1 Doctor and patient
General principles of history taking
Introduction
Setting the scene
History taking
Beginning the history
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.
Developing themes
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.
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
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
GP: I gather you’ve had some chest pain?
Patient: Yes, it’s been quite bad.
GP: Is it in the middle of your chest?
GP: And does it travel to your left arm?
Patient: Yes – and to my shoulder.
GP: Does it come on when you walk?
GP: And is it relieved by rest?
GP: I’m afraid I think this is angina and I will need to refer you to a heart specialist.
Alternatively, the GP keeps an open mind and starts as follows:
Judging the severity of symptoms
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.
Box 1.5 Areas of everyday life that can be used as a reference for the severity, importance or clarification of symptoms
Work: ‘Has this problem kept you off work?’, ‘Why exactly have you not been able to work?’
Sport: ‘Do you play regular sport and has this been affected?’
Eating: ‘Has this affected your eating?’, ‘Do any particular foods cause trouble?’
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.
Box 1.6 Suggested scheme for basic history taking
Name, age, occupation, country of birth, other clarification of identity
Past medical history – ‘Before we talk about why you have come, I need to ask you to tell me about any serious medical problems that you have had in the whole of your life’
Specific past medical history – e.g. diabetes, jaundice, TB, heart disease, high blood pressure, rheumatic fever, epilepsy
History of main presenting complaint
Drug and other treatment history
Direct questions about bodily systems not covered by the presenting complaint
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.
Box 1.7 Bodily systems and questions relevant to taking a full history from most patients. If the specific questions have been covered by the history of the presenting complaint, they do not need to be included again. If the answers are positive, the characteristics of each must be clarified
Clarifying detail
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.
Box 1.9 Clarifying questions in the drug history
Can you tell me all the drugs or medicines that you take?
Have any been prescribed from another clinic, doctor or dentist?
Do you buy any yourself from a pharmacy?
Are you sure you have told me about all tablets, capsules and liquid medicines?
What about inhalers, skin creams or patches, suppositories or tablets to suck?
Were you taking any medicines a little while ago but stopped recently?
Do you ever take any medicines prescribed for other people such as your spouse?
Family history
Like the drug history, the family history would seem at first glance to be simple and reliably quoted. In general this is true, but it can be dissected into sections that will uncover more information. These are set out in Box 1.10.
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).
Box 1.11 Probing the alcohol history
Doctor: Do you drink any alcoholic drinks?
Patient: Oh yes, but not much – just socially.
Doctor: Do you drink some every day?
Doctor: Tell me what you drink.
Patient: I usually have two pints of beer at lunchtime and two or three on my way home from work.
Paitent: I usually go out Saturday nights and have four or five pints.
Doctor: Do you drink anything other than beer?
Patient: On Saturdays I have a double whisky with each pint.
The first answer does not suggest a problem. Based on the figures in Box 1.12, the actual amount adds up to 70 units per week which clearly confers considerable health risks to this patient.
Box 1.12 Units of alcohol (1 unit contains 10 g of pure alcohol)
Standard-strength beer (3.5% abv): 1 pint = 2 units
Very strong lagers (6% abv): 1 pint = 3.5 units
Spirits (whisky, gin, etc., 40% abv): 1 UK pub measure (about 25 ml) = 1 unit
The recommended safe limits per week for alcohol are 21 units for men and 14 for women.
Box 1.13 The CAGE assessment for alcohol dependency
C – Have you ever felt the need to Cut down your alcohol consumption?
A – Have you ever felt Angry at others criticizing your drinking?
Two or more positive answers could indicate a problem of dependency.
Particular situations
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
Doctor: Tell me about what has led up to you coming here today.
Doctor (interrupting): Can you tell me what did happen when you woke up last Monday?
Doctor (interrupting): So you had some pain when you woke up then?
Doctor (interrupting): Was the pain burning or crushing?
Patient: Well, that depends on what you mean by …
Doctor (interrupting): Yes, but did you have any crushing pain?
Analysing symptoms
‘Hard and soft’ symptoms
A detective analysing evidence of a crime will put a lot of weight on fingerprint or DNA evidence and less weight on identification evidence. The same principles apply to analysing symptoms. A ‘hard’ symptom can be thought of as one which, if clearly present, adds a lot of weight to a particular diagnosis. A ‘soft’ symptom may be thought of as one which is either reported by patients so variably that its true presence is often in doubt, or one which is present in such a variety of conditions as to not be useful in confirming or refuting a diagnosis. Examples of these two groupings are given in Box 1.15.
Box 1.15 ‘Hard’ and ‘soft’ symptoms
‘Hard’ symptoms
Pneumaturia: almost always due to a colovesical fistula
Fortification spectra: if associated with unilateral headache, strongly suggests classical migraine
Rigors: strongly suggests bacteraemia, viraemia or malaria
A bitten tongue: if associated with a seizure, strongly suggests a grand mal fit
A sudden severe headache ‘like a hammer blow’: strongly suggests a subarachnoid haemorrhage
Pleuritic chest pain: strongly suggests pleural irritation due to infection or a pulmonary embolus
Itching: if associated with jaundice, indicates intra- or extrahepatic cholestasis
What does the patient actually want?
If a patient comes to a doctor with a long history, it is always worth trying to find out why he has come for medical help and what he actually wants from the consultation. There may be various scenarios as listed in Box 1.16. It is always worth trying to find out which might apply to the patient, because it sets the scene for giving advice and treatment, particularly if an exact diagnosis or a complete treatment cannot be provided. It is often much easier to reassure a patient that there is nothing seriously wrong than to give him an exact diagnosis or fully relieve his symptoms.
Box 1.16 General reasons that patients come to see doctors (other than for a severe or acute problem)
Cannot tolerate ongoing symptoms
Someone else noticing specific problems (e.g. jaundice)
Another doctor noticing specific problems (e.g. high blood pressure)
Worry about underlying diagnosis (often induced by relatives, friends, books, media or Internet)
Spouse or relative worried about patient
Colleagues/bosses complaining about patient’s work or time off
Requirement of others (insurance, employment benefit, litigation)
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.
Box 1.17 Duties of doctors registered with the UK General Medical Council
Make the care of your patient your first concern
Treat every patient politely and considerately
Respect patients’ dignity and privacy
Listen to patients and respect their views
Give patients information in a way they can understand
Respect the right of patients to be fully involved in all decisions about their care
Keep your professional knowledge and skills up to date
Recognize the limits of your professional competency
Respect and protect confidential information
Make sure that your personal beliefs do not prejudice your patients’ care
Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practise
Avoid abusing your position as a doctor
Work with colleagues in the ways that best serve patients’ interests