The practical examinations at present have a section called the “long case”. Here a patient or sometimes a simulator (a pretend patient) is used to see if the candidate knows how to take a history and ask the right questions. You will know which questions to ask if you have been going to the wards and accompanying the consultant or the registrar. The right question is not from a list that you may have memorized but the one that provides you with the information needed to to learn what is wrong with the patient, when it happened, what caused the disease or problem. We also need to learn how the disease is affecting the patient’s ability to perform their daily functions at home and in society. We also want to find out if we can modify the patient’s lifestyle in order to influence the course of the disease i.e. slowing it down or curing it or preventing further complications. In an equitable society we may be able to alter the life circumstances like provide the patient with ground floor accommodation if climbing the stairs causes problems, provide food if starvation is a problem, provide a taxi for visits to the hospital or alternatively regular visits from a health care provider.
So where shall we begin? Definitely the name and also ask them how they should be addressed. Next how are you feeling and do you have an urgent problem like pain or breathlessness which can be dealt with first. Will you be able to tell me about your illness or do you want a family member or caregiver to help you? Invite this person to join the interview.
Tell me in your own words why you think you are ill? Is this the only problem or are there other symptoms you would like to talk about? How long has this been going on? Which of these problems bothers you the most? If the patient has been ill for long ask if the symptoms have gotten worse or better or changed in any way? Have you taken any medicines or other treatment for your problems? (Do not make derogatory remarks about alternate methods of treatment). Did this treatment help you? Have you got any prescriptions or laboratory reports or other tests with you? Please show them to me. Which hospital or doctor did you go to? Were you told what was wrong with you? If the patient offers their own explanation of what is happening to them listen, try to make sense of it and do not make fun of them. This way you will be able to establish empathy with the patient and be able to gather better information from them.
Have a set of questions ready to ask about common symptoms. Understand how the answer will affect your understanding of the disease. Remember you are going to use this information not only to make a diagnosis but also to determine what test and other investigations you need to do and how you will manage the patient. Ask questions about what makes them better or worse. How long have the symptoms been there? Are there times when the patient is completely free of symptoms? Has the appetite been affected? Have they gained weight or lost weight? What is there energy level i.e. are they comfortable with the way they do their work at home or at the place of employment or do they feel tired and sleepy all the time? What is their or mood: unhappy or always in a bad temper; not wanting to talk to people; frustrated or afraid? Do they feel cheerful or feel like crying? How much time you need to spend on these questions depends on your judgement on whether it will help you with the diagnosis or management of the disease.
Remember you do not have to ask every patient all the questions only the relevant ones, for postgraduate trainees remember the examiner is listening to you take the history. You are more likely to create a bad impression asking too many irrelevant questions and spending too much time on the history. For example in a patient with epilepsy or ischemic heart disease or Parkinsonism there is no need to ask if they live in a crowded house and drink unboiled tap water. These questions are more relevant in infectious diseases, as is contact with animals. Remember that the questions you ask indicate to the listening examiner the extent of your knowledge. Asking too many questions specially ones related to esoteric diseases shows lack of common sense. Maintain a careful balance. Please do not repeat your questions, jot down answers in your notes so that you remember that you asked this question before.
Before we discuss some specific symptoms, remember that you have to interpret the answers too. you also have to assess whether the answer the patient gave was a definite indication that the symptom exists, or the patient did not understand your question and so said yes or that the patient said yes but the symptom you asked about is not the significant one.
Let us start with some respiratory symptoms. What should you ask about a cough?
- The obvious question is how long it has been there.
- Is it accompanied by other symptoms such as sneezing, dripping nose, watery eyes, an irritation in the throat? Or is it accompanied by systemic symptoms like malaise or a general sense of not being well with aches and pains all over, tiredness and a headache? Is it accompanied by fever? If these are present then think of the common cold, start of influenza or a viral upper respiratory infection.
A note about viruses causing the common cold. About 200 viruses can cause the symptoms of a common cold. These include rhinoviruses, corona viruses, adenoviruses, influenza and para influenza viruses, respiratory syncytial viruses and some enteroviruses. A vaccine (except for ‘flu shots) has not been developed because new viruses emerge very quickly, it is not economically feasible to identify the virus in each individual, the symptoms of all these viruses are identical so clinical differentiation is not possible, a person can be re-infected with the same virus and have another episode again so lasting immunity may not occur. Seasonal variation; rhinoviruses and the various parainfluenza types typically cause outbreaks of infection in autumn and late spring, while respiratory syncytial virus (RSV) and corona-viruses typically produce epidemics in winter and spring. Enteroviruses most often cause illness in the summer but can be detected throughout the year. Adenoviruses are usually not seasonal, but outbreaks may occur in mental health facilities, military facilities, schools and daycare centers, and hospital wards.
- Is the cough dry or productive? Is the phlegm dirty white (usually a virus) yellow or green (usually indicating bacterial invasion primary or secondary)? Volume of the expectoration; teaspoonful or cupfuls? Are you kept awake by the need to expectorate? (I have put these questions together because if the initial answer is no you do not need to ask the rest). Copious expectoration is a feature of chronic bronchitis, bronchiectasis, a lung abscess communicating with a bronchus.
- Have you ever coughed up blood? Think of tuberculosis, usually from a cavitating lesion where there is a distortion of the vasculature with the thin walled vessels likely to burst and bleed called a Rasmussen aneurysm or bronchial ulceration or necrosis of an artery involved in the inflammatory caseation of tuberculosis. Think of bronchiectasis or a bronchogenic carcinoma in older patients who are or have been smokers. Small amounts of frothy sputum streaked with blood indicates pulmonary edema usually from left heart failure.
- Is there chest pain when you cough? This occurs in pleurisy where the parietal pleura is involved, as it is rich in pain nerve endings, pneumonia involving the overlying pleura will do the same.
- Do you wheeze or have a whistling sound in your chest when you breathe? This indicates bronchospasm as in bronchitis, asthma, chronic bronchitis, bronchiectasis and pulmonary edema.
- Are you breathless? Think of the diseases mentioned above. How far can you walk and do you walk slowly? Can you run or walk fast? Can you climb stairs? Do you take extra pillows at night or sit up in a chair or lean forward on a rolled up quilt or on the back of a chair pulled up to your bed when sleep? These questions are important as you are trying to find out if the patient is
- Have you lost weight recently?
- Do you have fever or night sweats?
- Do you smoke? Ask details like how many packs a day and for how many years. Ask about beerhis (self rolled cigarettes in tobacco leaf not paper), cigars and the hookah or sheesha as well. Ask about chewing tobacco. Are you exposed to smoke from a spouse’s smoke habit? Do you live in a smoky environment i.e. near a factory belching out smoke or a brick baking kiln? Do you use wood fire for cooking food? Ask these questions if they are relevant.
With these inquiries you should be able to get a great deal of information about patients who present to you primarily with symptoms of the respiratory tract. If you want something else included then please ask me.