A TONGUE-IN-CHEEK APPROACH TO THE SIGNIFICANCE OF A WELL TAKEN PATIENT HISTORY
Guest Writer: Arun Swaminathan M.D
Patient histories are more than just histories or stories. They form the basis on which treating doctors decide their treatment or about 80 percent of it. Every point mentioned in a patient history has some significance for the treating doctor or for every other person who might read through it. Here’s a look why…Starting off, it is always important to mention the informant and his/her relationship to the patient, if the history is not being given by the patient himself/herself, as apart from the medically important reasons of determining patients’ consciousness/orientation, it helps the doctor decide if the history is reliable or not. A detailed history from the patient’s parent or spouse is certainly more reliable than a few warped details from his/her friend/neighbor/squash buddy/third cousin/great aunt’s sister-in-law’s daughter who was babysitting him/her for a few minutes…(I’m sure you get the point!!!)
‘What’s in a name?’ they ask. Apparently, a lot, as things go. Knowing a patient’s name is important to lend a personal touch to his treatment, rather than having to refer to him as ‘File no.M89’ or ‘Patient in room 238’ or ‘that dude with genital herpes’ or any other nasty way of keeping him in mind. Besides, it avoids any kind of mix-ups or errors like giving one patient another’s medication, especially if there are 2 patients in room 238.
Age is especially important as it helps one think of certain conditions that are more prominent in certain age groups. Though one does hear of rare diseases or rare presentations of conditions in atypical age groups, it is still prudent to assume that any difficulty in moving both legs in an elderly patient is most certainly not due to cerebral palsy.Patients’ sex is a major defining factor of treatment as apart from slight differences in dosage regimes among other things, it helps rule in or out certain conditions. I still remember being given a CT scan of a patient’s brain and being asked for a list of possible causes of the metastasized tumor to the brain and then getting dirty looks from him after I inadvertently blurted out ‘Breast Cancer’ first.
Handedness of a patient is important as knowing a patients’ dominant hand would help know his dominant brain hemisphere. As always, there are patients who hurt themselves in the most retarded ways possible and make you wonder about the presence of a brain in them, leave alone a dominant half.
Consanguinity is an important question to suggest certain inheritable conditions that might present with greater probability in certain patients. While I am highly sympathetic towards fellow medical professionals who must pursue this point delicately and systematically, I extend my deepest sympathies to a colleague (who possessed intelligence but lacked fluency in English) who asked a patient, “Were your parents related as brother and sister before they married?”After the short introductory history above, it is imperative to inquire for a detailed account of the presenting condition that brings the patient to your not-so-cheerful presence. A detailed account of the problem with its particulars would serve both doctor and patient very well. It would be prudent to mention that a large number of mistakes have been committed during this section of the history taking due to lack of attention to detail or forgetfulness, both of which are perfectly avoidable.
The next few questions would be dedicated to the details of the associated symptoms and other ongoing health issues. These help the treating doctor form a working hypothesis of the patient’s condition or the most likely possibilities. Mentioning the absence of certain symptoms is as important as a detailed description of the symptoms that are present.A detailed description of past medical conditions or surgeries is important to ensure that cases of laparoscopies for moderately severe abdominal pain are not freely performed on patients who have already had their appendices removed. It also ensures that patients are not given medications that they are known to be allergic to.
A thorough and detailed history of medication use and substance abuse of any kind is among the most important aspects of history taking. Finesse, attention to detail and timing are the keys to extracting details of these personal habits. I hope this helps avoid mistakes like the time when a patient undergoing a rectal examination was asked if he smoked cigarettes. The worried man looked around at the doctor and the vision scope in his rectum and said, “Yes. Why? Do you see smoke coming out of my arse?” Another example is that of the patient who vehemently denied the presence of a smoking habit and admitted on being questioned further that he had smoked 2 packs of cigarettes a day for 40 years and had ‘given up smoking’ 10 days ago when he developed pneumonia.
Family history is important to look for inheritable conditions that have been passed down generations of families, among the other endearing inheritances. It is a well known fact that diabetes and heart disease run in many families along with the presence of mental conditions. It has been suggested, jocularly though, that mental disease and heart disease run in all families with differences seen only in the severity of expression. Given the number of crazy relatives each one of us can think of, if only I had a nickel for every wacko member of my family…
Sexual history, while not always informative, is certainly a major point to focus on, given the fact that the patient’s disorder may have a psychiatric basis precipitated by sexual causes. A neurologist will tell you that headaches may have a sexual cause in herpes encephalitis while psychiatrists will write many chapters about women who feign headaches to avoid having sex. Inquiring about sexual history is in itself a delicate matter and something of a headache, especially if the doctor is not tactful and ends up getting punched in the face by an angry/embarrassed patient.
There are many other points that may need to be covered as part of routine history taking but these are essentially the major ones. Do bear in mind that this list is far from exhaustive and that tact, discretion and patience are the most important attributes that a medical practitioner may need to show to get a detailed description of the points mentioned thus far.
All the best and May you find the experience of reading this informative and amusing!!!
Naqi Haider 