The History

The History

To consider the sense of a question, consider what an answer to it would look like.


Importance of the History

For decades, medical students beginning the course in clinical examination were told that 90% of all diagnoses are suggested or made by the history, 90% of the remainder (9% of the total) by the physical examination, and only 1% of the total by the laboratory tests. (The purpose of laboratory tests is to confirm diagnoses already hypothesized on the basis of the history and physical.)

A careful study of competent clinicians (Hampton et al., 1975) reveals that 82% of diagnoses are still made by the history, 9% by the physical examination, and 9% by the laboratory. A later study showed results essentially unchanged: in 76%, the history led to the final diagnosis; in 12%, the physical examination; and in 11%, laboratory findings (Peterson et al., 1992).

The importance of the history is best illustrated by a research project from the Mayo Clinic (Beart and O’Connell, 1983). One hundred sixty-eight patients with carcinoma of the colon were entered into a prospective study comparing the history, physical, and a variety of laboratory tests in detecting recurrent carcinoma. The patients were seen at least every 15 weeks. The most sensitive sign of recurrence turned out to be the history. Of the 48 patients who developed a recurrence, 85% had coughing, abdominal or pelvic pain, a change in bowel habit, rectal bleeding, or malaise before signs of disease appeared on physical examination, radiologic examination, or serial determinations of the carcinoembryonic antigen level.

The fact remains that anyone can order laboratory tests; only a physician can make a diagnosis. The acquisition of the requisite clinical skills cannot be completed in a week, a month, a year, or probably much less than a decade. To achieve the results shown by the British and the Mayo Clinic studies, one must be quite skillful in eliciting and composing the history. The leading symptom must be described in as many dimensions as possible, and the story must be composed in a chronologically organized manner.

The Difference between Facts and Information

Facts are true statements. Information consists of facts arranged in a useful manner.

A history is not simply a collection of facts. It must also contain information, although a good history even goes beyond that. Simply writing down or reciting a gaggle of true statements is not composing a history. The facts must be placed in a form that makes them informative.

Many medical schools “teach” by having students memorize a large number of facts. But, these schools do not teach students how to decide what a fact is or how to collect facts in a useful and informative manner. This method is like teaching a neophyte cabdriver to work in a new city by having him memorize all the names and addresses in the telephone book, instead of showing him how to read a map.

Overview of History of Present Illness

As an aid in composing the history of present illness (HPI), the student needs to have in mind a structure. Figure 3-1 is a handout that has been used for more than 15 years to help students initiate an adequate bedside presentation of the HPI.

Example: An Unacceptable Presentation

“John is an unemployed veteran who is back again for his hypertension. His doctor said that he needs a different medicine. He had something like this once before, but he isn’t certain whether it was when he was a little boy or not.”

Example: A Satisfactory Presentation

“Mr. Smith is a 42-year-old black man who enters our hospital for the second time with a chief complaint of a ‘nosebleed’ of about 6 hours duration. The history of the present illness begins 5 years ago when a blood pressure of 180/120 was recorded by a plant physician at the time of a routine preemployment examination.

FIGURE 3-1 Form used by students to compose the history of the present illness.

“He sought no medical advice for this and remained asymptomatic until 4 years ago when he noted the gradual onset of headaches, usually but not always pounding, occurring on an average twice a week. There were no aggravating or alleviating factors (other than aspirin), nor any associated symptoms, until 2 years ago, when the headaches became more severe and blurred vision supervened. For this latter reason, he visited our emergency room (ER) and was admitted. At that time, he was also told for the first time that he had blood in his urine, although he himself recalls no change in its color … (etc.).”

Chief Complaint

The chief complaint is a statement (in the patient’s own words) of the index symptom that you have selected from the interview material as being chief or principal. Because it is a direct (albeit edited) quotation, it is placed in quotation marks. It is followed by a statement of duration: A number followed by a unit of time (e.g., 1 hour, 2 days, 3 weeks, 4 months, 5 years, etc.). Placing the chief complaint in the patient’s words is a device that prevents the inexperienced as well as the senile from placing their own diagnostic conclusions in the database. For instance, a patient who had actually complained of “spitting up blood” was presented as a case of hematemesis. After a protracted and fruitless workup, a consultant quickly discovered the fact that the patient was actually suffering from hemoptysis (see Chapter 16).

The statement of time is a modifier that helps the reader, or listener, select which computer program his brain will run to solve the patient’s problem (e.g., chronic diarrhea, acute shortness of breath, acute chest pain, etc.).

In psychiatry, the axiom is that the chief complaint “tells it all.” Although at first one does not have enough information about the patient to understand the true, deep meaning of the stated chief complaint, it is a key datum to the psychiatrist.

For the Student. Think of the chief complaint as the patient’s chief concern. A “concern” is less likely to be translated into biomedical language, and its verbatim statement may presage more attention to the patient’s voice, not just in the history of the present illness, but throughout the course of medical treatment (Donnelly, 1997).

For the Attending. In a study of four house officers presenting cases to senior clinicians at morning report (and unaware that they were being studied), no chief complaint was ever stated in 17% of the cases. In the remaining 83%, there was an average wait of 36 seconds (range: 5 seconds to 3 minutes 20 seconds) before the chief complaint was announced. This is simply too long a wait for “selecting a program” because unassimilable facts are meanwhile being presented with no framework upon which they could be arranged.

Dimensions of a Symptom

In order to analyze any symptom, including the leading symptom of the present illness, one must fully describe the symptom in all its dimensions. (If you have already learned a system, such as the PQRST1 method of describing pain [DeGowin and DeGowin, 1970] or the “seven dimensions” listed in Morgan and Engel [1969], you may elect to skip this section and continue with the good habits already formed. If you have not already learned a set of dimensions, this one is offered. A list of the dimensions [whichever one you choose] is probably the only list in all of clinical examination worth memorizing. Everything else can be learned by repetition and can be kept on an index card or a notebook in the interim.)

The dimensions I use are as follows:

  • Time

  • Quantity

  • Location

  • Aggravating factors

  • Alleviating factors

  • Quality

  • Setting

  • Associated symptoms

  • Inconstant dimensions (color, clarity, consistency, etc.)


Time may actually be of several dimensions, as we shall shortly see. At first glance, it might seem that the dimension of time has already been presented for the symptom of the chief complaint because the duration is a statement in this dimension. And for some symptoms, this is true (e.g., “cyanosis since birth” in cases of congenital heart disease with right-to-left shunting). But in other cases, the issue is much more complicated than a simple issue of duration.

For instance, consider this account of crescendo angina:

At first that squeezing pain just lasted about 10 or 20 seconds. It started to go away as soon as I stopped walking up the hill, but later, around that Christmas, when that aching became more frequent, I mean I started getting attacks almost everyday by then, just stopping didn’t do anything for me. I had to get the nitro under my tongue, and then I had to wait for it to work, oh maybe 2, 3 minutes, but I was still doing okay, going to work every day. Well, Sunday morning when we were getting ready for the birthday party, I noticed all of a sudden ….

Here the patient is describing the duration of the individual attack, the duration of the relief of symptoms, and the frequency of the attacks, all of which are expressed in units of time and each of
which must also be described in the record within the chronologic dimension. If one had only the duration of the symptom, one could not make the diagnosis of crescendo angina.

With further questioning, one could add still another time measure: How long the patient could walk up that hill before the “squeezing-aching” would appear.

It will become obvious that there are many other important symptoms existing in time that we have not discussed here. To give one additional example, students are taught to ask whether there is an “aura” or warning in evaluating the complaint of syncope. But even more useful is the time dimension of the aura because patients with vasovagal syncope tend to have a long aura (about 2.5 minutes), while those with cardiac syncope usually have a very brief aura (<3 seconds) rather than none at all (Martin et al., 1983).

When the onset of the illness is vague or the description seems somewhat sparse, a useful question to ask the patient is this: “When is the last time you can remember feeling perfectly healthy?” Use exactly these words.

The purpose of this question is to get the patient talking. It is not intended to determine when the history of the present illness began, although sometimes it will do that. The idea is to increase the number of historic facts at your disposal. After you get all the facts, you will be able to determine the beginning of the present illness. In addition to sharpening up the early history of the present illness by giving the patient a chance to reflect and recall, this question often stimulates patients to talk about other symptoms that they had momentarily pushed out of consciousness or that the listener had not attended to at first.

It is important to understand that this question is not the same as, “When did you first get sick?” or even, “When is the last time you did not have (the given symptom)?” Those are not really open-ended questions. The question as stated in the first paragraph is open-ended, provided that you listen to the answer without interrupting.

A feature of timing that is pertinent to a wide range of specific symptoms is the relationship of the onset to any drugs that the patient may be taking. The probability of various side effects may be found in the Physicians Desk Reference. However, this author frequently relearns the dictum taught at Parkland Memorial Hospital: “Any drug can do anything.” Adverse reactions may be paradoxical or difficult to distinguish from the condition being treated, as with suicidality or violent behavior associated with certain antidepressants (Kauffman, 2009). They may be rare, unanticipated from the drug’s purported mechanism of action, or simply underreported, for example, irritability and aggressive behavior on cholesterol-lowering drugs (Golomb et al., 2004; Tatley and Savage, 2007). Adverse effects do not necessarily have an immediate onset. Some, such as cognitive impairment due to diazepam, occur as a long-lived drug accumulates. Allergic or idiosyncratic reactions can occur unpredictably in patients who have previously tolerated a drug very well. The post hoc ergo proper hoc fallacy is always a risk when attributing a finding to a drug (see Chapter 27), yet continued use of a drug for fear of the fallacy can do continued harm if the drug truly is the culprit.


Some examples of quantity are “three tablespoons of sputum each morning,” “two-pillow orthopnea,” “about one-half cup of bloody emesis,” or “claudication that had formerly appeared after four or five level blocks, now occurring regularly at one block.”

Some symptoms, such as pain, have no international units but can still be expressed on an analog scale from 0 to 10, where 0 is the absence of the symptom and 10 is an extreme, such as “so bad you would have killed yourself.”

Other symptoms cannot be described in cardinal numbers but still require a salient, concrete description. Adjectives (such as “terrible”) are much less useful than the answer to the question, “What could you do in the past that you cannot do now because of (this symptom)?” The patient might respond that he can no longer walk across the room to the toilet because of shortness of breath.


Although location might well have been covered in the chief complaint, if the chief complaint is the leading symptom of the present illness, the use of the patient’s own words might preclude a precise description at that point. The pain in the “tummy” might be in the epigastrium, hypochondrium, periumbilical area, suprapubic area, or even the colon and rectum. A misinterpretation of the term “tummy” by the physician will, at best, delay the diagnosis. Similarly, the “hip” can be the buttock, the rectum, the actual hip joint, the iliac crest, the skin on the lateral surface of the buttock, or nodes in the inguinal or femoral areas. Sometimes it is the doctor who is imprecise; he might change the patient’s “thigh,” “knee,” “calf,” “ankle,” or “instep” into the “left lower extremity,” thereby homogenizing, instead of refining, these terms.

Some symptoms, such as weakness, do not always have a location. This is also important to establish and to note in the record. The differential diagnosis of weakness in the right hand is completely different from that of generalized weakness that is not focal.

For certain symptoms, particularly pain, the dimension of location also includes radiation, which is where the symptoms move (see the sections on the “Durga and pseudo-Durga syndromes”).

Aggravating and Alleviating Factors

The patient should be asked about aggravating factors in an open-ended manner: “What kinds of things might make it worse?” Although aggravating factors are usually analyzed in conjunction with alleviating factors, a separate question should be used for the latter. If you ask the patient, “What kinds of things make this better or worse?” most patients will answer only the second part of the question and will never return to the alleviating factors. The physician who asks this question may then remember “no data” as the alleviating factor. (This, of course, is one form of the dreaded double question [see Chapter 2]. If you audit your tape recordings carefully, you will be amazed by how often you use double questions. Avoiding them is a learned skill.)

To illustrate the utility of the aggravating and alleviating factors, consider two patients with left-sided anterior chest pain. One patient’s pain is induced by exercise and strong emotions but consistently relieved by rest and sublingual nitroglycerin; this is characteristic of angina pectoris. The other patient’s pain is aggravated by sneezing, coughing, and respiration but alleviated by shallow breathing and splinting of the left side of the chest; this patient has pleurisy. Although the patient may not always have such a classic history, the physician will never learn of these diagnostic
clues, even when readily available, if he does not ask the proper questions.


The quality of the symptom is most important for the very symptoms that at first glance seem to be least susceptible to a qualitative description. For instance, Samuel Levine used to tell his students that if the patient’s chest pain was glibly and clearly communicated it was probably not myocardial in origin. The difficulty that the patient experienced in describing the pain was in itself a diagnostic clue.

When a patient complains of “spells,” “falling out,” “risings” (or “kernels”), weakness, back pain, or fatigue, a good opening question is, “Could you tell me more about what that was like?”

Not all the information obtained in response to that question will necessarily be in the dimension of quality. In fact, some patients will proceed to describe almost everything else except the quality: where he was when the symptom occurred, the time of day, statements of other persons, opinions of other physicians, and accounts of the symptoms of other family members. Ask such patients, “Could you tell me more about what it felt like to you?” If the patient truly seems to display alexithymia (the inability to describe mood and feelings), try the question, “What might I have had that would feel most like what you are describing?”


Determination of the setting in which a symptom began is useful in direct proportion to the breadth of the interviewer’s view of the word “setting.” A narrow interviewer may only inquire, and episodically at that, as to the patient’s position (as in syncope), time of day (as for ulcer pain), recent ingestion of alcoholic beverages (for determining the etiology of pancreatitis), and so forth. This restricted view leads to a number of problems.

Narrow inquiries into “setting” are not open-ended information-gathering devices but branch-point signs at best, or, more usually, a means of confirming diagnoses already suggested to the interviewer. The answers to “setting” questions generated in this fashion cannot be used for research purposes because they are not asked of all patients. They cannot be used for learning purposes for a related reason (i.e., their unknown specificity). They are not useful in patient care because they are post facto to diagnoses considered for some other reason, or are simply window dressing, as in the following example.

One morning, I was presented a 28-year-old black man who had been admitted with crushing chest pain, precordial Q waves, huge ST-segment elevations, T wave inversions, and increased levels of the cardiac enzymes. The diagnosis of myocardial infarction was evident to everyone.

Most of the history of the present illness was a recitation of the following facts:

  • The patient was not sedentary, being a basketball player.

  • He was not overweight.

  • He had never smoked.

  • He did not have diabetes mellitus; his blood sugar was normal on a recent preemployment physical.

  • The cholesterol and triglyceride levels were known to be normal.

  • There was no family history of heart disease.

  • He was not hypertensive.

When I inquired why I was being given this information, I was told that the patient had been diagnosed (correctly) as suffering from a myocardial infarction and that these were the risk factors for atherosclerotic coronary artery disease. Although the patient did not have any of these risk factors, the cardiology consultant had nonetheless suggested atherosclerosis as the etiology of the disease. Because of the narrowness of focus in contemporary medicine (engendered, in part, by such post facto lists), unusual diagnoses, such as coronary artery arteritis, a coronary embolus, or a congenital anomaly of the coronary circulation, were not considered. Once the patient was labeled as having atherosclerosis, despite the absence of risk factors, all investigations were stopped cold.

Open-ended setting questions will often provide important clues to a correct diagnosis that will be missed by the Procrusteans (i.e., those who insist that the patient’s story must fit their preconceived notions, just as travelers had to fit the mythical innkeeper’s bed). The patient might start talking about something he had not told anyone before, for example, recent recurring spells of despondency, leading to further questions and possibly to a diagnosis of anxiety or depression on a positive basis, rather than the always treacherous exclusionary one. Also, open-ended questions help the interviewer understand the patient as a person.

Another error of the Procrusteans is to insist that the setting must be the one expected on a post facto basis, regardless of what the patient says. If the patient has told you that his symptoms do not occur in a setting of strong emotional arousal, you should not insist that they do. I have seen this error made in more than one patient suffering with (undiagnosed) acute intermittent porphyria, whose symptoms had been attributed to “nerves” by several physicians.

A broad interpretation of setting may lead to the discovery of new diseases, as in the story of Soma Weiss’ streetcar conductor (see Chapter 18). An interest in the setting is also important to the mental hygiene of the physician. If you do not have this basic curiosity about your patients and their illnesses, you will soon be practicing applesorter medicine. After a few years of seeing the apples only in the single dimension of size and ignoring their colors, tastes, smells, bumps, bruises, and curious travels, your medical practice will become onedimensional, causing boredom and burnout in your life’s work.

Finally, a broad understanding of the onset setting may be useful in management as well as diagnosis. The physician should be particularly sensitive to absences and partings. If the onset of the illness was in the setting of the loss of a significant other, then a similar loss of the physician (who may be quite significant to the patient) may be expected to produce perturbations both in the patient and in the patient-physician relationship. Loss can be permanent (death or abandonment), temporary (vacation or illness on the part of the physician), or anticipated (either based in reality or the fantasy of the patient).

For the Junior Student. If you do attempt to elicit the history in the manner described here, you may find yourself in conflict with some of the medical residents with whom you must work. They will want you to “get in and get out” and “just get the facts” as they perceive them. While their approach may yield certain short-term benefits, it will deprive you of the opportunity to learn certain enduring skills, which are not easily acquired later. You must decide
whether you want to learn a difficult but valuable technique from the patients assigned to you or whether you would prefer to be a donut-and-cup bearer to the tin gods of the buffed chart.

For Students of All Levels. If you want to excel at history taking, you must read about the problems that you are seeing. You will often want to return to the patient to obtain more information about certain dimensions of a symptom based on your reading.

For the Attending. The patient’s culture and language are extremely important parts of the setting, both for the interviewing process and the composition of the history. Unfortunately, this is very difficult to teach to the beginning student who is going through an acculturation process himself. By the time the young physician can appreciate these issues fully, he no longer needs to be reminded of them by the written word. The only effective method of instruction is at the bedside with a live patient.

Associated Symptoms

Associated symptoms are those that appear in some regular relationship to the symptom under analysis. This dimension often increases the diagnostic significance of the symptom severalfold. For instance, while polydipsia, polyphagia, and polyuria are each individually nonspecific, when combined they are so characteristic of new-onset diabetes mellitus that they can be considered a diagnostic triad. Weight loss, fatigue, and anorexia might suggest an occult neoplasm, but weight loss, fatigue, and perspiration could be symptoms of hyperthyroidism or tuberculosis. If paroxysms of perspiration and headaches were accompanied by palpitations, one would think of pheochromocytoma, but if they were temporally associated with bed-shaking chills, one would suspect an infectious process. The associated symptoms of dolor pectoris (chest pain) and angor animi (a sense of impending doom, vide infra) from myocardial infarction are an example of concurrent symptoms that may occur only once. Associated symptoms of a chronic complaint may not always be exactly concurrent, but they should be more or less consistent.

In infection, bed shaking occurs during the “chill” part of the temperature curve. Unfortunately, some patients may not notice the phases of their febrile illness, and they may report bed-shaking chills concurrent with or even preceding the fever. The association of symptoms is useful, even if the sequence is imprecisely remembered.

Associated symptoms do not lend themselves to easy listing like some of the other dimensions. Inquiring about them requires some knowledge of medicine. Otherwise, who would think to ask about itching when trying to evaluate jaundice? Yet this symptom can help distinguish hepatic obstruction (in which itching due to bile salt retention can occur before the individual becomes overtly jaundiced) from hemolytic jaundice. Factors that facilitate the appearance of bile salt pruritus are hot baths and aging, dry skin. Again, who would think to ask about hot baths if he had not seen or read much medicine?

Inconstant Dimensions

Inconstant dimensions are those that do not apply to all symptoms but that are, nevertheless, very important for some, such as color, clarity, consistency, and so forth.

Color Card

Color must be described for urine, sputum, feces, skin lesions, and the skin overlying an arthralgia. Sometimes it is of great importance to know the exact color. To be sure that you and the patient are thinking of the same colors, prepare a color card consisting of patches of various colors, particularly blood red, currant jelly purple, robin’s egg blue, tar black, very dark brown (almost but not quite black), cola brown, medium brown (umber or sienna), light brown, clay white, biliverdin green, bilirubin orange, lemon yellow, and several shades of gray. These can be mixed from oil paints or composed of paint store sample chips. More simply, cut the appropriate colors from magazine illustrations; paste them on a card; and, for permanence, laminate in plastic.

Clarity, Consistency, and So Forth

Body fluids may be clear, opalescent, translucent, opaque, transparent, turbid, like “gold paint,” and so forth. Each of these adjectives might be of diagnostic value when applied to a pleural effusion, if one is so fortunate as to have a patient who remembered what his pleural fluid looked like the last time it was tapped.

A description of the consistency of materials may be very helpful. For example, the term diarrhea may mean many different things, referring either to the frequency or to the volume of bowel movements. However, a statement of consistency (i.e., whether the stool would assume the shape of its container) is clearly understandable.

Similarly, pain, which does not have the properties of color or consistency, may have the property of being “colicky,” especially when it is abdominal (see Chapter 20).

Although precise descriptions are important, one must also avoid becoming dogmatic about the meaning of certain findings.

An Example

Pseudomonas was formerly known as Bacillus pyocyaneus. Pyocyaneus means bluish pus, although sometimes the pus from Pseudomonas infections is actually green from the fluorescein produced by the organism. However, the idea that green pus is diagnostic for Pseudomonas is not correct. Any pus can be green if it contains sufficient white cells and their verdoperoxidase, a copper-containing myeloperoxidase.

Abbreviated History in Trauma Patients

In trauma patients, especially those with a suspected head injury, an expedited history (and complete, if rapid, physical examination) must be obtained because the patient might lose consciousness after an initial lucid interval. In the context of an emergency in which surgery may be necessary, obtain at least the “AMPLE” history recommended by the Advanced Trauma Life Support Course of the American College of Surgeons: allergies, medications, past illnesses, last meal, and events preceding the injury.

Elaboration of Selected Symptoms

The symptoms discussed in this section might occur either in the review of systems or in the history of the present illness. The treatment is not encyclopedic but, rather, illustrative of how useful
the history can be and how detailed the history may need to be in order to arrive at a diagnosis. The actual inventory discussed here is quite small compared to the entire inventory of questions available to the clinician; it is even smaller compared to the short inventory of questions given in Chapter 4.


Pain is the body’s signal that something is wrong. The perception of pain consists of a somatic neuronal input and a psychologic interpretation. Pain as a manifestation of various specific ailments is discussed below. Frequently, however, pain persists beyond the time when an injury is healed or the neuronal source is apparent. Chronic, intractable “pain without lesion” is increasingly recognized as a medical problem in its own right. Nearly 15% of the population in Western societies is believed to suffer daily chronic pain; in more than 10%, the pain is severe enough to interfere with daily living (Mäntyselkä et al., 2003).

Symptomatic treatment with high-dose opioids has become increasingly accepted, though fraught with hazard because of the abuse potential of these medications, the incentives inherent in a black market for a highly desired substance, and the threat to physicians from overzealous regulators and prosecutors (see Chapter 2). Physicians who undertake the management of chronic patients with controlled substances need to stay abreast of the everchanging regulatory and legal climate. Particular care must be taken in monitoring and documenting the effect of pain and of treatment on the patient’s life and ability to work or carry on activities of daily living.

Pain is unavoidably a subjective experience. Attempts to quantitate it usually rely on a visual analog scale or ranking the severity of pain on a scale such as “0” for “pain free” to “10” for “the worst pain you can imagine” or “pain so bad you would kill yourself.” One clinical pain diagram is shown in Fig. 25-5. These days, students probably cannot avoid seeing the “smiley face” posters in their hospitals, provided by a manufacturer of analgesics.

Despite proclamations from the Joint Commission on Accreditation of Health Care Organizations, pain is not a “fifth vital sign.” It is a symptom reported by the patient and not an objective measurement of a physiologic process necessary to sustain life.

One attempt to measure pain quantitatively is described below.

Sternbach Pain Thermometer

Sternbach developed a technique to improve the interviewer’s understanding of both (a) the quantitative aspect of the patient’s pain and (b) the patient’s reporting of the pain, which he called the “pain thermometer” (Sternbach, 1974).

A Method

The patient is first asked to quantitate the intensity (not the character) of his pain on a scale from 0 to 10, wherein 0 is absolutely no pain and 10 is a pain so terrible that it would cause one to commit suicide.

A blood pressure cuff is then placed in the usual position and inflated to far above the systolic so as to produce ischemic pain. At the same time, a stopwatch is started. The patient is instructed to report the time at which the ischemic pain is of the same intensity as the pain reported in the history.

When the patient reports this experience, record the number of elapsed seconds but do not deflate the cuff. This will be the numerator. The end point or denominator of the pain thermometer ratio is reached when the patient either rips off the cuff or demands that it be removed.


For a hypothetical situation in which a patient reported his naturally occurring pain to be a 5 on a scale from 0 to 10, there are three possible results with the pain tourniquet test.

  • The patient hypothetically experienced the same intensity of pain after 50 seconds of tourniquet pressure and ripped off the cuff at 100 seconds, yielding a fraction exactly equal to that predicted from his subjective estimation of 5 out of 10. We would say that this patient is an excellent “reporter” of pain. That is, he is precise and accurate.

  • Overreporting would be suggested if the tourniquet test yielded, say, a fraction of 20 seconds over 200 seconds. This result would have been the equivalent of a 1 out of 10 on the patient’s subjective rating scale. This would suggest that the patient is sensitive to naturally occurring pain and tends to overrate or overreport it or that the patient could have a superior tolerance for experimental pain, superior even to his own estimation!

  • The patient might report the tourniquet pain to equal the naturally occurring pain at 90 seconds and rip the tourniquet off at 100 seconds, yielding a ratio of 0.9, rather than the expected 0.5. This patient could either be underreporting the naturally occurring pain or be demonstrating a low tolerance for the experimental pain.

Note that the pain thermometer, in itself, tells you nothing about the etiology of the pain, although occasionally it may be helpful in suggesting a more aggressive diagnostic effort. A malingerer might be expected to have widely varying tourniquet ratio scores from trial to trial or response 2, described above. One woman with a subjective rating of 5 out of 10 was thought to be a malingerer, especially after a completely negative radiologic evaluation of her epigastric pain. She still had not reported even the numerator for the pain thermometer after 9 minutes of ischemia. This was so startling that she was subjected to endoscopy, revealing a large gastric ulcer that had been missed by the contrast studies.

Angina and Other Chest Discomfort Syndromes

If you want to experience severe anginal pain yourself, place a blood pressure cuff on your upper arm, pump it up to 300 mm Hg, and occlude the tubing with a towel clip so there is no slippage. After 5 minutes, work your fist. The feeling in your forearm is the same as the feeling in the chest in severe angina.

Angina is a peculiar disorder in that its timing in some patients is absolutely predictable, coming on at certain times of day or with taking a certain number of steps (Swartout, 1987).

Angina pectoris may be associated with angor animi, which literally means anguish of the soul. Because modern man has shed his soul, we now call this a sense of impending doom, which may often accompany myocardial infarction, dissecting aneurysm, or massive pulmonary embolism. The visceral sensation that accompanies the catecholamine discharge can be confused with nausea.

In a description based on personal experience of angina pectoris and other chest pains (Swartout, 1987), it is noted that the substernal pressure caused by severe asthma and the pain of acute cholecystitis, which may be just as severe as angina, are not associated with angor animi. The pain of pericarditis is boring and continuous, but it is also positional.

A study of the utility of patient gestures in determining the etiology of chest discomfort showed that the frequently described Levine sign (clenched fist over the sternum) has a sensitivity of only 9% for myocardial infarction, with a specificity of 84%, a positive predictive value of 50%, and a negative predictive value of 31%. A flat hand placed over the sternum had a higher sensitivity (38%), with a specificity of 67%, positive predictive value 65%, and negative predictive value 49%. A larger area of chest discomfort was suggestive of myocardial ischemia (Marcus et al., 2007). An earlier British study, using patient interviews from the emergency department rather than after admission, showed that a clenched fist or flat hand over the sternum, or both flat hands drawn from the center of the chest outward, had a sensitivity of 80%, a specificity of 49%, a positive predictive value of 77%, and a negative predictive value of 53% (Edmondstone, 1995).

Various features of the history in patients with chest pain, and their value in calculating the probability of coronary artery disease, have been extensively studied. Pain brought on by exertion, a need to stop all activities when pain occurs, and pain relief within 3 minutes of taking nitroglycerin are strongly correlated with the presence of coronary artery disease. Substernal location, radiation to the left arm, and a “pressure” sensation are positively correlated, whereas pain described as “sharp” or pain brought on by cough, deep breathing, or moving the arms or torso is negatively correlated with coronary artery disease. Numeric weights can be assigned to each feature, and a logistic chest pain score can be calculated. Students are cautioned that such methods give a probability, not a diagnosis. Before placing too much reliance on a numeric score, students must remember the caveat that the predictive value of such scores, like that of isolated findings, depends on the prevalence of the disease in the population from which the patient comes (Sox et al., 1990).

An interesting by-product from studies of the chest pain rule is the finding that data obtained by physician interviews were better at predicting disease than data from self-administered questionnaires. The researchers concluded that physicians may have a higher sensitivity to subtle clues in the patient’s history that suggest severe disease (Hickam et al., 1985). An interview by a skilled human clinician is more than the sum of the boxes on a checklist.

Note that absence of chest pain does not rule out an impending myocardial infarction, especially in women. Only about 30% of women had chest discomfort, a hallmark symptom in men, before their acute infarction. The most frequent prodromal symptoms in the month before the event were fatigue (71%), sleep disturbance (48%), and shortness of breath (42%). Even at the time of the infarction, acute chest pain was absent in 43% of women (McSweeney et al., 2003).

An Illustrative Case

A patient with retrosternal pain, and what was reported as nausea, was sent to the gastroenterology unit for evaluation.

Patient: “… and with the pain I had this feeling in my stomach …”

Attending: “Nausea?” (The word the resident had used.)

Patient: “Yeah, I guess it was nausea. You could call it that. The pain was terrible.”

Attending: “Did you want to throw up, vomit, with the pain and nausea?”

Patient: “No, not at all. I just wanted to be still.”

Attending: “You had nausea, but you didn’t want to throw up.”

Patient: “No. If I was sick like that I would ordinarily want to vomit to feel better, but this wasn’t the same thing.”

Attending: (Motions “tell me more” with his hand.)

Patient: “… This was a bad feeling all over and also in the pit of my stomach. When that pain came on and stayed and would not go away, I got this feeling that the end of the world was coming … I didn’t think I was going to make it …”

Attending: “And the nausea? The feeling? … Was it really nausea? …”

Patient: “No, it was a bad feeling, it was worse than what I call nausea. It was this clutching feeling you get when you are very excited. Like in sports, when you are in sporting events, and you are about to go out there, … go on the playing field. … you get before a football game. I used to play football. Well that was the feeling I got in my stomach when this pain came on. I thought, my God, this is it. I was terrified. I thought maybe if I did nothing it would go away. I thought this is it, and that is when I got the stomach, the nausea feeling you [sic] call it. But I didn’t want to vomit, I didn’t want to do nothing, I just wanted to live. That was the worst part of the pain, knowing that there was something about that pain that could … you know, it could do you in.”

This patient was subsequently found to have had a myocardial infarction and was transferred from the gastroenterology unit to the coronary care unit.

Chills and Night Sweats

Patients who report chills should be asked whether the bed actually shook or moved on the floor. A true shaking chill also tends to last a definite period, on the order of 30 minutes. Shaking chills, as opposed to a sensation of chilliness, have diagnostic implications and are always high on the list of findings that must be explained by the primary diagnosis. They also imply that the fever was high, even though the patient may not have measured it.

Night sweats should be described in quantitative, practical terms. For example, “Were the sweats so bad that you had to change your pajamas?” Or, “Did you have to change the pillowcase to get back to sleep?” Or, “Did your wife change the sheets?” Note that patients who sleep in warm weather in non-air-conditioned rooms do not soak the sheets as highly febrile patients do. They simply cast the sheets off and roll away from any dampness, and of course, they are never awakened by a chill.

The old teaching that viral diseases did not cause bed-shaking chills is probably incorrect; patients with dengue fever, for instance, shake the bed.


Itching is usually a manifestation of cutaneous disease but may also result from a systemic condition (Bernhard, 1987). A drug history is most important. Phenothiazines, tolbutamide, erythromycin, anabolic hormones, estrogen, progesterone, and testosterone may cause itching by inducing cholestasis, narcotics through histamine release, and aspirin through prostaglandin effects. Any drug may
cause pruritus through an idiosyncratic effect, even if the patient has been taking it for years.

Inquire about exposures to fiberglass, dusts, and chemicals. In addition, in many patients with unexplained pruritus, a veterinary examination may identify exposure to ectoparasites from pets.

Itching severe enough to waken the patient at night should arouse suspicion of scabies or dermatitis herpetiformis. If these conditions are ruled out in a patient with severe itching, consider a systemic cause.

Systemic diseases associated with itching include renal failure (due to secondary hyperparathyroidism); endocrine conditions (thyroid dysfunction, diabetes mellitus, and carcinoid syndrome); hematologic conditions (such as hemochromatosis and polycythemia vera); and hepatobiliary disease, especially with biliary obstruction (as in primary biliary cirrhosis or carcinoma causing extrahepatic obstruction—note that itching due to the retention of bile salts may precede the appearance of jaundice). Itching produced by bathing (aquagenic pruritus) may be a symptom of polycythemia vera, Hodgkin disease, mastocytosis, or aging (Phillips, 1992). Nearly 30% of patients with Hodgkin disease have severe burning pruritus (Bernhard, 1987). Other malignant causes include visceral cancers, mycosis fungoides, multiple myeloma, and central nervous system tumors.

Hemoptysis versus Hematemesis

Hemoptysis literally means “to spit up blood,” and hematemesis means “to vomit up blood.” As actually used, hemoptysis refers to the experience of coughing up blood, and by extension, it refers to any blood produced through the mouth but originating in the pulmonary system.

The four main causes of hemoptysis used to be bronchogenic carcinoma, bronchiectasis, rheumatic mitral valve disease (especially mitral stenosis), and tuberculosis. While this remains a useful mnemonic for the previously asymptomatic patient who presents with a sudden hemoptysis, it is less accurate today. The prevalence of bronchiectasis, tuberculosis, and rheumatic heart disease has decreased substantially. In a study conducted in Jerusalem between 1990 and 1995, the most common causes of hemoptysis were bronchiectasis (20%), lung cancer (19%), bronchitis (18%), and pneumonia (16%) (Hirshberg et al., 1997). In a study in Kansas City, Missouri, the most common cause was bronchitis (26%) (Reisz et al., 1997).

A serious but treatable cause that may be overlooked in both children and adults is an inhaled foreign body. This may occur in persons who have no risk factors such as memory loss, seizures, or alcoholism. The hemoptysis may be massive in the case of inhaled vegetable matter, which may induce florid bronchiectasis and vascular changes (Dore et al., 1997). The patient is likely to have a chronic cough and may have a history of sudden onset of cough followed by wheezing or dyspnea (Al-Majed et al., 1997). This condition illustrates that to make a diagnosis, preferably by means other than surgical pathology, one must think of it.

In the areas of the world where tuberculosis is still a problem, more specific etiologies of hemoptysis need to be considered, including Rasmussen aneurysm or secondary aspergillosis. (Taking one item out of a differential diagnosis and performing a more sophisticated differential of that condition, as was just done, is called “going up to the next level of complexity.”)

In about 20% of cases, no cause for hemoptysis is found despite extensive investigation (and a lengthy list of uncommon possibilities). The risk of recurrence is low (Dore et al., 1997). Knowledge of facts like this will help a physician reassure a patient who has experienced a frightening symptom, but should not serve as a pretext to forgo a thorough investigation, particularly if the symptom is recurrent.

Of course, hematemesis is caused by an entirely different set of diagnostic possibilities. It usually implies a source of blood proximal to the ligament of Treitz and therefore includes gastric ulcer, gastric carcinoma, Osler-Weber-Rendu syndrome, esophageal varices, and so forth. Conceivably, it could be caused by epistaxis, assuming that the patient swallowed the blood and vomited it later.

The physician is responsible for making the distinction if the patient reports, “I spit up blood.” To qualify it as hematemesis, the patient should have actually gagged and regurgitated the bolus of blood. On the other hand, patients with hemoptysis usually can recall a clear episode of coughing. Often, they can point to the side of the thorax from which the blood came. Unfortunately, even excellent interviewers may not be able to make the distinction 100% of the time. However, one becomes more skilled by interviewing many patients with this complaint prior to knowing the anatomically determined source of the bleeding.

Chronic Cough

Chronic cough is one of the top five reasons for consulting family physicians. The diagnosis may be missed for years, especially if the physician focuses solely on the chest. There are receptors that can provoke a reflex cough in the ear, the esophagus, and the pericardium, as well as the tracheobronchial tree (Bellanti et al., 2000).

Important dimensions include exacerbating and relieving factors. Cough due to asthma may be provoked by exposures or exercise. Psychogenic cough, which may be quite severe, is relieved by sleep or distraction. Ask about response to past therapies. Relief from steroids suggests an inflammatory condition, from antibiotics, an infection, most often sinusitis. Proton pump inhibitors may relieve cough resulting from gastroesophageal reflux, whether due to microaspiration or receptors in the esophagus.

Always take a drug history: Up to 20% of patients taking ACE (angiotensin-converting enzyme) inhibitors have a cough. Important associated symptoms or signs include sinus congestion and postnasal drip, cardiac arrhythmias (which can cause a cough relieved by correcting the arrhythmia), and symptoms related to acid reflux. The presence or absence of purulent sputum is usually of little diagnostic help (Stulbarg, 2003).

image An unusual cause of cough, generally associated with headache, toothache, fever, or upper limb ischemic symptoms, is temporal arteritis (Hellmann, 2002). A high index of suspicion in patients older than about 50 may lead to early diagnosis and prevention of blindness or other devastating complications.

Think of risk factors for possible infectious etiologies. Ask about fevers, night sweats, past skin tests, and constitutional symptoms (weight loss, anorexia, fatigue, etc.). A recent viral illness may cause a postviral sensitivity with cough that lasts for months. In patients who might have been exposed, perhaps without being aware of it, pertussis is surprisingly common, even in adults who have been vaccinated. Pertussis is diagnosed in about 20% of patients who present to an
ER with a cough lasting from 3 to 12 weeks. Consider Mycobacterium avium complex (MAC) in patients who may be immunosuppressed.

Although physicians may gain some clues from listening to the cough, the patient’s description is generally not diagnostically helpful (Stulbarg, 2003).

A history of a negative chest radiograph is not helpful, as standard films are quite insensitive. Computerized tomography may reveal an endobronchial tumor, tuberculosis, interstitial disease, bronchiectasis, or the nodular infiltrate of MAC in a patient with a normal or nearly normal radiograph.

The three most common causes of cough in patients with a normal chest X-ray who are nonsmokers and not taking an ACE inhibitor are gastroesophageal reflux disease, postnasal drip syndrome, and asthma, with the majority of patients having more than one cause (Mello et al., 1996).

In children, consider congenital malformations, cystic fibrosis, and aspiration of foreign bodies. In adolescents, repetitive cough may be the presenting symptom of Tourette syndrome (Hogan and Wilson, 1999).

imageOne 30-year cough was instantly cured by removing a hair touching the patient’s eardrum (Stulbarg, 2003).


The diagnosis of difficulty swallowing can generally be made on the basis of the history. Dr Stuart Danovitch of Washington, DC, writes that progressive, short-duration dysphagia, chiefly for solids and ultimately for liquids, is exceedingly characteristic of cancer. Weight loss is generally associated. Progressive dysphagia for solids over years characterizes peptic stricture and would be supported by a history of heartburn and antacid ingestion. Nonprogressive, intermittent dysphagia for solids, especially occurring early in a meal, is typical for a lower esophageal (Schatzki) ring. Slowly progressive dysphagia, over a period of years, for both liquids and solids suggests achalasia. Intermittent, minimally progressive dysphagia and odynophagia characterize esophageal spasm, particularly when accompanied by chest pain. Reviewing previous medical records helps obtain a good picture of the longitudinal progression of the disease (S. Danovitch, personal communication, 2004).

Abdominal Pain

The differential diagnosis of abdominal pain in various locations is discussed in Chapter 20. A general observation is that lower abdominal disorders may present with upper and midabdominal complaints, whereas upper abdominal disease such as cholecystitis or pancreatitis are far less likely to present with lower abdominal complaints (S. Danovitch, personal communication, 2004).

Is the Pain Colicky?

To determine whether an abdominal pain is colicky, I prefer to get a description of temporal waves of pain, whose peak comes and goes with some regularity, like labor pains. Do not use the nonspecific descriptor “crampy.” To some patients, especially men, a cramp is a continuous muscle pain that does not have waves of intensity.

Colicky Pain Originates from a Hollow Viscus

If the pain is colicky, one knows that it is not coming from the liver, spleen, or kidney but could be coming from the bowel or the ureters. (Ureteral pain is easy to recognize because of its location in the flank. The distal ureters refer pain to the testicles.) However, a steady pain could also come from a hollow viscus, such as the gallbladder. Pain caused by pancreatitis (an inflammation of a solid organ) might be colicky because of associated small bowel ileus or a stone in the pancreatic ducts (although pain in the latter case, like a common bile duct obstruction, could also be steady). The term biliary colic is a misnomer; biliary obstruction produces pain of a steady, nonparoxysmal nature (see Cope’s classic work [Silen, 1979], reviewed in Chapter 20).

Periodicity of Abdominal Pain

If the pain is colicky, one should try to determine its periodicity. Women patients who have experienced childbirth are particularly good informants. The periodicity of the colic in pain from the upper ileum is stated to be 3 to 5 minutes, as opposed to 6 to 10 minutes for the lower ileum (Silen, 1979).

This contention seems contrary to current gastrointestinal physiology, which leads one to expect pacemakers lower in the gut to have shorter periods. Cope (Silen, 1979) does not offer any data but cites a reference that states: “There is support for the thesis that the waves of propulsive activity in the intestine come with somewhat greater frequency high in the ileum than lower down. In practice, an obstruction high in the ileum appears to be characterized oftener by a period of 3 to 5 minutes between peaks of crampy pain, and obstruction in the terminal ileum by intervals between the pains that are as much as twice as long (Dennis, 1954).”

Sometimes the periodicity of abdominal pain exists in a much longer time framework than we are used to thinking about when we describe the periodicity of colic. Abdominal pain due to allergic eosinophilic gastrointestinal disease has a periodicity of days; pain due to lead poisoning, a periodicity of days to weeks; pain due to porphyria, a periodicity of weeks; and pain due to familial Mediterranean fever, a periodicity of weeks to months.

Biliary pain, unlike renal colic, has a circadian periodicity, with the majority of attacks occurring at night; the incidence peaks around midnight. The majority of patients experience either all or more than half of the episodes of pain at or about a particular clock time, which is characteristic for the individual. The pain is not usually related to meals (Rigas et al., 1990).

Aggravating and Relieving Factors

A relationship between fluctuations in pain and gastrointestinal activity suggests a link to a hollow viscus and may point to a specific etiology. Relief by vomiting, for example, suggests a pyloric or proximal small bowel lesion. The specific nature of food that relieves or exacerbates the pain, however, is of dubious value, popular belief notwithstanding (Pasricha, 2003).

The pain of retroperitoneal processes, such as pancreatitis, tends to be relieved by maneuvers that increase the volume of this space, such as sitting up and leaning forward.

Visceral processes induce restlessness, but when parietal and somatic structures become involved, aggravation by motion, straining, or coughing is characteristic (Pasricha, 2003).

Associated Symptoms

Visceral pain tends to induce autonomic phenomena, such as changes in blood pressure and heart rate, pallor, sweating, vomiting,
and diarrhea. Most inflammatory conditions in visceral organs are associated with systemic reactions such as anorexia, malaise, or fever (Pasricha, 2003).

Epigastric Pain

If the patient is over 50 years of age, with his first attack of epigastric pain, and is also experiencing weight loss not clearly related to significant vomiting, one should suspect gastric carcinoma.

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Aug 10, 2020 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on The History

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