Chapter 1 The general principles of history taking
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.
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
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
| 1 Presenting (principal) symptom (PS) |
| 2 History of presenting illness (HPI) |
Introductory questions
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.
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.
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.
History of the presenting illness
Current symptoms
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.
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.
