I Introduction and History Taking

Introduction

Patient care begins with the development of a personal relationship between the patient and the physician. In the absence of trust and confidence between the two, the effectiveness of a therapeutic measure may not be optimal. In many cases, confidence and reassurance to the patient maybe all that is required. When no treatment is available or possible, the patient should be given a feeling that the doctor is trying his or her best. A subjective assessment of the quality of life or assessment of what each patient values most has to be made. This requires a detailed and intimate knowledge of the patient, through unhurried conversation, in a comfortable atmosphere. Improvement of the quality of life is the main goal in all incurable diseases.

As the cost of medical care continues to rise, it is becoming necessary to apply stringent priorities in the expenditure on health care. In most cases, prevention may be better than cure. Such measures as vaccination, immunization, reduction in accidents and occupational hazards, improved environmental control, and screening of newborns for common diseases may be found to be economical. As investigations are becoming increasingly expensive, it is mandatory to tailor the investigations according to the need of the patient. The equation of cost versus benefit and necessity should always be kept in mind. Confirmatory tests instead of screening seem logical where the clinical diagnosis is almost certain.

History taking is an art as well as science that requires a thorough knowledge of medicine along with patience and good command on the language of the patient. The history is the written record of all the facts about the patient’s present and past illnesses. It is best to use the patients’ words and not to suggest answers. Quite often, the main problem of the patient may not be clinically significant, but some other problem on which the patient may be paying very little attention, may be more significant for the doctor to reach a correct diagnosis. In order to write a good history, patience, attention, concentration, and encouragement of the patient is required.

Physical findings are subject to change. Just because the examination is normal on one occasion does not guarantee that this will be the case on subsequent examinations. Likewise, abnormal findings may disappear in the course of illness. Therefore, repeat the physical examination as frequently as the clinical situation warrants.

Diagnosis requires a logical approach, an analytic mind that is able to interpret and synthesize ideas. It is most important to keep the objective of history taking in mind.

Objective of History Taking

• To make a clinical diagnosis and then formulate a management plan with relevant investigations and start management plan.

• To determine the etiology.

• To rule out relevant differential diagnosis.

• To pick any complications in relation to the disease.

• To look for other illnesses that the patient may not be aware of or which may be silent for the time being.

• To know your patient’s socio-psychological and economic condition.

A good history should be able to fulfill these objectives. History is not writing of an elegant essay of the patient’s complaints. Each question that is asked should be directed toward a diagnosis or help to exclude relevant differential diagnosis. It is best to use the patient’s words in history taking, rather than using medical terms. Asking the most appropriate questions in relation to patient’s complaint will save time and be most fruitful. This art is best learned at the bedside after interviewing a large number of patients.

A general introduction should include:

Introductory Remarks
Name	Date of birth
Sex	Occupation
Religion	Date of admission
Address	Mode of admission

History Taking

After introductory remarks, the presenting complaints are listed in chronological order, that is, the most prolonged complaint first and most recent last, which forced the patient to seek medical advice. It is also possible to write the presenting complaints in order of importance, with the most significant complaint first and least significant last. Mention any known disease like hypertension, diabetes, and so on, if they are thought to contribute to presenting complaints.

Presenting Complaints
• Diarrhea since	4 days
• Vomiting since	3 days
• Blood in stool since	1 day

Presenting Complaints
• Known case of rheumatoid arthritis	since 10 years
• Severe pain epigastrium	since 2 weeks
• Vomiting	since 5 days
• Blood in the vomitus	since 1 day

In the preceding example, rheumatoid arthritis, although did not primarily bring the patient to the hospital, is considered the likely cause of the underlying presenting problem. Therefore, they are mentioned in the presenting complaints or can even be mentioned as opening remarks in the history of presenting illness.

After the presenting complaint, the details of these complaints are given. This is termed the history of presenting illness. It is described in the same order as the presenting complaints, and one at a time. The opening remark usually begins by mentioning when the patient was perfectly healthy. At the end of the description of each complaint, a reasonable conclusion about the underlying cause of the complaint should be possible. If not, there are deficiencies in the history taking or background medical knowledge. The detailed description of the complaint should include:

Details of History of Presenting Illness
1.	When and how it started?
2.	How did it progress?
3.	What are its special characteristics?
4.	Are there any associated features?
5.	How has it affected the patient?
6.	What medications have been used?
7.	What investigations have been performed?
8.	What was the presumed diagnosis, if any?
9.	What was the effect or side effect of treatment?
10.	Ask related questions to confirm the diagnosis.
11.	Ask questions to exclude differential diagnosis.

Each presenting complaint is pursued with relevant questions until all the details have been gathered. It is important to note how the complaint started, progressed, and evolved. What are the precipitating and relieving factors, and whether there is any relation to any particular event like meals or breathing? Also, ask how the complaint has altered the patient’s lifestyle. At times, a lot of cross-questioning may be required until a fair conclusion about the diagnosis is reached. A patient with abdominal pain may be interviewed as follows:

Patient with Epigastric Pain
1.	When did you first have the pain?
2.	How did it start or what were you doing at the time?
3.	Where exactly did it start and does it radiate?
4.	How would to grade it in severity from 1 to 10?
5.	What was its character (heaviness, stabbing, sharp, dull, colicky, and so on)?
6.	How did it progress?
7.	How long did it last?
8.	Were there any associated symptoms (nausea, vomiting, sweating, fainting, fever, palpitations, cough and phlegm, skin rash, and so on)?
9.	What makes it worse?
10.	What makes it better?
11.	Is it related to anything like meals, exertion, body position, coughing, and so on?
12.	Is there any local tenderness?
13.	Did you take any treatment, and what was its effect?
14.	Have you ever had any heart, lung, or ulcer problem?
15.	History of similar problem in the past?
16.	History of blood in stool or vomitus or passing black-colored stools?
17.	Did you have any investigations?

During history taking, the doctor is thinking about peptic ulcer disease, heart disease, pericardial disease, esophageal disease, pancreatic disease, pleuritic problems, colonic problems, and skin, soft tissue, and musculoskeletal problems.

The intention of these questions is to reach a fair diagnosis, exclude relevant differential diagnosis, and determine any associated complication or the cause of the underlying disorder, if applicable.

It is up to the doctor to decide which part of the patient’s history is relevant, and which is not. A good doctor will prevent the patient form side tracking and wasting time in irrelevant details. At the same time, a vigilant physician will pick up minute detail in the history, which, although not important to the patient, may clinch the diagnosis. In some patients, however, the diagnosis is only possible after proper examination or even after investigations. At the end of the history of presenting illness, it is necessary to inquire about any other complaints the patient may have in any of the major systems.

Direct Questioning in History
CNS	History of headache, seizures, imbalance, dizziness, sensory or motor problems, loss of consciousness, and so on.
CVS	Chest pain, palpitations, dyspnea, syncope, orthopnea and paroxysmal nocturnal dyspnea, and so on.
RT	Cough, sputum, dyspnea, hemoptysis, and so on.
GIT	Abdominal pain, dyspepsia, nausea, heartburn, diarrhea, and constipation.
MKL	Joint pains, morning stiffness, limitation of movement and restricted activities, and so on.
ENDO	Changes in growth, weight, and metabolism. Ask about problems related to thyroid, parathyroid, pancreas, and adrenal glands.
GUT	Polyuria, dysuria, frequency, oliguria, and change in color and smell of urine. History of passage of blood, stones, gravel, or any kidney problems should be inquired.

CNS = central nervous system, CVS = cardiovascular system, RT = respiratory system, GIT = gastrointestinal tract, MSKL = musculoskeletal system, ENDO = endocrine system, GUT = genitourinary tract

Past History

This includes a detail of the patient’s past medical and surgical record. It is not sufficient to say that nothing abnormal is detected. List important positive and negative findings in chronological order. Ask about past illnesses and hospitalizations for any reason. Ask about past operations, if any. A past illness may be the source of the present problem.

Details of Past Illness
How long have you had the illness?	How well is your disease controlled?
What treatment are you taking for it?	Is it associated with any complications?
Do you take your treatment regularly?

Direct questions about common diseases like diabetes, hypertension, jaundice, peptic ulcer, asthma, joint disease, bowel problems, and so on may be mentioned here or at the end of the presenting complaint.

Family History

Ask about the family members and any significant history of disease in the immediate (first-degree relatives) or distant family. Has any relative, an identical or similar illness? Does any relative suffer from an unusual disease, or died from a rare condition?

Common GI Disease with Familial Incidence

• Peptic ulcer may run in families or more common in blood group O.

• Irritable bowel syndrome.

• Inflammatory bowel disease.

• Familial adenomatous polyposis (Gardner’s syndrome autosomal dominant).

• Peutz–Jegher’s syndrome (autosomal dominant).

• Familial gastric cancer.

• Colorectal cancer

• Hereditary hemorrhagic telangiectasia.

• GIST (gastrointestinal stromal tumors).

• Zollinger–Ellison syndrome.

If a disease happens to run in the family, it does not mean that all the sufferers may have the same manifestations. In others, it may involve a different system, for example, In Marfan syndrome, there may be predominant cardiac, musculoskeletal, or eye involvement. Ask about marriages within the family, as consanguineous marriage may be the source of rare autosomal recessive syndromes. What is the ethnic origin of the family? Various ethnic groups have higher incidence of certain inherited disorders.

Various diseases tend to run in families and have different modes of inheritance. There are three basic kinds of inherited disorders. (1) Chromosomal abnormalities, (2) Mendelian disorders may be autosomal dominant, autosomal recessive, or X-linked types, and (3) multifactorial disorders.

Some Chromosomal Disorders
Turner’s syndrome	45 X.
Klinefelter’s syndrome	47 XXY.
Down’s syndrome	+21 (Trisomy 21).

Mendelian Disorders
Autosomal dominant
Familial hypercholesterolemia.	Peutz–Jegher’s syndrome.
Gardner syndrome.	Adult polycystic kidney.
MEN 1A	Neurofibromatosis.
Autosomal recessive
Muconium ileus	Sickle cell anemia.
Wilson’s disease.	Hemochromatosis.
Cystic fibrosis.
X-linked
Hemophilia-A.	G6PD deficiency.
Color blindness.	Hypophosphatemic rickets.

Ask about the health of parents, if alive, and if dead, the cause of death. Always ask about the probable cause of death and circumstances leading to death. Ask about health of wife and children, if applicable.

Personal History

Ask about personal habits like tobacco use or smoking, addictions (especially alcohol and others) and hobbies. Ask about recent travel (especially to areas where AIDS is common or endemic) and sex life, if thought necessary for the diagnosis. It is necessary at this stage to take the patient into confidence and tell him or her that their personal life will always remain a secret. It may be necessary to inquire about beliefs and faith and about psychological problems, as psychotherapy may be required as a form of treatment. Ask about living conditions, as some diseases are prone to occur in poor hygienic and overcrowded conditions.

Socioeconomic Status

Ask about the means of earning and whether the patient is well to do or can hardly make both ends meet. The patient may have more than one source of income. Also, ask about support from the family, as the patient may have or is likely to develop a disabling illness. It may be important to avoid choosing expensive medications, whenever possible, as the patient may not be able to afford them.

Occupational History

Ask about the present and past occupations that the patient may have had, as it may be related to the disease. Many a times, the disease may be related to the patient’s work or workplace.

Occupational Lung Disease
Anthrax can affect the GI tract by eating undercooked and contaminated food. The patient may have abdominal pain, nausea, loss of appetite, and bloody diarrhea.
Exposure to vinyl-chloride (plastic workers) may cause liver cancer.
Exposure to epoxy resins (rubber factory) may cause acute hepatitis.
Carbon tetrachloride exposure (dry cleaners) may cause acute liver toxicity.
Other exposures like cement, iron, graphite, cadmium, chromium, cotton worker, chemical worker, and so on can have lung disease with increased mucous secretion and variable obstruction.
Halides like chloride and fluoride in workers of textile and paper may cause dental fluorosis, pulmonary edema, epistaxis, and dryness.

History of Allergy and Immunization

Ask the patient if there is any history to any material including drugs. If yes, what kind of reaction was noted with the offending agent. Also, ask about pervious or any regular course of immunization that the patient has received.

Travel History

Ask about any history of travel in the recent past. This may be useful especially in diarrheal illnesses and infectious diseases.

Treatment History

It is mandatory to take a detailed history of the past medical and surgical treatment. This includes not only the treatment of the present problem, but any significant and especially related problems in the past.

Some Related Questions
What diseases have you suffered in the past?	What medication were you prescribed?
In what doses and for how long?	What was the effect in terms of benefit?
What were the complications, if any?	Are you still taking any treatment?