This tutorial is aimed at medical students primarily but postgraduate registrars-in-training will also be able to hone their skills in taking a history and presenting cases to teachers and examiners. Working in Pakistan or other countries where a doctor need to deal with multilingual patients difficulties will have to be dealt with. Many women are unwilling to talk to a male doctor and sometimes even to a woman doctor.
What is a patient’s history? It is the information you gather when you interview the patient. This is a communication skill you will start learning as soon as your clinical years start. You will continue to improve this skill as you progress in your career and will probably continue to improve on all your life.
Who do you take the history from?
- The patient if she/he is willing and able to give you the information. Many older patients are intimidated by a doctor who does not speak their language or dialect. Many women may hesitate to talk to a doctor and will refer you to another person to take the history from. Have a chaperone with you when you are talking to young women. Ask if the patient wants a care giver to be present.
- Care giver or relative who knows about the patient. Beware of an alpha male relative who comes forward and gives you his version of what happened to the patient or what he thinks is wrong. Politely ask if he usually takes care of the patient or was even present at the time symptoms occurred. A dominating matriarch will do the same. Make sure you get the information from a person who knows about the patient.
- Prescriptions of doctors who have treated the patient are a good source of information.
- The referring doctor will have information which is useful. Ask for a phone number and talk to the doctor.
- Previous hospital records.The patient may have brought them to the interview. Or they can be retrieved. Please use them to earn about the patient and their illnesses.
- Previous investigations will give you a clue. Do ask for them.
Remember that there are 3 parts to the history;
- Interviewing the patient and writing it down in a file as a permanent record. This is also called “clerking”. To improve the validity of the case file it must have a date and time recorded at the time of the initial interview. This can be used to compare changes in the patient’s condition as time progresses and is a very important part of the management of the patient. The medical clerk should also sign the file and clearly write his/her name or use a printed stamp. Remember this is a legal document so you must comply with the date, time and signature and name requirement.
- The logical editing of the information you gather from the patient. As the patient does not know what information is important asking sensible questions is very important. Asking relevant questions can reduce the time of the interview and let you identify important points in the history. Do not be too didactic or the patient will shy away from giving you information. How do you edit the information the patient gives you? From your knowledge of disease you put information that is essential to the diagnosis first, next you put in the information which may help in the management of the patient or at least require the treating doctor’s attention, last you put in the information that is incidental. You do not leave anything out.
- Presenting the information to your teacher, examiner or the treating medical team. Here is the real test. If you understand why you asked certain questions and if you understood the answers not just the language but the relationship to the diagnosis and how the answer clarifies the clinical problem, then your presentation will be good. Here is where you think about why, what and how: why am I asking this question? Why did the character of the pain or symptoms change? What difference does the answer make? What is the duration of the symptoms? What weight-age should I give the answer? How did the disease progress? How should I present this case? Why did the patient take so long to come to a hospital or consult a doctor?
In presenting the case the emphasis is different from the written history. In the written case file you are required to write the patient’s bio data first e.g. name, age, marital status, occupation, home address, telephone, next of kin, person to call in an emergency. Do not recite all this when you are presenting the case. During the presentation it is sufficient to give the name, age and what the patient was doing at the time of onset of the symptoms if this was sudden or related to exercise. The other information can be given later.
For example: “Abdul Hameed who is probably 30 years old, was working at the top of an electric pole, as he is an electrician. He fell down and was brought unconscious to the hospital one hour later.” The name gives the gender, the occupation gives the reason for his being up an electric pole, you have tried to guess his age and given a time frame for the injury. Another example is “This pregnant young woman Jamal Bibi,was brought by her husband. She had high fever and a rash on her face and chest for the last 2 days. She comes from Jamkanda where an outbreak of dengue fever has been reported. She has received no medical treatment as her husband was away from home and there was no one to take her to the hospital.” Her gender and marital status are obvious from the presentation. Her pregnancy has been pointed out, the most likely cause of the fever is suggested as she lives in an area where dengue fever is prevalent. She may of course have another disease but it is sensible to rule out dengue.
Outline of the written history.
Patient’s bio data. This must be entered in the patient’s file. In most hospitals there is usually a printed sheet which needs to be filled in. Name, age, marital status, occupation, postal address, telephone number, name of next of kin, person to contact in an emergency with phone number. This is very important.
Consent for surgery or special treatment like dialysis, requires permission from the patient if they are legally competent , the legal guardian if the patient is unconscious or not willing to make the decision. In countries where medical insurance is responsible for payment the name of the insurance company or credit card details of provider are required. In some countries nurses may fill in this part of the file or the patient may be required to fill in this information on a file. In Pakistan the house officer or medical intern is responsible for this information.
Reason for admission. (This term has replaced presenting complaints as the patient may not have any complaints. They may be admitted for observation or a procedure or investigation). If the reason for admission is a medical symptom then the most distressing symptom or one that needs immediate attention must be noted first with duration and severity. Other symptoms are then added also according to severity and duration. For example a history of a gastrointestinal bleed may be noted thus:
Reason for admission:
- Vomiting of blood 3 times in the past 4 hours. The amount of blood Filled a plastic bowl each time, (about 2 cupfuls).
- Nausea and vertigo for 6 hours.
- Passed a black stool 12 hours ago.
- Has had epigastric pain for 15 days.
It is the the vomiting of blood which requires immediate attention not the epigastric pain. This complaint is critical and setting up an IV lifeline, arranging and starting a blood transfusion, a consult with the Gastroenterologist for an emergency endoscopy and a surgeon in case active intervention is required are indicated. Remember that it is the way you present the information that will guide the reaction of the medical team.
If you label the patient a case of peptic ulcer with epigastric pain, a clinician may not order a blood transfusion and frequent monitoring of vital signs may not be forthcoming. This will endanger the patient’s life. Bleeding into the stomach may make the patient vomit out altered blood often described as “coffee grounds” or the patient may vomit out frank blood or blood clots or the blood may go into the intestines and from where it comes out as soft tarry stools known as malena. The passage of black tarry (not hard) stools indicates that the bleeding may have been there for more than 24 hours. The patient may already be significantly exsanguinated hence is critically ill.
Commonly made mistakes.
- The clerking med student or doctor fails to determine which is the most important reason for the patient to seek treatment so he/she latches onto a symptom that is familiar and tries to fit in the patient’s illness onto that symptom.
Example: an emaciated woman with an increased appetite, palpitation, weight loss with stary eyes was being interviewed in the FCPS 2 practical exam as part of the long case The candidate asked her why she had sought medical consultation. She answered “Nothing much. I had become very weak.” The candidate jumped to the conclusion that she had TB because she was emaciated. The conversation then went as follows:
Doctor; do you have a cough?
Patient: I do cough sometimes when I have a flu occasionally once or twice a year. Usually the whole family has flu.
Doctor do you have a fever?
Patient: no I do not have a fever.
Doctor: you have never had a fever? ( He asked about fever in different ways three times)
Patient” (finally) I do have fever once or twice a year. Who doesn’t?
The doctor then proceeded to ask all the questions he could think about fever such as night sweats, timing of the fever, duration of the fever, rigors etc. The bewildered patient gave negative answers, occasionally being intimidated into saying yes. The candidate presented the case as one of pyrexia of unknown origin. The lady had thyrotoxicosis. She had not come to the hospital because of fever but because of palpitations and weight loss. This is classic cooking up a history.
2. Common mistake 2. Ignoring symptoms and thinking that the patient is malingering or making up the complaints and is not suffering from a real disease. This can be dangerous.
Warning. Some diseases have vague symptoms and can affect many organ systems. You should be aware of these presentations and be able to recognize them.
Diabetes mellitus can present to an internist with weight loss or weight gain with an increased appetite and urinary infections, a nephrologist with proteinuria, a cardiologist with ischemic heart disease, a neurologist with peripheral neuropathy, a rheumatologist with carpal tunnel syndrome, an ophthalmologist with retinopathy, a surgeon with peripheral vascular disease or gangrene or carbuncle, a dermatologist with fungal infections, an obstetrician with complications of pregnancy!!!!! It is confirmed by all of these professionals by checking the blood sugar or HbA1C. Why do they do these tests? Prior knowledge of the disease and a high index of suspicion will help you make the diagnosis.
As a doctor you are detective, the disease is the criminal who leaves behind clues and the patient is an informant. Once you have caught the criminal you use treatment to get rid of the disease or keep it under control i.e. death penalty for the disease if you can cure it or prison sentence for the disease if you can keep it under control. Remember the disease is going to get out and strike again!!! Watch out! This is called a follow up of the patient. Your responsibility does not end when you discharge the patient or write a prescription. Give a date for follow up. Explain the importance of the follow up visit to the patient. Give an appointment
If you need help from another professional write a referral and get an appointment for the patient. This is your responsibility.