza (nasal); an attenuated live-bacteria vaccine is bacille Calmette-Guérin (BCG—for tuberculosis). Pregnant women and immunosuppressed people should not be given attenuated live vaccines. Travel to rural Asia and other exotic places may be an indication for additional vaccinations (e.g. Japanese encephalitis, typhoid).

The elderly patient

Patients who are in their seventies or older present with similar illnesses to younger patients but certain problems are more likely in older patients. History taking should address these potential problems as part of the ‘maintenance of good health’ aspect of history taking.

Evidence-based history taking and differential diagnosis

The principles of evidence-based clinical examination are discussed in the next chapter in more detail, but they also have an application to history taking. The starting point of the differential diagnosis of a certain symptom is the likelihood (or probability) that a certain condition will occur in this person. Most clinicians still rely on their own experience when making this assessment, although some information of disease prevalence in different populations is becoming available. Unfortunately, one person’s experience is a relatively small sample, and past experience may bias the clinician in favour of or against a certain diagnosis.

Some diagnoses may largely be excluded from the differential diagnosis list at once. This may be based, for example, on the patient’s age, sex or race or the extreme rarity of the disease in a particular country. For example, chronic obstructive pulmonary disease would be very unlikely in a 20-year-old non-smoker who presents with breathlessness.

The differential diagnosis is gradually narrowed as more information about the patient’s symptoms comes from the patient directly, and as a result of specific questioning about features of the symptoms that will help to refine the list.

A symptom typical of a certain condition will increase the likelihood of the diagnosis by a certain percentage. If the prevalence of the condition is already high, a high likelihood ratio (LR) should bring that condition towards the top of the differential list. For example, a patient’s description of ‘typical angina’ has a strong LR of 5.8 for the diagnosis of significant coronary artery disease. This would make the diagnosis highly likely in a patient from a population with a high prevalence of coronary disease (e.g. a man over the age of 50 with typical anginal chest pain) but still very unlikely in someone from a very low risk population (e.g. a 19-year-old woman). Likelihood ratios are discussed in more detail in Chapter 3.

The clinical assessment

After the physical examination, the interview with the patient concludes with an assessment by the clinician of what the diagnosis or possible diagnoses are, in order of probability.¹⁴ This will, not unreasonably, be the most important part of the whole process from the patient’s point of view.

The explanation must relate to the patient’s symptoms or perception of the problem. The clinician should explain how the symptoms and any examination findings relate to the diagnosis. For example, if a patient presents with dyspnoea, the clinician should begin by saying, ‘I believe your shortness of breath is probably the result of pneumonia, but there are a few other possibilities’. The complexity of the explanation will depend on the clinician’s understanding of the patient’s ability to follow any technical aspects of the diagnosis. The patient’s desire for a detailed explanation is also variable, and this must be taken into account.

If the diagnosis is fairly definite, then the prognosis and the implications of this must be outlined. A serious diagnosis must be discussed frankly but always in the context of the variability of outcome for most medical conditions and the benefits of correct treatment. When a patient seems unwilling to accept a serious diagnosis and seems likely to decline treatment, the clinician must attempt to find out the reason for the patient’s decision. Have there been previous bad experiences with medical treatment, or has a friend or relative had a similar diagnosis and a difficult time with treatment or complications?

Sometimes blunt language may be justified. For example, ‘It is important for you to realise that this is a life-threatening illness which needs urgent treatment.’ Patients who seem unable to accept advice of this sort should be offered a chance to discuss the matter with another doctor or with their family. This must be done sympathetically: ‘This is obviously a difficult time for you. Would you like me to arrange for you to see someone for another opinion about it? Or would you like to come back with some of your family to talk about it again?’ The patient’s response should be carefully documented in the notes.

Patients may need to be cautioned about certain activities until the condition is treated. For example, a patient with a possible first epileptic seizure must be told that he or she may not legally drive a motor vehicle.

Concluding the interview

After talking to the patient about the assessment and prognosis, the need for investigations and any urgency involved should be discussed. Admission to hospital may be recommended if the problem is a serious one. This may involve major inconvenience to a patient; the clinician must be ready to justify the recommendation and attempt to predict the likely length of stay. If the investigations are onerous or involve risk, this must also be explained and alternatives discussed, if they are available.

If drug treatment is being prescribed, the patient is entitled to know why this is necessary, what it is likely to achieve and what possible important adverse effects might occur. This is a complex topic. On the clinician’s part, it requires a comprehensive understanding of drug interactions and adverse effects, as well as an assessment of what it is reasonable to tell a patient without causing alarm or symptoms by suggestion. Patients must at least know what dangerous symptoms should lead to immediate cessation of the drug. Pharmacies often provide patients with long and unedited lists of possible adverse effects when they dispense drugs. Patients may be too frightened to take the prescription unless these are explained at the time of the consultation. Dealing with this difficult area takes time and experience.

There is no shame in telling a patient you will look up possible side-effects and interactions of a drug before you prescribe it or if a patient expresses concern about it. You could say ‘I haven’t heard of that problem with this drug but let me look it up and check.’

Finally, the patient must be given the opportunity to ask questions. Few people, given a complicated diagnosis, can absorb everything that has been said to them. The patient should be reminded that there will be an opportunity to ask further questions at the next consultation, when the results of tests or the effects of treatment can be assessed.