The importance of a clear history
Understanding the patient’s experience of illness by taking a history is central to the practice of all branches of medicine. The process requires patience, care and understanding to yield the key information leading to correct diagnosis and treatment.
In a perfect situation a calm, articulate patient would clearly describe the sequence and nature of their symptoms in the order of their occurrence, understanding and answering supplementary questions where required to add detail and certainty. In reality a multitude of factors may complicate this encounter and confound the clear communication of information. This chapter is a guide to facilitating the taking of a clear history. Information on specific symptoms and presentations is covered in the relevant system chapters.
Gathering information
Beginning the history
Preparation
Read your patient’s past records, if they are available, along with any referral or transfer correspondence before starting.
Allowing sufficient time
Consultation length varies. In UK general practice the average time available is 12 minutes. This is usually adequate, provided the doctor knows the patient and the family and social background. In hospital, around 10 minutes is commonly allowed for returning outpatients, although this is challenging for new or temporary staff unfamiliar with the patient. For new and complex problems a full consultation may take 30 minutes or more. For students, time spent with patients learning and practising history taking is highly valuable, but patients appreciate advance discussion of the time students need.
Starting your consultation
Introduce yourself and anyone who is with you, shaking hands if appropriate. Confirm the patient’s name and how they prefer to be addressed. If you are a student, inform patients; they are usually eager to help. Write down facts that are easily forgotten, such as blood pressure or family tree, but remember that writing notes must not interfere with the consultation.
Using different styles of question
Begin with open questions such as ‘How can I help you today?’ or ‘What has brought you along to see me today?’ Listen actively and encourage the patient to talk by looking interested and making encouraging comments, such as ‘Tell me a bit more.’ Always give the impression that you have plenty of time. Allow patients to tell their story in their own words, ideally without interruption. You may occasionally need to interject to guide the patient gently back to describing the symptoms, as anxious patients commonly focus on relating the events or the reactions and opinions of others surrounding an episode of illness rather than what they were feeling. While avoiding unnecessary repetition, it may be helpful occasionally to tell patients what you think they have said and ask if your interpretation is correct (reflection).
The way you ask a question is important:
- •
Open questions are general invitations to talk that avoid anticipating particular answers: for example, ‘What was the first thing you noticed when you became ill?’ or ‘Can you tell me more about that?’
- •
Closed questions seek specific information and are used for clarification: for example, ‘Have you had a cough today?’ or ‘Did you notice any blood in your bowel motions?’
Both types of question have their place, and normally clinicians move gradually from open to closed questions as the interview progresses.
The following history illustrates the mix of question styles needed to elucidate a clear story:
When did you first feel unwell, and what did you feel? (Open questioning) Well, I’ve been getting this funny feeling in my chest over the last few months. It’s been getting worse and worse but it was really awful this morning. My husband called 999. The ambulance came and the nurse said I was having a heart attack. It was really scary . When you say a ‘funny feeling’, can you tell me more about what it felt like? (Open questioning, steering away from events and opinions back to symptoms) Well, it was here, across my chest. It was sort of tight, like something heavy sitting on my chest. And did it go anywhere else? (Open but clarifying) Well, maybe up here in my neck. What were you doing when it came on? (Clarifying precipitating event) Just sitting in the kitchen, finishing my breakfast. How long was the tightness there? (Closed) About an hour altogether. So, you felt a tightness in your chest this morning that went on for about an hour and you also felt it in your neck? (Reflection) Yes that’s right. Did you feel anything else at the same time? (Open, not overlooking secondary symptoms) I felt a bit sick and sweaty.
Showing empathy when taking a history
Being empathic helps your relationship with patients and improves their health outcomes ( p. 5 ). Try to see the problem from their point of view and convey that to them in your questions.
Consider a young teacher who has recently had disfiguring facial surgery to remove a benign tumour from her upper jaw. Her wound has healed but she has a drooping lower eyelid and facial swelling. She returns to work. Imagine how you would feel in this situation. Express empathy through questions that show you can relate to your patient’s experience.
So, it’s 3 weeks since your operation. How is your recovery going? OK, but I still have to put drops in my eye. And what about the swelling under your eye? That gets worse during the day, and sometimes by the afternoon I can’t see that well. And how does that feel at work? Well, it’s really difficult. You know, with the kids and everything. It’s all a bit awkward. I can understand that that must feel pretty uncomfortable and awkward. How do you cope? Are there are any other areas that are awkward for you, maybe in other aspects of your life, like the social side?
The history of the presenting symptoms
Using these questioning tools and an empathic approach, you are now ready to move to the substance of the history.
Ask the patient to think back to the start of their illness and describe what they felt and how it progressed. Begin with some open questions to get your patient talking about the symptoms, gently steering them back to this topic if they stray into describing events or the reactions or opinions of others. As they talk, pick out the two or three main symptoms they are describing (such as pain, cough and shivers); these are the essence of the history of the presenting symptoms. It may help to jot these down as single words, leaving space for associated clarifications by closed questioning as the history progresses.
Experienced clinicians make a diagnosis by recognising patterns of symptoms ( p. 362 ). With experience, you will refine your questions according to the presenting symptoms, using a mental list of possible diagnoses (a differential diagnosis) to guide you. Clarify exactly what patients mean by any specific term they use (such as catarrh, fits or blackouts); common terms can mean different things to different patients and professionals ( Box 2.1 ). Each answer increases or decreases the probability of a particular diagnosis and excludes others.
| Patient’s term | Common underlying problems | Useful distinguishing features |
|---|---|---|
| Allergy | True allergy (immunoglobulin E-mediated reaction) | Visible rash or swelling, rapid onset |
| Intolerance of food or drug, often with nausea or other gastrointestinal upset | Predominantly gastrointestinal symptoms | |
| Indigestion | Acid reflux with oesophagitis | Retrosternal burning, acid taste |
Abdominal pain due to:
| Site and nature of discomfort:
| |
| Arthritis | Joint pain | Redness or swelling of joints |
| Muscle pain | Muscle tenderness | |
| Immobility due to prior skeletal injury | Deformity at site | |
| Catarrh | Purulent sputum from bronchitis | Cough, yellow or green sputum |
| Infected sinonasal discharge | Yellow or green nasal discharge | |
| Nasal blockage | Anosmia, prior nasal injury/polyps | |
| Fits | Transient syncope from cardiac disease | Witnessed pallor during syncope |
| Epilepsy | Witnessed tonic/clonic movements | |
| Abnormal involuntary movement | No loss of consciousness | |
| Dizziness | Labyrinthitis | Nystagmus, feeling of room spinning, with no other neurological deficit |
| Syncope from hypotension | History of palpitation or cardiac disease, postural element | |
| Cerebrovascular event | Sudden onset, with other neurological deficit |
In the following example, the patient is a 65-year-old male smoker. His age and smoking status increase the probability of certain diagnoses related to smoking. A cough for 2 months increases the likelihood of lung cancer and chronic obstructive pulmonary disease (COPD). Chest pain does not exclude COPD since he could have pulled a muscle on coughing, but the pain may also be pleuritic from infection or thromboembolism. In turn, infection could be caused by obstruction of an airway by lung cancer. Haemoptysis lasting 2 months greatly increases the chance of lung cancer. If the patient also has weight loss, the positive predictive value of all these answers is very high for lung cancer. This will focus your examination and investigation plan.
What was the first thing you noticed wrong when you became ill? (Open question) I’ve had a cough that I just can’t get rid of. It started after I’d had flu about 2 months ago. I thought it would get better but it hasn’t and it’s driving me mad. Could you please tell me more about the cough? (Open question) Well, it’s bad all the time. I cough and cough, and bring up some phlegm. It keeps waking me at night so I feel rough the next day. Sometimes I get pains in my chest because I’ve been coughing so much. Already you have noted ‘Cough’, ‘Phlegm’ and ‘Chest pain’ as headings for your history. Follow up with key questions to clarify each. Cough: Are you coughing to try to clear something from your chest or does it come without warning? (Closed question, clarifying) Oh, I can’t stop it, even when I’m asleep it comes. Does it feel as if it starts in your throat or your chest? Can you point to where you feel it first? It’s like a tickle here (points to upper sternum) . Phlegm: What colour is the phlegm? (Closed question, focusing on the symptom) Clear. Have you ever coughed up any blood? (Closed question) Yes, sometimes. When did it first appear and how often does it come? (Closed questions) Oh, most days. I’ve noticed it for over a month. How much? (Closed question, clarifying the symptom) Just streaks. Is it pure blood or mixed with yellow or green phlegm? Just streaks of blood in clear phlegm. Chest pain: Can you tell me about the chest pains? (Open question) Well, they’re here on my side (points) when I cough. Does anything else bring on the pains? (Open, clarifying the symptom) Taking a deep breath, and it really hurts when I cough or sneeze.
Pain is a very important symptom common to many areas of practice. A general scheme for the detailed characterisation of pain is outlined in Box 2.2 .
S ite
- •
Somatic pain, often well localised, e.g. sprained ankle
- •
Visceral pain, more diffuse, e.g. angina pectoris
O nset
- •
Speed of onset and any associated circumstances
C haracter
- •
Described by adjectives, e.g. sharp/dull, burning/tingling, boring/stabbing, crushing/tugging, preferably using the patient’s own description rather than offering suggestions
R adiation
- •
Through local extension
- •
Referred by a shared neuronal pathway to a distant unaffected site, e.g. diaphragmatic pain at the shoulder tip via the phrenic nerve (C 3 , C 4 )
A ssociated symptoms
- •
Visual aura accompanying migraine with aura
- •
Numbness in the leg with back pain suggesting nerve root irritation
T iming (duration, course, pattern)
- •
Since onset
- •
Episodic or continuous:
- •
If episodic, duration and frequency of attacks
- •
If continuous, any changes in severity
- •
E xacerbating and relieving factors
- •
Circumstances in which pain is provoked or exacerbated, e.g. eating
- •
Specific activities or postures, and any avoidance measures that have been taken to prevent onset
- •
Effects of specific activities or postures, including effects of medication and alternative medical approaches
S everity
- •
Difficult to assess, as so subjective
- •
Sometimes helpful to compare with other common pains, e.g. toothache
- •
Variation by day or night, during the week or month, e.g. relating to the menstrual cycle
Having clarified the presenting symptoms, prompt for any more associated features, using your initial impression of the likely pathology (lung cancer or chronic respiratory infection) to direct relevant questions:
Do you ever feel short of breath with your cough? A bit. How has your weight been? (Seeking additional confirmation of serious pathology) I’ve lost about a stone since this started.
The questions required at this point will vary according to the system involved. A summary of useful starting questions for each system is shown in Box 2.3 . Learn to think, as you listen, about the broad categories of disease that may present and how these relate to the history, particularly in relation to the onset and rate of progression of symptoms ( Box 2.4 ).
| System | Question |
|---|---|
| Cardiovascular | Do you ever have chest pain or tightness? Do you ever wake up during the night feeling short of breath? Have you ever noticed your heart racing or thumping? |
| Respiratory | Are you ever short of breath? Have you had a cough? If so, do you cough anything up? What colour is your phlegm? Have you ever coughed up blood? |
| Gastrointestinal | Are you troubled by indigestion or heartburn? Have you noticed any change in your bowel habit recently? Have you ever seen any blood or slime in your stools? |
| Genitourinary | Do you ever have pain or difficulty passing urine? Do you have to get up at night to pass urine? If so, how often? Have you noticed any dribbling at the end of passing urine? Have your periods been quite regular? |
| Musculoskeletal | Do you have any pain, stiffness or swelling in your joints? Do you have any difficulty walking or dressing? |
| Endocrine | Do you tend to feel the heat or cold more than you used to? Have you been feeling thirstier or drinking more than usual? |
| Neurological | Have you ever had any fits, faints or blackouts? Have you noticed any numbness, weakness or clumsiness in your arms or legs? |
| Disease causation | Onset of symptoms | Progression of symptoms | Associated symptoms/pattern of symptoms |
|---|---|---|---|
| Infection | Usually hours, unheralded | Usually fairly rapid over hours or days | Fevers, rigors, localising symptoms, e.g. pleuritic pain and cough |
| Inflammation | May appear acutely | Coming and going over weeks to months | Nature may be multifocal, often with local tenderness |
| Metabolic | Very variable | Hours to months | Steady progression in severity with no remission |
| Malignant | Gradual, insidious | Steady progression over weeks to months | Weight loss, fatigue |
| Toxic | Abrupt | Rapid | Dramatic onset of symptoms; vomiting often a feature |
| Trauma | Abrupt | Little change from onset | Diagnosis usually clear from history |
| Vascular | Sudden | Stepwise progression with acute episodes | Rapid development of associated physical signs |
| Degenerative | Gradual | Months to years | Gradual worsening with periods of more acute deterioration |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
