HELPING
THE DOCTOR HELP YOU
Roshan Jacob
A simple omission can be disastrous is what I learned when
Sateesh Reddy explained me how his brother in-in law got into coma stage. Past
eight months, Prabhakar is lying in a coma stage in a hospital. Prior to his
unconsciousness, he consulted three doctors complaining about neck pain
radiating to shoulders. All the doctors prescribed him analgesics and some pain
balms and could not find anything suspicious.
Prabhakar overlooked his fall from bike few months ago and never
mentioned it to the doctors who he consulted.
Untreated cervical hairline fracture due to the fall resulted in the
coma. The information (history of fall) was crucial for the doctors for further
investigations, and this omission is in one way resulted in the mishap. It is widely taught that diagnosis is
revealed in the patient's history. Above mentioned scenario involving
inadequate history taking leads to serious consequences illustrate the importance
of medical histories in diagnosis and here Prabhakar’s case is the classic
example of the value of history.
Recently I interacted with three retired consultants, two
physicians and a surgeon on the sidelines of a conference and when I broached
the subject of the value of history taking, with no dissent, all of them
expressed their dismay at their denigration of the importance of proper history
taking in clinical practice. Modern day doctors, mostly nudged by managements
give preference to ‘investigations’, and happy to go with figures rather facts.
As champions of evidence based medicine can they produce evidence that taking a
proper history is "unhelpful"?
Extracting a proper history means listening carefully to what
the patient has to say, followed by relevant systematic and constructive
questions. As examples of clinical situations in which this discipline yields
rich rewards we would cite the elucidation of chest pain or the recognition of
da Costa's syndrome, where a proper history could save expensive and
anxiety-producing investigations.
The foundation of a true history is nothing but a smooth
communication between doctor and patient. Here patient should not show any
inhibitions and the doctor is a good listener. Listening is at the heart of
good history taking. The patient may not be looking for a diagnosis when giving
their history and may even have irrelevant aspects and the doctor's search for
one under such circumstances is likely to be fruitless. The patient's problem,
whether it has a medical diagnosis attached or not, needs to be identified.
Without the patient's perspective, the history is likely to be much less
revealing and less useful to the doctor who is attempting to help the patient.
There was a time not long ago; often the history alone does
reveal a diagnosis. Sometimes it is all that is required to make the diagnosis.
A classic example is with the complaint of headache where the diagnosis can be
made from the narration of the headache and perhaps some further questions. For
example, in cluster headache the history is very characteristic and reveals the
diagnosis without the need for examination or investigations for an experienced
consultant.
To acquire a plausible, representative account of what is
troubling a patient and how it has evolved over time, is definitely not an easy
task. It takes practice, patience, understanding and concentration. The history
as told in the beginning is a sharing of experience between patient and doctor
and certainly time consuming. A consultation can allow a patient to pour out
his agony. They may be upset about their condition or with the frustrations of
many other aspects of life other than the present affliction and it is
important to allow patients to give vent to these feelings. Ultimately how it
may be transformed from the grumbles of a heartsink patient, to a useful
diagnostic and therapeutic tool is what matters.
The traditional method of detailed history taking and physical
examination and thinking about what tests to be ordered, (if any) are needed
may take somewhat longer time with the patient, but must remain the cornerstone
of clinical practice. The content of the history involved in primary care
consultations is very variable and will depend on the presenting symptoms,
patient concerns and the past medical, psychological and social history.
However the general framework for history taking is as follows:
• First
is the presenting complaint.
• History
of presenting complaint, including investigations, treatment and referrals
already done and provided.
• Significant
past diseases/illnesses, surgery, including complications, trauma.
• Medications
now and past, prescribed and over-the-counter, allergies.
• Family
history must be enquired to especially parents, siblings and children.
• Social
history also matters. Here we find many habits and his addictions like smoking, alcohol, drugs, accommodation and
living arrangements, marital status, baseline functioning, occupation, pets and
hobbies.
•
Finally, the systems review:
cardiovascular system, respiratory system, gastrointestinal system, nervous
system, musculoskeletal system, genitourinary system.
Let’s go back to the coma patient Prabhakar. Prabhakar, who went
and consulted three doctors but never mentioned his fall from the bike,
thinking that it is insignificant. He thought the presenting complaint; neck
pain is not even remotely connected with the fall, which happened three months
back. None of the doctors have any leading questions to this effect like, ‘did
you have any fall in the past?’ sometimes you may have to ask some wild
questions when you as a doctor have no other suspecting reasons. The doctors
set no agenda in this case and they missed the vital clue, which finally ended
in a tragedy.
After taking the history, it's useful to give the patient a
run-down of what they've told. For
example: 'So, Prabhakar, from what I understand you've been getting this pain
since one month and you are sure no incident worth mentioning like any fall in
the recent past. Is that right?'. This summarizing or leading question could
have helped Prabhakar mentioning the history fall, which he felt trivial.
It is vital to remember that a good elicitation of the patient’s
history, in his own words coupled with few leading questions from the doctor
can help the latter to arrive into ‘provisional diagnosis’. This does no
suggest the patient doesn’t need any detailed evaluation. History alone cannot lead into a definitive
diagnosis unless until validated by other pertinent tests. Having said that,
history taking has an integral and irreplaceable role in the appropriate
diagnosis. 'Listen to your patient; they
are telling you the diagnosis' is oft quoted aphorism. In olden days, it is
widely taught that diagnosis is revealed in the patient's history. It is true even today, provided the doctor is
willing to listen.