The general principles of history taking

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Chapter 1 The general principles of history taking

Medicine is learned by the bedside and not in the classroom.

Sir William Osler (1849–1919)

An extensive knowledge of medical facts is not useful unless a doctor is able to extract accurate and succinct information from a sick person about his or her illness. In all branches of medicine, the development of a rational plan of management depends on a correct diagnosis or sensible, differential diagnosis (list of possible diagnoses). Except for patients who are extremely ill, taking a careful medical history should precede both examination and treatment. A medical history is the first step in making a diagnosis; it will often help direct the physical examination and will usually determine what investigations are appropriate. More often than not, an accurate history suggests the correct diagnosis, whereas the physical examination and subsequent investigations merely serve to confirm this impression.1,2 The history is also, of course, the least expensive way of making a diagnosis.

Changes in medical education mean that much student teaching is now conducted away from the traditional hospital ward. Students must still learn how to take a thorough medical history, but obviously adjustments to the technique must be made for patients seen in busy surgeries or outpatient departments. Much information about a patient’s previous medical history may already be available in hospital or clinic records; the detail needed will vary depending on the complexity of the presenting problem and whether the visit is a follow-up or a new consultation. All students must, however, have a comprehensive understanding of how to take a complete medical history.

Bedside manner and establishing rapport

History taking requires practice and depends very much on the doctor–patient relationship.3 It is important to try to put the patient at ease immediately, because unless a rapport is established, the history taking is likely to be unrewarding.

There is no doubt that the treatment of a patient begins the moment one reaches the bedside or the patient enters the consulting rooms. The patient’s first impressions of a doctor’s professional manner will have a lasting effect. One of the axioms of the medical profession is primum non nocere (the first thing is to cause no harm).4 An unkind and thoughtless approach to questioning and examining a patient can cause harm before any treatment has had the opportunity to do so. You should aim to leave the patient feeling better for your visit. This is a difficult technique to teach. Much has been written about the correct way to interview patients, but each doctor has to develop his or her own method, guided by experience gained from clinical teachers and patients.5–8

To help establish this good relationship, the student or doctor must make a deliberate point of introducing him- or herself and explaining his or her role. This is especially relevant for students or junior doctors seeing patients in hospital. A student might say: ‘Good afternoon, Mrs Evans. My name is Jane Smith; I am Dr Osler’s medical student. She has asked me to come and see you.’ A patient seen at a clinic should be asked to come and sit down, and be directed to a chair. The door should be shut or, if the patient is in the ward, the curtains drawn to give some privacy. The clinician should sit down beside or near the patient so as to be close to eye level and give the impression that the interview will be an unhurried one.9,10 It is important here to address the patient respectfully and use his or her name and title. Some general remarks about the weather, hospital food or the crowded waiting room may be appropriate to help put the patient at ease, but these must not be patronising.

Obtaining the history

Allow the patient to tell the whole story, then ask questions to fill in the gaps. Always listen carefully. At the end of the history and examination, a detailed record is made. However, many clinicians find it useful to make rough notes during the interview. With practice this can be done without loss of rapport. In fact, pausing to make a note of a patient’s answer to a question suggests that it is being taken seriously.

Many clinics and hospitals use computer records which may be displayed on a computer screen on the desk. Notes are sometimes added to these during the interview via a keyboard. It can be very off-putting for a patient when the interviewing doctor looks entirely at the computer screen rather than at the patient. With practice it is possible to enter data while maintaining eye contact with a patient, but at first it is probably preferable in most cases to make written notes and transcribe them later.

The final record must be a sequential, accurate account of the development and course of the illness or illnesses of the patient (Appendix I, page 461). There are a number of methods of recording this information. Hospitals may have printed forms with spaces for recording specific information. This applies especially to routine admissions (e.g. for minor surgical procedures). Follow-up consultation questions and notes will be briefer than those of the initial consultation; obviously, many questions are only relevant for the initial consultation. When a patient is seen repeatedly at a clinic or in a general practice setting, the current presenting history may be listed as an ‘active’ problem and the past history as a series of ‘inactive’ or ‘still active’ problems.

A sick patient will sometimes emphasise irrelevant facts and forget about very important symptoms. For this reason, a systematic approach to history taking and recording is crucial (Table 1.1).11

Table 1.1 History-taking sequence

1 Presenting (principal) symptom (PS)
2 History of presenting illness (HPI)

Details of current illnesses
Details of previous similar episodes
Current treatment and drug history
Menstrual and reproductive history for women
Extent of functional disability

3 Past history (PH)

Past illnesses and surgical operations
Past treatments
Allergies
Blood transfusions
4 Social history (SH)

Occupation, education
Smoking, alcohol, analgesic use
Overseas travel, immunisation
Marital status, social support
Living conditions
5 Family history (FH) 6 Systems review (SR)

See Questions box 1.1, page 9
Also refer to Appendix I.

Introductory questions

In order to obtain a good history the clinician must establish a good relationship, interview in a logical manner, listen carefully, interrupt appropriately, note non-verbal clues, and correctly interpret the information obtained.

The next step after introducing oneself should be to find out the patient’s major symptoms or medical problems. Asking the patient ‘What brought you here today?’ can be unwise, as it often promotes the reply ‘an ambulance’ or ‘a car’. This little joke wears thin after some years in clinical practice. It is best to attempt a conversational approach and ask the patient ‘What has been the trouble or problem recently?’ or ‘When were you last quite well?’ For a follow-up consultation some reference to the last visit is appropriate, for example: ‘How have things been going since I saw you last?’ or ‘It’s about … weeks since I saw you last, isn’t it? What’s been happening since then?’ This lets the patient know the clinician hasn’t forgotten him or her. Some writers suggest the clinician begin with questions to the patient about more general aspects of his or her life. There is a danger that this attempt to establish early rapport will seem intrusive to a person who has come for help about a specific problem, albeit one related to other aspects of his or her life. This type of general and personal information may be better approached once the clinician has shown an interest in the presenting problem or as part of the social history. The best approach and timing of this part of the interview must vary, depending on the nature of the presenting problem and the patient’s and clinician’s attitude. Encourage patients to tell their story in their own words from the onset of the first symptom to the present time.

When a patient stops volunteering information, the question ‘What else?’ may start things up again.8 However, some direction may be necessary to keep a garrulous patient on track later during the interview. It is necessary to ask specific questions to test diagnostic hypotheses. For example, the patient may not have noticed an association between the occurrence of chest discomfort and exercise (typical of angina) unless asked specifically. It may also be helpful to give a list of possible answers. A patient with suspected angina who is unable to describe the symptom may be asked if the sensation was sharp, dull, heavy or burning. The reply that it was burning makes angina less likely.

Appropriate (but not exaggerated) reassuring gestures are of value to maintain the flow of conversation. If the patient stops giving the story spontaneously, it can be useful to provide a short summary of what has already been said and encourage him or her to continue.

The clinician must learn to listen with an open mind.10 The temptation to leap to a diagnostic decision before the patient has had the chance to describe all the symptoms in his or her own words should be resisted. Avoid using pseudo-medical terms; and if the patient uses these, find out exactly what is meant by them, as misinterpretation of medical terms is common.

Patients’ descriptions of their symptoms may vary as they are subjected to repeated questioning by increasingly senior medical staff. The patient who has described his chest pain as sharp and left-sided to the medical student may tell the registrar that the pain is dull and in the centre of the chest. These discrepancies come as no surprise to experienced clinicians; they are sometimes the result of the patient’s having had time to reflect on his or her symptoms. This does mean, however, that very important aspects of the story should be checked by asking follow-up questions, such as: ‘Can you show me exactly where the pain is?’ and ‘What do you mean by sharp?’

Some patients may have medical problems that make the interview difficult for them; these include deafness and problems with speech and memory. These must be recognised by the clinician if the interview is to be successful. See Chapter 2 for more details.

The presenting (principal) symptom

Not uncommonly, a patient has many symptoms. An attempt must be made to decide which symptom led the patient to present. It must be remembered that the patient’s and the doctor’s ideas of what constitutes a serious problem may differ. A patient with symptoms of a cold who also, in passing, mentions that he has recently had severe crushing retrosternal chest pain needs more attention to his heart than to his nose. Record each presenting symptom in the patient’s own words, avoiding technical terms.

History of the presenting illness

Each of the presenting problems has to be talked about in detail with the patient, but in the first part of the interview the patient should lead the discussion. In the second part the doctor should take more control and ask specific questions. When writing down the history of the presenting illness, the events should be placed in chronological order; this might have to be done later when the whole history has been obtained. If numerous systems are affected, the events should be placed in chronological order for each system.

Current symptoms

Certain information should routinely be sought for each current symptom if this hasn’t been volunteered by the patient. The mnemonic SOCRATES summarises the questions that should be asked about most symptoms:

• Site
• Onset
• Character
• Radiation (if pain or discomfort)
• Alleviating factors
• Timing
• Exacerbating factors
• Severity.

Site

Ask where the symptom is exactly and whether it is localised or diffuse. Ask the patient to point to the actual site on the body.

Some symptoms are not localised. Patients who complain of dizziness do not localise this to any particular site—but vertigo may sometimes involve a feeling of movement within the head and to that extent is localised. Other symptoms that are not localised include cough, shortness of breath (dyspnoea), or change in weight.

Onset (Mode of onset and pattern)

Find out whether the symptom came on rapidly, gradually or instantaneously. Some cardiac arrhythmias are of instantaneous onset and offset. Sudden loss of consciousness (syncope) with immediate recovery occurs with cardiac but not neurological disease. Ask whether the symptom has been present continuously or intermittently. Determine if the symptom is getting worse or better, and, if so, when the change occurred. For example, the exertional breathlessness of chronic obstructive pulmonary disease may come on with less and less activity as it worsens. Find out what the patient was doing at the time the symptom began. For example, severe breathlessness that wakes a patient from sleep is very suggestive of cardiac failure.

Character

Here it is necessary to ask the patient what is meant by the symptom; to describe its character. If the patient complains of dizziness, does this mean the room spins around (vertigo) or is it more a feeling of light-headedness? Does indigestion mean abdominal pain, heartburn, excess wind or a change in bowel habit? If there is pain, is it sharp, dull, stabbing, boring, burning or cramp-like?

Radiation of pain or discomfort

Determine whether the symptom, if localised, radiates; this mainly applies if the symptom is pain. Certain patterns of radiation are typical of a condition or even diagnostic, e.g. the nerve root distribution of pain associated with herpes zoster (shingles).

Alleviating factors

Ask whether anything makes the symptom better. For example, the pain of pericarditis may be relieved when a patient sits up. Have analgesic medications been used to control the pain? Have narcotics been required?

Timing

Find out when the symptom first began and try to date this as accurately as possible. For example, ask the patient what was the first thing he or she noticed that was ‘unusual’ or ‘wrong’. Ask whether the patient has had a similar illness in the past. It is often helpful to ask patients when they last felt entirely well. In a patient with long-standing symptoms, ask why he or she decided to come and see the doctor at this time.

Exacerbating factors

Ask if anything makes the pain or symptom worse. The slightest movement may exacerbate the abdominal pain of peritonitis or the pain in the big toe caused by gout.

Severity

This is subjective. The best way to assess severity is to ask the patient whether the symptom interferes with normal activities or sleep. Severity can be graded from mild to very severe. A mild symptom can be ignored by the patient, while a moderate symptom cannot be ignored but does not interfere with daily activities. A severe symptom interferes with daily activities, while a very severe symptom markedly interferes with most activities. Alternatively, pain or discomfort can be graded on a 10-point scale from 0 (no discomfort) to 10 (unbearable).

The severity of some symptoms can be quantified more precisely; for example, shortness of breath on exertion occurring after walking 10 metres on flat ground is more severe than shortness of breath occurring after walking 90 metres up a hill. Central chest pain from angina occurring at rest is more significant than angina occurring while running 90 metres to catch a bus.

It is crucial to quantify accurately the severity of each symptom—but also to remember that symptoms a patient considers mild may be very significant.

Associated symptoms

Here an attempt is made to uncover in a systematic way symptoms that might be expected to be associated with disease of a particular area. Initial and most thorough attention must be given to the system that includes the presenting complaint (see Questions box 1.1, page 9). Remember that while a single symptom may provide the clue that leads to the correct diagnosis, usually it is the combination of characteristic symptoms that most reliably suggests the diagnosis.

Questions box 1.1

The systems review

Enquire about common symptoms and three or four of the common disorders in each major system listed below. Not all these questions should be asked of every patient. Adjust the detail of questions based on the presenting problem, the patient’s age and the answers to the preliminary questions.

! denotes symptoms for the possible diagnosis of an urgent or dangerous (alarm) problem.

Cardiovascular system

1. Have you had any pain or pressure in your chest, neck or arm?—Myocardial ischaemia
2. Are you short of breath on exertion? How much exertion is necessary?
3. Have you ever woken up at night short of breath?—Cardiac failure
4. Can you lie flat without feeling breathless?
5. Have you had swelling of your ankles?
6. Have you noticed your heart racing or beating irregularly?
7. Have you had blackouts without warning?—Stokes-Adams attacks
8. Have you felt dizzy or blacked out when exercising?—Severe aortic stenosis or hypertrophic cardiomyopathy
9. Do you have pain in your legs on exercise?
10. Do you have cold or blue hands or feet?
11. Have you ever had rheumatic fever, a heart attack, or high blood pressure?

Respiratory system

1. Are you ever short of breath? Has this come on suddenly?—Pulmonary embolism
2. Have you had any cough?
3. Is your cough associated with shivers and shakes (rigors) and breathlessness and chest pain?—Pneumonia
4. Do you cough up anything?
5. Have you coughed up blood?—Bronchial carcinoma
6. What type of work have you done?—Occupational lung disease
7. Do you snore loudly? Do you fall asleep easily during the day? When? Have you fallen asleep while driving? (Sleep history)
8. Do you ever have wheezing when you are short of breath?
9. Have you had fevers?
10. Do you have night sweats?
11. Have you ever had pneumonia or tuberculosis?
12. Have you had a recent chest X-ray?
13. Have you had any bleeding or discharge from your breasts or felt any lumps there?—Carcinoma of the breast

Gastrointestinal system

1. Are you troubled by indigestion?
2. Do you have heartburn?
3. Have you had any difficulty swallowing?—Oesophageal cancer
4. Have you had nausea or vomiting, or vomited blood?—Gastrointestinal bleeding
5. Have you had pain or discomfort in your abdomen?
6. Have you had any abdominal bloating or distension?
7. Has your bowel habit changed recently?—Carcinoma of the colon
8. How many bowel motions a week do you usually pass?
9. Have you lost control of your bowels or had accidents (faecal incontinence)?
10. Have you seen blood in your motions or vomited blood?—Gastrointestinal bleeding
11. Have your bowel motions been black?—Gastrointestinal bleeding
12. Have you lost weight recently without dieting?—Carcinoma of the colon
13. Have your eyes or skin ever been yellow?
14. Have you ever had hepatitis, peptic ulceration, colitis, or bowel cancer?
15. Tell me about your diet recently.

Genitourinary system

1. Do you have difficulty or pain on passing urine?
2. Is your urine stream as good as it used to be?
3. Is there a delay before you start to pass urine? (Applies mostly to men)
4. Is there dribbling at the end?
5. Do you have to get up at night to pass urine?
6. Are you passing larger or smaller amounts of urine?
7. Has the urine colour changed?
8. Have you seen blood in your urine?—Urinary tract malignancy
9. Have you any problems with your sex life? Difficulty obtaining or maintaining an erection?
10. Have you noticed any rashes or lumps on your genitals?
11. Have you ever had a sexually transmitted disease?
12. Have you ever had a urinary tract infection or kidney stone?
13. Are your periods regular?
14. Do you have excessive pain or bleeding with your periods?

Haematological system

1. Do you bruise easily?
2. Have you had fevers, or shivers and shakes (rigors)?
3. Do you have difficulty stopping a small cut from bleeding?—Bleeding disorder
4. Have you noticed any lumps under your arms, or in your neck or groin?—Haematological malignancy !
5. Have you ever had blood clots in your legs or in the lungs?

Musculoskeletal system

1. Do you have painful or stiff joints?
2. Are any of your joints red, swollen and painful?—Septic arthritis
3. Have you had a skin rash recently?
4. Do you have any back or neck pain?
5. Have your eyes been dry or red?
6. Have you ever had a dry mouth or mouth ulcers?
7. Have you been diagnosed as having rheumatoid arthritis or gout?
8. Do your fingers ever become painful and become white and blue in the cold?

Endocrine system

1. Have you noticed any swelling in your neck?
2. Do your hands tremble?
3. Do you prefer hot or cold weather?
4. Have you had a thyroid problem or diabetes?
5. Have you noticed increased sweating?
6. Have you been troubled by fatigue?
7. Have you noticed any change in your appearance, hair, skin or voice?
8. Have you been unusually thirsty lately?—New onset of diabetes

Reproductive history (women)

1. How many pregnancies have you had?
2. Have you had any miscarriages?
3. Have you had high blood pressure or diabetes in pregnancy?
4. Were there any other complications during your pregnancies or deliveries?
5. Have you had a Caesarean section?

Neurological system and mental state

1. Do you get headaches?
2. Is your headache very severe and did it begin very suddenly?—Sub-arachnoid haemorrhage
3. Have you had memory problems or trouble concentrating?
4. Have you had fainting episodes, fits or blackouts?
5. Do you have trouble seeing or hearing?
6. Are you dizzy?
7. Have you had weakness, numbness or clumsiness in your arms or legs?
8. Have you ever had a stroke or head injury?
9. Have you had difficulty sleeping?
10. Do you feel sad or depressed, or have problems with your ‘nerves’?
11. Have you ever been sexually or physically abused?

The elderly patient

1. Have you had problems with falls or loss of balance?—High fracture risk
2. Do you walk with a frame or stick?
3. Do you take sleeping tablets or sedatives? —Falls risk
4. Do you take blood pressure tablets?—Postural hypotension and falls risk
5. Have you been tested for osteoporosis?
6. Can you manage at home without help?
7. Are you affected by arthritis?
8. Have you had problems with your memory or with managing things like paying bills?—Cognitive decline
9. How do you manage your various tablets?—Risk of polypharmacy and confusion of doses

Concluding the interview

Is there anything else you would like to talk about?

Current treatment and drug allergies

Ask the patient whether he or she is currently taking any tablets or medicines (the use of the word ‘drug’ may cause alarm); the patient will often describe these by colour or size rather than by name and dose. Then ask the patient to show you all his or her medications, if possible, and list them. Note the dose, length of use, and the indication for each drug. This list may provide a useful clue to chronic or past illnesses, otherwise forgotten. Remember that some drugs are prescribed as transdermal patches or subcutaneous implants (e.g. contraceptives and hormonal treatment of carcinoma of the prostate). Ask whether the drugs were taken as prescribed. Always ask specifically whether a woman is taking the contraceptive pill, because this is not considered a medicine or tablet by many who take it. The same is true of inhalers, or what many patients call their ‘puffers’.

To remind the patient, it is often useful to ask about the use of classes of drugs. A basic list should include questions about treatment for blood pressure, high cholesterol, diabetes, arthritis, anxiety or depression, impotence, contraception, hormone replacement, epilepsy, anticoagulation and the use of antibiotics. Also ask the patient if he or she is taking any over-the-counter preparations (e.g. aspirin, antihistamines, vitamins). Aspirin and standard non-steroidal anti-inflammatory drugs (NSAIDs), but not paracetamol, can cause gastrointestinal bleeding. Patients with chronic pain may consume large amounts of analgesics, including drugs containing opioids such as codeine or morphine. A careful history of the period of use of opioids and the quantities used is important because they are drugs of dependence.

Approximately 50% of people now use ‘natural remedies’ of various types. They may not feel these are a relevant part of their medical history, but these chemicals, like any drug, may have adverse effects. Indeed, some of these have been found to be adulterated with drugs such as steroids and NSAIDs. More information about these substances and their effects is becoming available and there is an increasing responsibility for clinicians to be aware of them.

There may be some medications or treatments the patient has had in the past which remain relevant. These include corticosteroids, chemotherapeutic agents (anti-cancer drugs) and radiotherapy. Often patients, especially those with a chronic disease, are very well informed about their condition and their treatment. However, some allowance must be made for patients’ non-medical interpretation of what happened.10

Note any adverse reactions in the past. Also ask specifically about any allergy to drugs (often a skin reaction or episode of bronchospasm) and what the allergic reaction actually involved, to help judge if it was really an allergic reaction.12 The patient often confuses an allergy with a side-effect of a drug.

Ask about ‘recreational’ drug use. The use of intravenous drugs has many implications for the patient’s health. Ask whether any attempt has been made to avoid sharing needles. This may protect against the injection of viruses, but not against bacterial infection from the use of impure substances.

Not all medical problems are treated with drugs. Ask about courses of physiotherapy or rehabilitation for musculoskeletal problems or injuries, or to help recovery following surgery or a severe illness. Certain gastrointestinal conditions are treated with dietary supplements (e.g. pancreatic enzymes for chronic pancreatitis) or restrictions (e.g. of gluten for coeliac disease).

Menstrual history

For women, a menstrual history should be obtained; it is particularly relevant for a patient with abdominal pain, a suspected endocrine disease or genitourinary symptoms. Write down the date of the last menstrual period. Ask about the age at which menstruation began, if the periods are regular, or whether menopause has occurred. Ask if the symptoms are related to the periods. Do not forget to ask a woman of childbearing age if there is a possibility of pregnancy; this, for example, may preclude the use of certain investigations or drugs.13 Observing the well-known axiom that ‘every woman of childbearing years is pregnant until proven otherwise’ can prevent unnecessary danger to the unborn child and avoid embarrassment for the unwary clinician. Ask about any miscarriages. Record gravida (the number of pregnancies) and para (the number of births of babies over 20 weeks’ gestation).

The effect of the illness

A serious illness can change a person’s life—for example, a chronic illness may prevent work or further education. The psychological and physical effects of a serious health problem may be devastating and, of course, people respond differently to similar problems. Even after full recovery from a life-threatening illness, some people may be permanently affected by loss of confidence or self-esteem. There may be continuing anxieties about the capability of supporting a family. Try to find out how the patient and his or her family have been affected. How has he or she coped so far, and what are the patient’s expectations and hopes for the future with regard to health? What explanations of the condition has the patient been given or obtained (e.g. from the internet)?

Helping a patient manage ill-health is a large part of the clinician’s duty. This depends on sympathetic and realistic explanations of the probable future course of the disease and the effects of treatment.

The past history

Ask the patient whether he or she has had any serious illnesses, operations or admissions to hospital in the past. Don’t forget to inquire about childhood illnesses and any obstetric or gynaecological problems. Previous illnesses or operations may have a direct bearing on the current health of the patient. It is worth asking specifically about certain operations that have a continuing effect on the patient’s health; for example, operations for malignancy, bowel surgery or cardiac surgery—especially valve surgery. Implanted prostheses are common in surgical, orthopaedic and cardiac procedures. These may involve a risk of infection of the foreign body, while magnetic metals—especially cardiac pacemakers—are a contraindication to magnetic resonance imaging (MRI). Chronic kidney disease may be a contraindication to X-rays using iodine contrast materials and MRI scanning using gadolinium contrast. Pregnancy is usually a contraindication to radiation exposure (X-rays and nuclear scans—remember that CT scans cause hundreds of times the radiation exposure of simple X-rays).

The patient may believe that he or she has had a particular diagnosis made in the past, but careful questioning may reveal this as unlikely. For example, the patient may mention a previous duodenal ulcer, but not have had any investigations or treatment for it, which makes the diagnosis less certain. Therefore it is important to obtain the particulars of each relevant past illness, including the symptoms experienced, tests performed and treatments prescribed.

Patients with chronic illnesses such as diabetes mellitus will probably have had their condition managed with the help of various doctors and at specialised clinics where diabetic educators, nurses and dieticians will have had a primary role in management of the illness. Find out what supervision and treatment these have provided. For example, who does the patient contact if there is a problem with the insulin dose, and does the patient know what to do (an action plan) if there is an urgent or dangerous complication? Patients with chronic diseases are often very much involved in their own care and are very well informed about aspects of their treatment. For example, diabetics should keep records of their home-measured blood sugar levels; heart failure patients should monitor their weight daily, and so on. These patients will often make their own adjustments to their medication doses. Assessing a patient’s understanding of and confidence in making these changes should be part of the history taking.

The social and personal history

This is the time to find out more about the patient as a person. The questions should be asked in an interested and conversational way and should not sound like a routine learned by rote. This history includes the whole economic, social, domestic and industrial situation of the patient. Ask first about the places of birth and residence, and the level of education obtained. Recent migrants may have been exposed to infectious diseases like tuberculosis; ethnic background is important in some diseases, such as thalassaemia and sickle cell anaemia.

Smoking

The patient may claim to be a non-smoker if he or she stopped smoking that morning. Therefore, ask whether the patient has ever smoked and, if so, how many cigarettes (or cigars or pipes) were smoked a day and for how many years. Find out if the patient has stopped smoking, and if so when that was. Calculate the number of packet-years of smoking (20 cigarettes a day for 1 year = a packet-year).

Cigarette smoking is a risk factor for vascular disease, chronic lung disease, several cancers and peptic ulceration, and may damage the fetus (Table 1.2). Cigar and pipe smokers typically inhale less smoke than cigarette smokers, and overall mortality rates are correspondingly lower in this group, except from carcinoma of the oral cavity, larynx and oesophagus.

Table 1.2 Smoking and clinical associations*

1 Cardiovascular disease

Premature coronary artery disease
Peripheral vascular disease
Cerebrovascular disease

2 Respiratory disease

Lung cancer
Chronic obstructive pulmonary disease (chronic airflow limitation)
Increased incidence of respiratory infection
Increased incidence of postoperative respiratory complications

3 Other cancers

Larynx, oral cavity, oesophagus, nasopharynx, bladder, kidney, pancreas, stomach, uterine cervix
4 Gastrointestinal disease

Peptic ulceration
5 Pregnancy

Increased risk of spontaneous abortion, fetal death, neonatal death, sudden infant death syndrome
6 Drug interactions

Induces hepatic microsomal enzyme systems, e.g. increased metabolism of propranolol, theophylline

* Individual risk is influenced by the duration, intensity and type of smoke exposure, as well as by genetic and other environmental factors. Passive smoking is also associated with respiratory disease.

Alcohol

Ask whether the patient drinks alcohol.14 If so, ask what type, how much and how often. If the patient claims to be a social drinker, find out exactly what this means. In a glass of wine, a nip (or shot) of spirits, a glass of port or sherry, or a 200 mL (7 oz) glass of beer, there are approximately 8–10 g of alcohol (1 unit = 8 g). In the UK, the current recommended safe limits are 21 units (168 g of ethanol) a week for men and 14 units (112 g of ethanol) for women; weekly consumption of more than 50 units for men and 35 units for women defines a high-risk group. Alcohol becomes a major risk factor for liver disease in men if more than 80 g and in women if more than 40 g are taken daily for 5 years or longer. The National Health & Medical Research Council (NHMRC) in Australia recommends a maximum alcohol intake of no more than 40 g per day for males on average (and 20 g per day for females) with two alcohol-free days a week. Alcoholics are notoriously unreliable about describing their alcohol intake, so it may be important to suspend belief and sometimes (with the patient’s permission) talk to the relatives.

Certain questions can be helpful in making a diagnosis of alcoholism; these are referred to as the CAGE questions:15

1. Have you ever felt you ought to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye opener)

If the patient answers ‘yes’ to any of these questions, this suggests there may be a serious alcohol dependence problem. The complications of alcohol abuse are summarised in Table 1.3.

Table 1.3 Alcohol (ethanol) abuse: complications

Gastrointestinal system

• Acute gastric erosions
• Gastrointestinal bleeding from varices, erosions, Mallory-Weiss tear, peptic ulceration
• Pancreatitis (acute, recurrent or chronic)
• Diarrhoea (watery, due to alcohol itself, or steatorrhoea from chronic alcoholic pancreatitis or, rarely, liver disease)
• Hepatomegaly (fatty liver, chronic liver disease)
• Chronic liver disease (alcoholic hepatitis, cirrhosis) and associated complications
• Cancer (oesophagus, cardia of stomach, liver, pancreas)

Cardiovascular system

• Cardiomyopathy
• Arrhythmias
• Hypertension
Nervous system

• ‘Blackouts’
• Nutrition-related conditions, e.g. Wernicke’s encephalopathy, Korsakoff’s psychosis, peripheral neuropathy (thiamine deficiency), pellagra (dementia, dermatitis and diarrhoea from niacin deficiency)
• Withdrawal syndromes, e.g. tremor, hallucinations, ‘rum fits’, delirium tremens
• Cerebellar degeneration
• Alcoholic dementia
• Alcoholic myopathy
• Autonomic neuropathy
Haematopoietic system

• Anaemia (dietary folate deficiency, iron deficiency from blood loss, direct toxic suppression of the bone marrow, rarely B12 deficiency with chronic pancreatitis, or sideroblastic anaemia)
• Thrombocytopenia (from bone marrow suppression or hypersplenism)
Genitourinary system

• Erectile dysfunction (impotence), testicular atrophy in men
• Amenorrhoea, infertility, spontaneous abortion, fetal alcohol syndrome in women
Other effects

• Increased risk of fractures and osteonecrosis of the femoral head

Occupation and education

Ask the patient about present occupation;16 the WHACS mnemonic is useful here:17

1. What do you do?
2. How do you do it?
3. Are you concerned about any of your exposures or experiences?
4. Co-workers or others exposed?
5. Satisfied with your job?

Finding out exactly what the patient does at work can be helpful (page 113). Note particularly any work exposure to dusts, chemicals or disease; for example, mine and industrial workers may have the disease asbestosis. Find out if any similar complaints have affected fellow workers.

Ask about the education level attained; this can influence the way things are explained. Checking on hobbies can also be informative (e.g. bird fanciers and lung disease).

Overseas travel and immunisation

If an infectious disease is a possibility, ask about recent overseas travel, destinations reached, and how the patient lived when away (e.g. did he or she drink unbottled water and eat local foods, or dine at expensive international hotels). Ask about immunisation status and whether any prophylactic drugs (e.g. for malaria) were taken during the travel period. Find out whether the patient has had recent immunisations (e.g. for hepatitis B, pneumococcal disease, Haemophilus influenzae or influenza).

Marital status, social support and living conditions

To determine the patient’s marital status, ask who is living at home with the patient. Find out about the health of the spouse and of any children. Check if there are any other household members. Establish who is the patient’s main ‘caregiver’. Discreet questions about sexual activity may be very relevant. For example, erectile dysfunction may occur in neurological conditions, debilitating illness or psychiatric disease. Questions about living arrangements are particularly important for chronic or disabling illnesses, where it is necessary to know what social support is available and whether the patient is able to manage at home (for example, the number of steps required for access to the house, or the location of the toilet).

Ask if the patient considers him- or herself to be a spiritual person. Spirituality is an important factor, especially in the care of dying patients, in the creation of living wills and in understanding the support network available for the patient.

Ask about the adequacy of the patient’s diet, who does the cooking, availability of ‘meals on wheels’ and other services such as house cleaning. Also ask about the amount of physical activity undertaken. The presence of pets in the home may be important if infections or allergies are suspected.

The family history

Many diseases run in families. For example, ischaemic heart disease that has developed at a young age in parents or siblings is a major risk factor for ischaemic heart disease in the offspring. Various malignancies, such as breast and large-bowel carcinoma, are more common in certain families. Both genetic and common environmental exposures may explain these familial associations. Some diseases (e.g. haemophilia) are directly inherited.18

Ask about any history of a similar illness in the family. Inquire about the health and, if relevant, the causes of death and ages of death of the parents and siblings. If there is any suggestion of a hereditary disease, a complete family tree should be compiled showing all members affected (Figure 1.1). Patients can be reluctant to mention that they have relatives with mental illnesses, epilepsy or cancer, so ask tactfully about these diseases. Consanguinity (usually first cousins marrying) increases the probability of autosomal recessive abnormalities in the children; ask about this if the pedigree is suggestive.

image

Figure 1.1 Preparing a family tree: note the symbols used for the documentation

Systems review

As well as detailed questioning about the system likely to be diseased, it is essential to ask about important symptoms and disorders in other systems (Questions box 1.1), otherwise important diseases may be missed.19,20 An experienced clinician will perform a targeted systems review, based on information already obtained from the patient; clearly it is not realistic to put all of the listed questions to a patient.

When recording the systems review, list important negative answers (‘relevant negatives’). Remember: if other recent symptoms are unmasked, more details must be sought; relevant information is then added to the history of the presenting illness. Before completing the history, it is often valuable to ask what the patient thinks is wrong, and what he or she is most concerned about. General and sympathetic questions about the effect of a chronic or severe illness on the patient’s life are important for establishing rapport and for finding out what else might be needed (both medical and non-medical) to help the patient.

Major presenting symptoms for each system are described in the following chapters. Examples of supplementary important questions to ask about past history, social history and family history are also given there for each system.

Skills in history taking

In summary, several skills are important in obtaining a useful and accurate history.21 First, establish rapport and understanding. Second, ask questions in a logical sequence. Start with open-ended questions. Listen to the answers and adjust your interview accordingly. Third, observe and provide non-verbal clues carefully. Encouraging, sympathetic gestures and concentration on the patient that makes it clear he or she has your undivided attention are most important and helpful, but are really a form of normal politeness. Fourth, proper interpretation of the history is crucial.

Your aim should be to obtain information that will help establish the likely anatomical and physiological disturbances present, the aetiology of the presenting symptoms and the impact of the symptoms on the patient’s ability to function. (In Chapter 2, some advice on how to take the history in more challenging circumstances is considered.) This type of information will help you plan the diagnostic investigations and treatment, and to discuss the findings with, or present them to, a colleague if necessary (see page 462). First, however, a comprehensive and systematic physical examination is required.

These skills can be obtained and maintained only by practice.

References

1. Longson D. The clinical consultation. J R Coll Physicians Lond. 1983;17:192-195. Outlines the principles of hypothesis generation and testing during the clinical evaluation

2. Nardone DA, Johnson GK, Faryna A, et al. A model for the diagnostic medical interview: nonverbal, verbal and cognitive assessments. J Gen Intern Med. 1992;7:437-442. Verbal and non-verbal questions and diagnostic reasoning are reviewed in this useful article

3. Bellet PS, Maloney MJ. The importance of empathy as an interviewing skill in medicine. JAMA. 1991;266:1831-1832. Distinguishes between empathy, reassurance and patient education

4. Brewin T. Primum non nocere? Lancet. 1994;344:1487-1488. Review of a key principle in clinical management

5. Platt FW, McMath JC. Clinical hypocompetence: the interview. Ann Intern Med. 1979;91:898-902. A valuable review of potential flaws in interviewing, condensed into five syndromes: inadequate content, database flaws, defects in hypothesis generation, failure to obtain primary data and a controlling style

6. Coulehan JL, et al. ‘Tell me about yourself’: the patient-centred interview. Ann Intern Med. 2001;134:1079-1084.

7. Fogarty L, et al. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17:371-379.

8. Barrier P, et al. Two words to improve physician–patient communication: What else? Mayo Clin Proc. 2003;78:211-214.

9. Blau JN. Time to let the patient speak. BMJ. 1999;298:39. The average doctor’s uninterrupted narrative with a patient lasts less than 2 minutes (and often much less!), which is too brief. Open interviewing is vital for accurate history taking

10. Smith RC, Hoppe RB. The patient’s story: integrating the patient- and physician-centered approaches to interviewing. Ann Intern Med. 1991;115:470-477. Patients tell stories of their illness, integrating both the medical and psychosocial aspects. Both need to be obtained, and this article reviews ways to do this and to interpret the information

11. Beckman H, Markakis K, Suchman A, Frankel R. Getting the most from a 20-minute visit. Am J Gastroenterol. 1994;89:662-664. A lot of information can be obtained from a patient even when time is limited, if the history is taken logically

12. Salkind AR, Cuddy PG, Foxworth JW. The rational clinical examination. Is this patient allergic to penicillin? An evidence-based analysis of the likelihood of penicillin allergy. JAMA. 2001;285(19):2498-2505.

13. Ramosaka EA, Sacchetti AD, Nepp M. Reliability of patient history in determining the possibility of pregnancy. Ann Emerg Med. 1989;18:48-50. One in ten women who denied the possibility of pregnancy, in this study, had a positive pregnancy test

14. Kitchens JM. Does this patient have an alcohol problem? JAMA. 1994;272:1782-1787. A useful guide to making this assessment

15. Beresford TP, Blow FC, Hill E, Singer K, Lucey MR. Comparison of CAGE questionnaire and computer-assisted laboratory profiles in screening for covert alcoholism. Lancet. 1990;336:482-485.

16. Newman LS. Occupational illness. N Engl J Med. 1995;333:1128-1134. The importance of knowing the occupation for the diagnosis of an illness cannot be overemphasised

17. Blue AV, Chessman AW, Gilbert GE, Schuman SH, Mainous AG. Medical students’ abilities to take an occupational history: use of the WHACS mnemonic. J Occup Environ Med. 2000;42(11):1050-1053.

18. Rich EC, Burke W, Heaton CJ, Haga S, Pinsky L, Short MP, Acheson L. Reconsidering the family history in primary care. J Gen Intern Med. 2004;19(3):273-280.

19. Hoffbrand BI. Away with the system review: a plea for parsimony. BMJ. 1989;198:817-819. Presents the case that the systems review approach is not valuable. A focused review still seems to be useful in practice (see below)

20. Boland BJ, Wollan PC, Silverstein MD. Review of systems, physical examination, and routine test for case-finding in ambulatory patients. Am J Med Sci. 1995;309:194-200. A systems review can identify unsuspected clinically important conditions

21. Simpson M, Buchman R, Stewart M, et al. Doctor–patient communication: the Toronto consensus statement. BMJ. 1991;303:1385-1387. Most complaints about doctors relate to failure of adequate communication. Encouraging patients to discuss their major concerns without interruption or premature closure enhances satisfaction and yet takes little time (average 90 seconds). Factors that improve communication include use of appropriate open-ended questions, giving frequent summaries, and the use of clarification and negotiation. Giving premature advice or reasurance, or inappropriate use of closed questions, badly affects the interview. These skills can be learned but require practice

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