Medical history is a structured assessment conducted to generate a comprehensive picture of a patient health and health problems. Taking together the history, information from the physical examination and any investigations or tests, this should provide all the information needed to make a diagnosis.
History taking is a special form of communication and you should put the patient at ease and encourage him/her to communicate or talk freely and to tell their story in their own way, in own words comfortably so that doctor/physician can diagnose the problem. An experienced doctor can diagnose the problem of the patient from the moment the patient enters or walks into the room. Patients general appearance or attitude and personality in spite of the proliferation of modern diagnostic techniques/tests and sometimes freely available. History can vary according to the whether it is being taken in the wards, out patients clinic, emergency unite or in the home. According to the availability of time and status of the patient and try to be gentle and always tell the patient what you are doing and never try to cause pain.
Physician should ask a patient about the following information
- Marital status
- Blood group, Nationality
- History of present illness/disease i.e. time of illness, location etc
- Family history
- Past surgical history
- Past medical history
- Menstrual history in females
Doctor/physician should ask the patients about the pain, symptoms of the illness, disease. He should make the patient comfortable and should create an friendly and healthy environment and then ask for the pain or symptoms. This will help the physician to analyze the disease. To analyze the pain, doctor should ask:
- Site of the pain
- Severity of the pain
- Timings and duration
- Character of the pain like stabbing, pricking burning, colicky or continuous steady pain
- Aggravating and relieving factors
Negative data is also important to be mentioned. This will also helps the physician to diagnose the disease and its adverse effects. Physician must know about any allergy or infection to the patient. Drug history of patient is also an important factor to be considered. Drug history should include:
- Medication of the patient is taking (prescribed and over the counter)
- Medication that the patient is known to be sensitive.
This information is needed because:
- Medication may be the cause of the presenting problem current medication may preclude the use of other medications
- Is a person is admitted to hospital they may need to continue current medication
- It provides an opportunity to review the need for taking medications and to find out whether the person is actually taking them
- The patient may be suffering from side effects
Personal and Social History: Illness may be related to occupation, to environment or to being employed and to being unemployed. Home responsibilities may preclude admission to hospital. Information to be gathered in personal and social history includes:
- General well being
- Alcohol, smoking, recreational drug use
- HIV risk factors
- Family relationships and support
- Occupation and job security
- Social or financial problems
It should be kept in mind that a well taken history will usually provide more clues to the diagnosis than the physical examination. It provides a basis for confidence and trust between the patient and physician. More the interaction between patient and physician, the more comfortably patient can describe about the illness or disease. This will also generate a hope in patient for better and healthy life and to get back in his/her daily routine.
The content of the history required in primary care consultations is very variable and will depend on the presenting symptoms, patient concerns and the past medical, psychological and social history. However the general framework for history taking is as follows:
- Presenting complaint.
- History of presenting complaint, including investigations, treatment and referrals already arranged and provided..
- Past medical history: significant past diseases/illnesses, surgery, including complications, trauma.
- Drug history: now and past, prescribed and over-the-counter, allergies.
- Family history: especially parents, siblings and children.
- Social history: smoking, alcohol, drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets and hobbies.
- Systems review: cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, genitourinary system.
It is widely taught that diagnosis is revealed in the patient's history. 'Listen to your patient; they are telling you the diagnosis' is a much quoted aphorism.
The basis of a true history is good communication between doctor and patient. The patient may not be looking for a diagnosis when giving their history and the doctor's search for one under such circumstances is likely to be fruitless. The patient's problem, whether it has a medical diagnosis attached or not, needs to be identified.
It is important for doctors to acquire good consultation skills which go beyond prescriptive history taking learned as part of the comprehensive and systematic clerking process outlined in textbooks. A good history is one which reveals the patient's ideas, concerns and expectations as well as any accompanying diagnosis. The doctor's agenda, incorporating lists of detailed questions, should not dominate the history taking. Listening is at the heart of good history taking. Without the patient's perspective, the history is likely to be much less revealing and less useful to the doctor who is attempting to help the patient.
Often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A good example is with the complaint of headache where the diagnosis can be made from the description of the headache and perhaps some further questions. For example, in cluster headache the history is very characteristic and reveals the diagnosis without the need for examination or investigations.
To obtain a true, representative account of what is troubling a patient and how it has evolved over time, is not an easy task. It takes practice, patience, understanding and concentration. The history is a sharing of experience between patient and doctor. A consultation can allow a patient to unburden himself or herself. They may be upset about their condition or with the frustrations of life and it is important to allow patients to give vent to these feelings. The importance of the lament and how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutic tool for both patient and physician, has been discussed in an excellent paper.
The skills required to obtain the patient's true story can be learned and go beyond knowing what questions to ask. Indeed 'questions' may need to be avoided, as they limit the patient to 'answers'. There is a lot written about consultation skills and different models of consulting. These have been developed through consultation analysis and now form an important part of undergraduate medical training and GP training in the Curriculum for Speciality Training for General Practice. There are many examples of aspects of consulting which may assist history taking for doctors working with patients in all specialties.
- The layout of the consulting room can assist good consulting. It can facilitate establishing rapport with patients by, for example, allowing for good eye contact, enabling easy access to computers or notes and avoiding 'distance' between the doctor and patient.
- Take care with the opening greeting, as this can set the scene for what follows. It may assist or inhibit rapport. Generally, it helps to be warm and welcoming so as to put the patient at ease. Good eye contact, shaking hands with the patient and showing an active interest in the patient should help to establish trust and encourage honest and open communication.
- Take care not to let the computer intrude on the consultation. This can be difficult when there is useful information available on a screen. Make use of the time before and after consultations to obtain information from the computer.
- Listen first and listen second
- Let the patient tell you the story they have been storing up for you. This can be encouraged by active listening. This implies that the doctor is seen to be interested and attentive by the patient.
Give the patient a chance to tell you their pre-constructed narrative, rather than diving in with a series of questions to delineate detail (such as the exact frequency and colour of their diarrhoea). This approach affords a better chance of obtaining a true 'flavour' of their experience of an illness, its temporal development and the relative importance to the patient of the symptoms that they have (which ultimately is what, from their viewpoint, you'll be attempting to cure, not 'the diagnosis', about which most patients do not really care).
It is important to be able to ask discriminating, delineating questions about particular symptoms to verify their actual nature and give enough information to support the process of reaching a diagnosis; however, timing is everything. Get down a record of each of the major symptoms in the order that they are presented to you by the patient. Then go back to this overall picture and break down any aspects of the history that you need to from there. This is a much better way of doing things than interrupting (and probably losing for ever) the patient's initial narrative.
Listening does not just involve using your ears. Also use facial expression, body language and verbal fluency to help understand what is really troubling someone and to suggest other areas in which the history might need to proceed. This is very useful where there is a psychological origin for physical symptoms, of which the patient may be unconscious, but you could get at if you noticed that talking about a certain aspect of their story makes them uncomfortable or hesitant. Remember that speech is not the only means of communicating, especially where someone has a poor command of the language in which you are taking the history, or has hearing impairment. Make full use of communication aids such as translators, sign-language interpreters, picture boards, drawings done by the patient showing where the pain is, when this is a more appropriate form of discourse.
Some patients do not come readily prepared with a narrative of their illness and, in this situation, it is unavoidable to use questioning and clarification of details to 'draw out' the history. However, if your prompting sparks off a narrative then try to hear it out if it seems to be relevant.
What questions are to be asked?
These are seen as the gold standard of historical inquiry. They do not suggest a 'right' answer to the patient and give them a chance to express what is on their mind. Examples include questions such as 'How are you?'. There are other similar open questions but it may be effective just to let the patient start speaking sometimes.
Open questions can be used to obtain specific information about a particular symptom as well. For example: 'Tell me about your cough' or 'How are your waterworks bothering you?'. Open questions cannot always be used, as sometimes you will need to delve deeper and obtain discriminating features about which the patient would not be aware. However, they should be kept foremost in the mind as a way to broach a subject or unexplored symptom.
Questions with options
Sometimes it is necessary to 'pin down' exactly what a patient means by a particular statement. In this case, if the information you are after cannot be obtained through open questioning then give the patient some options to indicate what information you need. For instance, if a male patient complains of 'passing blood' and it is difficult to tell what he means, even after being given a chance to expand on the subject, you could ask: 'Is that in your water or your motions?'. This technique must be used with care as there is a danger of getting the answer you wanted rather than what the patient meant (he might be having nosebleeds). Try to avoid using specific medical terms such as 'coffee grounds' (one of the options you might give if trying to find out if a patient is vomiting blood). If you can use an open question such as: 'What colour was the vomit?', rather than suggesting options, it is more likely to give you a true picture of what the patient has experienced; however, sometimes questions suggesting possible answers cannot be avoided.
These are best avoided if at all possible. They tend to lead the patient down an avenue that is framed by your own assumptions. For instance, a male patient presents with episodic chest pain. You know he is a smoker and overweight so you start asking questions that would help you to decide if it's angina. So you ask: 'Is it worse when you're walking?', 'Is it worse in cold or windy weather?'. The patient is not sure of the answer, not having thought of the influence of exercise or the weather on his pain, but answers yes, remembering a cold day when walking the dog when the pain was bad. You may be off on the wrong track and find it hard to get back from there. It is much better to ask an open question such as: 'Have you noticed anything that makes your pain worse?'. When the patient answers: 'Pork pies', you are on firmer ground in suspecting that this may be chest pain of gastrointestinal origin.
After taking the history, it's useful to give the patient a run-down of what they've told you as you understand it. For example: 'So, Michael, from what I understand you've been losing weight, feeling sick, had trouble swallowing - particularly meat - and the whole thing's been getting you down. Is that right?'. If there is a nod of approval or expressed agreement with the story then it's fairly certain you're getting what the patient wanted to tell you. If not, then you may need to try another approach. This technique can avoid incorrect assumptions by the doctor.
It's always a good idea to ask the patient if there's anything they want to ask you at the end of a consultation. This can help you to impart further information if there's something they haven't understood and it can reveal something that's been troubling them that hasn't been touched upon or got to the bottom of. It is an opportunity to confirm that a shared understanding has been reached between doctor and patient.
- Try to let patients tell you their story freely.
- When you use questions, try to keep them as open as possible.
- Use all your senses to 'listen'.
- Check that what you think is wrong is what your patient thinks is wrong.
- Keep an open mind and always ask yourself if you're making assumptions.
- Be prepared to reconsider the causes of symptoms that you or a colleague have decided upon.