Doctor and patient: General principles of history taking

Published on 02/03/2015 by admin

Filed under Internal Medicine

Last modified 02/03/2015

Print this page

This article have been viewed 6017 times

1 Doctor and patient

General principles of history taking

Michael Glynn

Introduction

If asked why they entered medicine, most doctors would say that they wish to relieve human suffering and disease. In order to achieve this aim for every patient, it is essential to understand what has gone wrong with normal human physiology in that individual, and how the patient’s personality, beliefs and environment are interacting with the disease process. History taking and clinical examination are crucial initial steps to achieving this understanding, even in an era in which the availability of sophisticated investigations might suggest to a lay person that a blood test or scan will give all the answers. In addition, the distinction between cure of disease and relief of symptoms remains as valid today as in the past. No patient should leave a medical consultation feeling that nothing can be done to help them, even when the disease is incurable.

Clinical methods – the skills doctors use to diagnose and treat disease – are acquired during a lifetime of medical work. Indeed, they evolve and change as new techniques and new concepts arise, and as the experience and maturity of the doctor develop. Clinical methods are acquired by a combination of study and experience, and there is always something new to learn.

The aims of any first consultation are to understand patients’ own perceptions of their problems and to start or complete the process of diagnosis. This double aim requires a knowledge of disease and its patterns of presentation, together with an ability to interpret a patient’s symptoms (what the patient reports/complains of, e.g. cough or headache) and the findings on observation or physical examination (called physical signs or, often, simply ‘signs’). Appropriate skills are needed to elicit the symptoms from the patient’s description and conversation, and the signs by observation and by physical examination. This requires not only experience and considerable knowledge of people in general, but also the skill to strike up a relationship, in a short space of time, with a range of very different individuals.

There are two main steps to making a diagnosis:

1 To establish the clinical features by history and examination – this represents the clinical database.

2 To interpret the clinical database in terms of disordered function and potential causative pathologies, whether physical, mental, social or a combination of these.

This book is about this process. This chapter introduces the basic principles of history and examination, while more detail about the history and examination of each system (cardiovascular, respiratory, etc.) is set out in individual succeeding chapters. Throughout the book, the patient is referred to as ‘he’, the editors preferring this to ‘he/she’ or ‘they’ (except in specific scenarios involving female patients).

Setting the scene

Most medical encounters or consultations do not occur in hospital wards but in a primary care or outpatient setting. Whatever the setting, a certain stability to the context of the consultation, including the consulting room itself, the waiting area and all the associated staff, makes the process of clinical diagnosis easier. Patients are less often assessed in their own home than previously, and many doctors now find this a strange concept.

Meeting the patient in the waiting room allows the doctor to make an early assessment of his demeanour, hearing, walking and any accompanying persons. It is good to offer a greeting and careful introduction and to observe the response unobtrusively, but with care. Patients are easily confused by medical titles and hierarchies. All of the following questions should be quickly assessed:

Does the patient smile, or appear furtive or anxious?

Does the patient make good eye contact?

Is he frightened or depressed?

Are posture and stance normal?

Is he short of breath, or wheezing?

In some conditions (e.g. congestive heart failure, Parkinson’s disease, stroke, severe anaemia, jaundice), the nature of the problem is immediately obvious. It is very important to identify the patient correctly, particularly if he has a name that is very common in the local community. Carefully check the full name, date of birth and address.

Pleasant surroundings are very important. It is essential that both patient and doctor feel at ease, and especially that neither feels threatened by the encounter. Avoid having patients full-face across a desk. Note taking is important during consultations while being able to see the patient and establish eye contact, and to show sympathy and awareness of his needs during the discussion of symptoms, much of which may be distressing or even embarrassing. If the doctor is right-handed and the patient sits on their left, at an angle to the desk, the situation is less formal, and clues such as agitated foot and hand movements are more evident. If other people are present, arrange the seating to make it clear that it is the patient who is the centre of attention, rather than any others present.

History taking

Having overcome the strangeness of meeting and talking to a wide variety of people that they might not ordinarily meet, the new medical student usually feels that history taking ought to be fairly simple but that physical examination is full of pitfalls such as unrecognized heart murmurs and confusing parts of the neurological examination. However, the experienced doctor comes to realize that history taking is immensely skilled, and that the extent to which skill increases with experience is probably greater than for clinical examination.

Beginning the history

The process of gathering information about a patient often begins by reading any referral documentation and with the immediate introduction of doctor and patient. However, once the social introductions are achieved, the doctor will usually begin with a single opening question. Broadly, there are two ways to do this.

A single open-ended question along the lines of ‘Tell me about what has led up to you coming here today’ gives the opportunity for the patient to begin with what he feels to be most important to him and avoids any prejudgement of issues or exclusion of what at first hearing may seem less important. However, at this stage the patient may be very anxious and nervous and still making his own assessment of how he will react to the doctor as a person. A beginning which focuses on issues which may be more factual and less emotive can be more rewarding and lead to a more satisfactory consultation. Box 1.1 lists some of the areas of questioning that can be usefully included at the beginning of the history. It is important to inform the patient that this is going to be the order of things, so that he does not feel that his pressing problems are being ignored. A statement along the lines of ‘Before we discuss why you have come today, I want to ask you some background questions’ should inform the patient satisfactorily.

Box 1.1 Areas of questioning that can be covered at the beginning of history taking

Confirm date of birth and age

Occupation and occupational history

Past medical history

Smoking

Alcohol consumption

Drug and treatment history

Family history

There is a particular logic in taking the past medical history at this stage. For many conditions, the distinction as to what is a current problem and what is past history is unclear and arbitrary in the patient’s mind. A patient presenting with an acute exacerbation of chronic obstructive pulmonary disease may have a history of respiratory problems going back many years. Therefore, taking the history along a ‘timeline’ will often build up a much better picture of all of the patient’s problems, how they have developed and how they now interact with life and work.

Once these preliminaries have been completed, the doctor should use a simple and open-ended question to encourage the patient to give a full and free account of the current issues. Say something along the lines of ‘Tell me about what has led up to you coming here today’. This wording leaves as open as possible any question about the cause of the patient’s problems and why he is seeing a doctor, and could give rise to an initial answer beginning with such varied phrases as ‘I have this pain …’, ‘I feel depressed …’, ‘I am extremely worried about …’, ‘I don’t know but my family doctor thought …’, ‘My wife insisted …’ or even ‘I thought you would already know from the letter my family doctor wrote to you’. All these answers are perfectly valid but each gives a different clue as to what are the real issues for the patient, and how to develop the history-taking process further for that individual.

This part of history taking is probably the most important and the most dependent on the skill of the doctor. It is always tempting to interrupt too early and, once interrupted, the patient rarely completes what he was intending to say. Even when he appears to have finished giving his reasons for the consultation, always ask if there are any more broad areas that will need discussion before beginning to discuss each in more detail.

Developing themes

This stage of the history is likely to see the patient talking much more than the doctor, but it remains vital for the doctor to steer and mould the process so that the information gathered is complete, coherent and, if possible, logical. Some patients will present a clear, concise and chronologically perfect history with little prompting, although they are in the minority. For most patients, the doctor will need to do a substantial amount of clarifying and summarizing with statements such as ‘You mean that …’, ‘Can I go back to when …’, Can I check I have understood …’, So up to that point you …’, ‘I am afraid I am not at all clear about …’ and ‘I really do not understand, can we go over that again?’ If a patient clearly indicates that he does not wish to discuss particular aspects of the history, then this wish must be respected and the diagnosis based on what information is available, although it is also important to explain to the patient the limitations that may be imposed by this lack of information.

Non-verbal communication

Within any consultation, the non-verbal communication is as important as what the patient says. There may be contradictions such as a patient who does not admit to any worries or anxieties but who clearly looks as if he has many. Particular gestures during the description of pain symptoms can give vital clinical clues (Box 1.2). While concentrating on the conversation with the patient, the doctor should keep a wide awareness of all other clues that can be gleaned from the consultation. These include the patient’s demeanour, dress and appearance, any walking aids, the interaction between the patient and any accompanying people and the way that the patient reacts to the developing consultation.

Box 1.2 Particular gestures useful in analysing specific pain symptoms

A squeezing gesture to describe cardiac pain

Hand position to describe renal colic

Rubbing the sternum to describe heartburn

Rubbing the buttock and thigh to describe sciatica

Arms clenched around the abdomen to describe mid-gut colic

It is very important to use vocabulary that the patient will understand and use appropriately. This understanding needs to be on two levels: he must understand the basic words used, and his interpretation of those words must be understood and clarified by the doctor. Box 1.3 lists words and phrases that may be used in the consultation that the doctor needs to be very careful to clarify with the patient. If the patient uses one of the ordinary English words listed, its meaning must be clarified. A patient who says he is dizzy could be describing actual vertigo, but could just mean light-headedness or a feeling that he is going to faint. A patient who says that he has diarrhoea could mean liquid stools passed hourly throughout the day and night, or could mean a couple of urgent soft stools passed first thing in the morning only. Therefore, the doctor needs to use words that are almost certainly going to be clearly understood by the patient, and the doctor must clarify any word or phrase that the patient uses, to avoid any possibility of ambiguity.