Doctor and patient: General principles of history taking

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1 Doctor and patient

General principles of history taking

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:

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:

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.

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.

Vocabulary

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.

Indirect and direct questions

Broadly, questions asked by the doctor can be divided into indirect or open-ended and direct or closed. Indirect or open-ended questions can be regarded as an invitation for the patient to talk about the general area that the doctor indicates is of interest. These questions will often start with phrases like ‘Tell me more about …’, ‘What do you think about …’, ‘How does that make you feel …’, ‘What happened next …’ or ‘Is there anything else you would like to tell me?’ They inform the patient that the agenda is very much with him, that he can talk about whatever is important and that the doctor has not prejudged any issues. If skilfully used, and if the doctor is sensitive to the clues presented in the answers, a series of such questions should allow the doctor to understand the issues that are most important from the patient’s point of view. The patient will also be allowed to describe things in his own words.

Many patients are in awe of doctors and have some conscious or subconscious need to please them and go along with what they say. If the doctor prejudges the patient’s problems and tends to ‘railroad’ the conversation to fit their assumed diagnosis too early in the process, then the patient can easily go along with this and give simple answers that do not fully describe his situation. Box 1.4 illustrates this extremely simple, common and important pitfall of history taking.

Box 1.4 Example of a history that leads to a poor conclusion

A GP is seeing a 58-year-old man who is known to be hypertensive and a smoker. The receptionist has already documented that he is coming in with a problem of chest pain. The GP makes an automatic assumption that the pain is most likely to be angina pectoris, because that is probably the most serious cause and the one that the patient is likely to be most worried about, and therefore starts taking the history with the specific purpose of confirming or refuting that diagnosis.

The GP has only asked very direct and closed questions. Each answer has begun with ‘Yes’. The patient has already been quite firmly tagged with a ‘label’ of angina, and anxiety has been raised by the specialist referral.

Alternatively, the GP keeps an open mind and starts as follows:

The GP has asked questions which are either completely open-ended or leave the patient free to describe exactly what happens within a directed area of interest. Clarifying questions have been used. While being reassuring, the GP expresses some concern about angina, and is clear about the exact reason for the specialist referral (for clarification).

Judging the severity of symptoms

Many symptoms are subjective and the degree of severity expressed by the patient will depend on his own personal reaction and also on how the symptoms interact with his life. A tiny alteration in the neurological function of the hands and fingers will make a huge impression on a professional musician, whereas most others might hardly notice the same dysfunction. A mild skin complaint might be devastating for a professional model but cause little worry in others.

Trying to assess how the symptoms interact with the patient’s life is an important skill of history taking. A simple question such as ‘How much does this bother you?’ might suffice. It may be helpful to ask specific questions about how the patient’s daily life is affected, with comparison to events that many patients will experience. Box 1.5 illustrates some of the relevant areas.

Medical symptomatology often involves pain, which is probably more subjective than almost anything else. Many patients are stoical and bear severe pain uncomplainingly whereas others seem to complain much more about apparently less severe pain. A simple pain scale can be very helpful in assessing the severity of pain. The patient is asked to rate his pain on a scale from 1 to 10, with 1 being a pain that is barely noticeable and 10 the worst pain he can imagine, or the worst pain he has ever experienced. It is also useful to clarify what the reference point is for ‘10’, which for many women will be the pain of labour. The pain scale assessment is useful in diagnosis and in monitoring disease, treatment and analgesia. Assessing a patient with pain is discussed in more detail in Chapter 9.

A schematic history

A suggested schematic history is detailed in Box 1.6. There will be many clinical situations in which it will be clear that a different scheme should be followed. An important part of learning about history taking is that each doctor develops their own personal scheme that works for them in the situations that they generally come across. Nevertheless, it is useful to start with a basic outline in mind.

Direct questions about bodily systems

Within the variety of disease processes that may present to doctors, many have features that occur in many of the bodily systems which at first may not seem to be related to the patient’s main complaint. A patient presenting with back pain may have had some haematuria from a renal cell carcinoma that has spread and is the cause of the presenting symptom. For this reason, any thorough assessment of a patient must include questions about all the bodily systems and not just areas that the patient perceives as problematic. This area of questioning should be introduced with a statement such as ‘I am now going to ask you about other possible symptoms that could be important and relevant to your problem’. A list of such question areas is given in Box 1.7.

In addition, during any medical consultation, however brief, it is the duty of the doctor to be alert to all aspects of the patient’s health and not just the area or problem that he has presented with. For example, a GP would not ignore a high blood pressure reading in a patient presenting with a rash, even though the two are probably not connected. This function of any consultation can be regarded as ‘screening’ the patient. In health economic terms, a true screening programme for a particular disease across a whole population (such as for cervical cancer) has to be evaluated as being useful, economic and with no negative effects. However, once the patient has attended a doctor with a complaint, a simple screening process can be incorporated into the consultation with little extra time or effort. The direct questions (and full routine examination) encompass this screening function as well as contributing to solving the patient’s presenting problems.

Clarifying detail

One of the basic principles of history taking is not to take what the patient says at face value but to clarify it as much as possible. Almost all of the history will involve clarification but there are specific areas where this is particularly important.

Pain

Whenever a patient complains of pain, there should follow a series of clarifying questions as listed in Box 1.8. Of all symptoms, pain is perhaps the most subjective and the hardest for the doctor to truly comprehend. A simple pain scale has been described above. The other characteristics are vital in analysing what might be the cause of pain. Some painful conditions have classic sites for the pain and the radiation (myocardial ischaemia is classically felt in the centre of the chest radiating to the left arm). Pain from a hollow organ is classically colicky (such as biliary or renal colic). The pain of a subarachnoid haemorrhage is classically very sudden, ‘like a hammer blow to the head’. Some pains have clear aggravating or relieving factors (peptic ulcer pain is classically worse when hungry and better after food). Colicky right upper quadrant abdominal pain accompanied by jaundice suggests a gallstone obstructing the bile duct and a headache accompanied by preceding flashing lights suggests migraine. It is always worth making sure that any symptom of pain has been clarified in this way, and while some of the points will come out in the open-ended part of the history taking, others will need specific questions.

Drug history

At first glance, asking a patient what drugs he is taking would seem to be one of the simplest and most reliable parts of taking a history. In practice, this could not be further from the truth, and there are many pitfalls for the inexperienced. This is partly because many patients are not very knowledgeable about their own medications, and also because patients often misinterpret the question, giving a very narrow answer when the doctor wants to know about medications in the widest sense. The need for clarification in the drug history is given in Box 1.9. The drug history, almost more than any other, benefits from being repeated at another time and in a slightly different way. For example, in trying to define a possible drug reaction as a cause of liver dysfunction, it is not unusual to find that the patient has taken a few relevant tablets (such as over-the-counter non-steroidal anti-inflammatory drugs) just before the onset of the problem, and only remembered or realized it was important to say so when asked repeatedly in great detail.

Alcohol history

The detrimental effects of alcohol on health cause a variety of problems and the frequency of excess alcohol use in Western countries means that up to 10% of adult hospital inpatients have a problem related to alcohol. To make an accurate estimate of alcohol consumption and any possible dependency, it is essential to enquire carefully and not to take what the patient says at face value, but to probe the history in different ways (Box 1.11). For documentation, the reported amount should then be converted into units of alcohol per week (Box 1.12). If the reported amount seems at all excessive then an assessment should be made of possible dependency for which the CAGE questions are very useful (Box 1.13).

Particular situations

It is true to say that while there are many themes, patterns and common areas to history taking, and some areas of history taking might seem routine, the process of history taking for different patients will never be identical. There are some particular and often challenging situations that deserve some further description.

Garrulous patients

A new medical student will soon meet a patient who says a huge amount without really revealing the information that goes towards a useful medical history. This will be in marked contrast to some other patients who, from the first introductory question (e.g. ‘Tell me about what has led up to you coming here today’), will reveal a perfect history with virtually no prompting. A fictitious, but typical, history from the former type of patient is given in Box 1.14. When faced with such a patient, the doctor will need to significantly alter the balance of open-ended and direct questions. Open-ended questions will tend to lead to such a patient giving a long recitation but with little useful content. The doctor will have to use many more clear direct questions which may just have yes/no answers. The overall history will inevitably be less satisfactory but it is not possible to get the ‘perfect’ history in every patient.

Box 1.14 A typical ‘garrulous’ history

The doctor gradually changes from very open-ended to very closed questions in order to try to get some information that is useful to building up the diagnostic picture – eventually a question is asked that just has a yes/no answer.

Angry patients

Few patients are overtly angry when they see a doctor, but anger expressed during a clinical consultation may be an important diagnostic clue while at the same time getting in the way of a smooth diagnostic process. Some patients will be angry with the immediate circumstances such as a late-running outpatient clinic. Others will have longer term anger against the surgery, department or institution which will be more difficult to address. It is always important to acknowledge anger and to try and tease out what underlies it. Even if it is not the doctor’s immediate fault that the clinic is running late or there have been other problems, it is always worth apologizing on behalf of the unit or institution.

For some patients, anger may be part of the symptomatology or expressed as a reaction to the diagnosis or treatment. This will be particularly true in patients with a non-organic diagnosis who insist that there is ‘something wrong’ and that the doctor must do something. Many types of presentation will fall into this group, including tension headache, irritable bowel and back pain. There may be obvious secondary gain for the patient (such as staying off work and claiming benefits) and challenging this pattern of behaviour may provoke anger.

It is the duty of a doctor to attempt to work with and help a wide variety of patients and those who are angry are no exception. However, occasionally it may be best to acknowledge that the doctor–patient relationship has broken down and facilitating a change to another doctor may be in the best interests of the patient.

Accompanying persons

Some people come to consultations alone, others with one or more friends or family members. Always spend time during the initial exchange of greetings to identify who is present and to get some idea of the group dynamics. If they appear to be alone, ask whether there is someone waiting outside. There is always a reason why people come accompanied, but if there appear to be too many people present, or if the presence of others might threaten the relationship with the patient at any time in the consultation, it is appropriate to consider asking the others to leave, even if only briefly. It is reasonable, if in doubt, to ascertain why others wish to be present, and, certainly, whether this is also the patient’s wish. It is very important to be certain that the patient is happy for any others to be present and to be as certain as possible that the patient does not wish to object but feels unable to do so. This is particularly difficult if the doctor does not speak the patient’s language but can speak to those accompanying. Consider whether specific questions about the history should be asked of those accompanying, either with the patient or separately, with specific consent.

Beware of a situation in which the accompanying people answer all the questions, even if there is not a language difficulty. Many clues to diagnosis may be masked if direct communication with the patient is not possible (using an interpreter/advocate for patients who do not speak the same language as the doctor is discussed below). There may be many reasons that the patient does not speak for himself. These may include embarrassment in front of those accompanying (such as a teenager with his parents). In such circumstances, it may be necessary to leave parts of the history until those accompanying can reasonably be asked to leave, such as during the examination. Occasionally it is clear that the patient will not talk for himself, in which case the history from those accompanying will have to be the working information.

Using interpreters/advocates

Particularly in the inner cities of Western countries, there will often be a large immigrant population who do not speak the first language of the country, even if they have been resident for some years, and it is impractical for each patient to be looked after by health professionals who speak their language. In these circumstances, the medical consultation has to be undertaken with an interpreter. The most immediate solution may be to use a family member, but if the issues are private or embarrassing, this often does not work well. It is unethical to use an underage family member as an interpreter.

The best solution is to have available an independent interpreter/advocate for the consultation, although in areas where many patients are not native speakers, many interpreters will be needed for a range of languages. Another solution for infrequently encountered languages is a telephone interpreting service.

When taking a history via an interpreter/advocate, the overall style usually has to change. The breadth of history and the clinical clues that can be obtained from a good initial open-ended question may well be lost in the double translation, and the doctor often changes to a much more direct style of questioning for which the answers will be unambiguous even when going through the double translation. It is also not unusual for the interpreter/advocate and the patient to have a few minutes of conversation following an apparently simple question from the doctor, but then a very short answer is returned to the doctor. This leaves the doctor bemused as to what is really going on with the patient. Finally, history taking via an interpreter/advocate usually takes much longer than when the doctor and the patient speak the same language.

Analysing symptoms

The objective of the history and examination is to begin identifying the disturbance of function and structure responsible for the patient’s symptoms. This is done by analysis of the symptoms and signs leading to a differential diagnosis (a list of possible diagnoses that will account for the symptoms and signs, usually set out in descending order of likelihood). This list of possibilities is then often refined by the use of special investigations but, in up to 80% of patients, the likely diagnosis is clear after the initial history and examination. The process of analysis can be likened to detective work, in which the symptoms and signs are the evidence. When a medical student is first faced with the myriad of data gleaned on taking a history, he is often baffled as to how to start the analysis, but inevitably the process becomes easier as more medical knowledge is acquired. An analysis of symptoms from a medical student is more based on facts learned from textbooks, whereas an experienced doctor will tend to base the analysis more on patterns of disease presentation that they have encountered many times. While the analytical process is largely acquired through this type of experience, some principles can be described.

Time course

A simple epithet states that the type of symptom suggests the ‘anatomy’ of the problem and the time course the ‘pathology’ of it. For instance, a vascular event such as a myocardial infarct, stroke or subarachnoid haemorrhage usually has a sudden onset, whereas something that gradually progresses or for which the onset cannot be exactly dated by the patient, such as weight loss or dysphagia, may be a malignant process. There are some pitfalls in this type of analysis which must be borne in mind to avoid confusion.

Disease processes that gradually progress may start off by being asymptomatic and the patient may only notice symptoms when they start to interfere with his lifestyle and activities. For example, exertional breathlessness in a largely sedentary patient may develop late on in a cardiorespiratory disease process, whereas a patient who actively exercises is likely to notice symptoms much earlier. This phenomenon is also seen where the relevant bodily organ or system has a lot of reserve and the symptom may only show itself when the reserve is used up. This could be true for a relatively chronic liver disease such as primary biliary cirrhosis apparently presenting acutely. The proverb of the ‘straw that broke the camel’s back’ is a good analogy of this sort of situation (a camel is steadily loaded up with straw until suddenly it appears that a tiny piece of straw is sufficient to make the camel collapse). In addition, the disease process may have a step-wise worsening rather than a linear decline, such as in a situation of multiple small strokes when the patient may not present until a single small stroke makes a big difference to his functional ability.

Conclusion

History taking is the cornerstone of medical practice. It combines considerable interpersonal skill and diversity with the need for logical thought based on a wealth of medical knowledge, and represents the beginning of treating and caring for patients in the widest sense. Almost all the attributes of good medical practice as set out by the UK General Medical Council (Box 1.17) are encompassed in good history taking. Taking a detailed history while getting to know a patient and arriving at a likely diagnosis is as rewarding in itself as performing a technical procedure for a patient or seeing him get better in the end.