Hutchison's Clinical Methods 24th Edition PDF

HUTCHISON’S CLINICAL METHODS  24th Edition HUTCHISON’S CLINICAL METHODS An integrated approach to clinical practice Edited by Michael Glynn MA MD FRCP FHEA Consultant Physician, Gastroenterologist and Hepatologi...

HUTCHISON’S CLINICAL METHODS  24th Edition HUTCHISON’S CLINICAL METHODS An integrated approach to clinical practice Edited by Michael Glynn MA MD FRCP FHEA Consultant Physician, Gastroenterologist and Hepatologist Barts Health NHS Trust; Honorary Senior Lecturer Barts and the London School of Medicine and Dentistry; Former National Clinical Director for GI and Liver Diseases NHS England William M. Drake DM FRCP Professor of Clinical Endocrinology St Bartholomew’s Hospital London, UK Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2018 © 2018 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). First edition 1897 Twenty-fourth edition 2018 ISBN 978-0-7020-6739-6 International ISBN 978-0-7020-6740-2 Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. The publisher’s policy is to use paper manufactured from sustainable forests Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1  Preface to the Twenty-fourth Edition Hutchison’s Clinical Methods is a book for students situations, the core body systems and key clinical of all ages and all degrees of experience. Although specialties. Overall, this forms a logical sequence if the scope, complexity and technology of clinical read straight through but also allows study of each medicine continues to evolve with great speed, the section separately. aim of this text is exactly as it was when Robert As in previous editions, new contributors have Hutchison published the very first edition in 1897: joined the book. Some have written entirely new to provide insight into the acquisition of the traditional chapters and others have modified the work of their clinical skills of history taking and physical examina- predecessors (including the work of Alan Naftalin, tion leading to the formulation of a differential Consultant Gynaecologist, who has sadly died since diagnosis and management plan. This approach the last edition was published). All the contributors remains as essential as ever to providing good patient are accustomed to working closely together and the care; indeed, as the array of potential investigations book reflects these professional relationships. It is the expands (and the overall cost continues to rise), it is editors’ responsibility to mould the chapters into a imperative that such technological advances are single text with a logical narrative, but the expertise integrated with traditional methods. Even though lies with the contributing authors, whose time and many patients now have easy access, via the Internet, dedication is gratefully acknowledged, as are the to information about disease and diagnosis, it is the extensive contributions of previous experts. editors’ experience that patients appreciate just as Some of the changes to the previous edition have much as ever time spent listening to their symptoms, been made as a result of formally gathered feedback careful physical examination and simple human from the newly formed International Advisory Board. compassion. Although the circumstances of clinical In addition a reader survey elicited a range of positive practice of the readers will vary hugely across the suggestions for improvements to the book. Construc- world (with different structures and levels of funding tive readers’ comments direct to the editors are always of healthcare), a sound clinical method is indispen- welcome. sable. The organisation of this edition adheres to Hutchison’s original approach, with sections on the Michael Glynn and Will Drake overall patient assessment, assessment in particular Royal London and St Batholomew’s Hospitals Sir Robert Hutchison MD FRCP (1871-1960) Clinical Methods began in 1897, three years after Robert Hutchison was appointed Assistant Physician to The London Hospital (named the Royal London Hospital since its 250th anniversary in 1990). He was appointed full physician to The London and to the Hospital for Sick Children, Great Ormond Street in 1900. He steered Clinical Methods through no less than 13 editions, at first with the assistance of Dr H. Rainy and then, from the 9th edition, published in 1929, with the help of Dr Donald Hunter. Although Hutchison retired from hospital practice in 1934, he continued to direct new editions of the book with Donald Hunter, and from 1949 with the assistance also of Dr Richard Bomford. The 13th edition, the first produced without Hutchison’s guiding hand, was published in 1956 under the direction of Donald Hunter and Richard Bomford. Dr A. Stuart Mason and Dr Michael Swash joined Richard Bomford on Donald Hunter’s retirement to produce the 16th edition, published in 1975, and following Richard Bomford’s retirement prepared the 17th, 18th and 19th editions. Dr Swash edited the 20th and 21st editions himself and was joined by Dr Michael Glynn for the 22nd edition. On Dr Swash’s retirement Prof William Drake joined Dr Glynn as a co-editor on the 23rd and now this 24th edition. In keeping with the tradition that lies behind the book, each of these editions has been revised with the help of colleagues at The Royal London Hospital, and the other hospitals which now form Barts Health NHS Trust, namely St Bartholomew’s Hospital, Whipps Cross University Hospital and Newham University Hospital. Sir Robert Hutchison died in 1960 in his 90th year. It is evident from the memoirs of his contemporaries that he had a remarkable personality. Many of his clinical sayings became, in their day, aphorisms to be remembered and passed on to future generations of students. Of these, the best known is his petition, written in 1953, his 82nd year: ‘From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.’ Michael Glynn and Will Drake Royal London Hospital  Contributors Rino Cerio BSc FRCP(Lon) FRCP(Edin) FRCPath James Green LLM FRCS(Urol) DipRCPath ICDPath Consultant Urological Surgeon Consultant Dermatologist and Professor Department of Urology of Dermatopathology Whipps Cross University Hospital Department of Cutaneous Medicine and Surgery Barts Health NHS Trust; Barts Health NHS Trust Visiting Professor London, UK London South Bank University London, UK Tahseen A. Chowdhury MD FRCP Consultant Physician Lina Hijazi Department of Diabetes and Metabolism Consultant Physician Barts Health NHS Trust Associate Foundation Programme Director London, UK Whipps Cross University Hospital Barts Health NHS Trust Andrew Coombes BSc MBBS FRCOphth London, UK Consultant Eye Surgeon and Lead Clinician for Ophthalmology Ali Jawad MBChB MSc(Lond) DCH FRCP(Lond) Barts Health NHS Trust; FRCP(Edin) DMedRehab Honorary Senior Lecturer Consultant Rheumatologist Barts and the London School of Medicine Barts Health NHS Trust and Dentistry London, UK London, UK Stephen Kelly MB ChB MRCP Ceri Davies MD FRCP Consultant Rheumatologist Consultant Cardiologist Barts Health NHS Trust Barts Health NHS Trust London, UK London, UK Rehan Khan MRCOG DipIPM William M. Drake DM FRCP Consultant Obstetrician and Gynaecologist Professor of Clinical Endocrinology St Bartholomew’s and Royal London Hospitals St Bartholomew’s Hospital Barts and the London NHS Trust London, UK London, UK Adam Feather FRCP Richard Langford MB BS Consultant Acute Physician Consultant in Anaesthesia and Pain Medicine Barts Health NHS Trust Barts Health NHS Trust London, UK London, UK Michael Glynn MA MD FRCP FHEA Geraint Morris BMedSc MB BS FRCP DCH FRCEM Consultant Physician, Gastroenterologist Consultant in Emergency Medicine and Hepatologist Homerton University Hospital Foundation Barts and the London NHS Trust; NHS Trust Honorary Senior Lecturer London, UK Barts and the London School of Medicine and Dentistry; John Peters FRCS Regional Adviser, Royal College of Physicians Consultant Urologist (London) Whipps Cross University Hospital Barts Health NHS Trust London, UK x Contributors Shankar Ramaswamy MBBS MD FRCA Trevor Turner FFPMRCA EDRA Honorary Consultant Psychiatrist Locum Consultant in Anaesthesia and East London Foundation Trust; Pain Medicine Former Vice-President of the Royal College Barts and the London NHS Trust of Psychiatrists London, UK London, UK Anna Riddell BSc MBBS MRCPCH Rodney W.H. Walker MA BM PhD FRCP Consultant Paediatrician Consultant Neurologist The Royal London Children’s Hospital Barts Health NHS Trust Barts Health NHS Trust London, UK London, UK Michael P. Wareing MBBS BSc FRCS(ORL-HNS) Andrew Rochford MSc FRCP Consultant Otolaryngologist, Head and Consultant Gastroenterologist Neck Surgeon Barts Health NHS Trust Barts Health NHS Trust London, UK London, UK Caryn Rosmarin MBBCh DTM&H FCPath(SA) Veronica L.C. White FRCPath(UK) Consultant Respiratory Physician Consultant Microbiologist Barts and the London NHS Trust Division of Infection London, UK Barts and the London School of Medicine and Dentistry Barts and the London NHS Trust London, UK  International Advisory Board Dr Maisam Waid Akroush Dr Aniruddha Ghose Consultant Gastro-hepatologist, Amman, Jordan Associate Professor, Department of Medicine, Chittagong Medical College, Chittagong, Dr Ala’ Al-Heresh Bangladesh Clinical Associate Professor, Senior Consultant Physician and Rheumatologist, Head of Professor Christeine Ariaranee Gnanathasan Rheumatology Unit, King Hussein Medical Center, Professor in Medicine, Department of Clinical Royal Medical Services, Jordan Medicine, University of Colombo; Honorary Consultant Physician, University Medical Unit, Dr Mohammad Radwan Al-Majali National Hospital of Sri Lanka, Sri Lanka Clinical Fellow in Cardiology, Jordan Royal Medical Services, Amman, Jordan Dr Ambanna Gowda Consultant Physician and Diabetologist, Fortis Dr Md Robed Amin Hospital; Associate Professor of Medicine, Dr BR Associate Professor of Medicine, Dhaka Medical Ambedkar Medical College, Bengaluru, India College, Dhaka, Bangladesh Dr A L Kakrani Dr M A Andrews Professor and Head, Department of Medicine, Dr Professor and Head of Department of Medicine, D Y Patil Medical College, Hospital & Research Government Medical College, Thrissur, Kerala, Centre and Dean, Faculty of Medicine, Dr DY India Patil Vidyapeeth Deemed University, Pimpri, Pune, India Professor Raghavendra Bhat Professor and Head of Department of General Professor Alladi Mohan Medicine, Kasturba Medical College, Mangalore, Professor and Head of Department of Medicine, India Sri Venkateswara Institute of Medical Sciences, Tirupati, India Dr Deepak Bhosle Professor, Department of Medicine, Bharati Professor Jotideb Mukhopadhyay Vidyapeeth Deemed University Medical College, Professor and Head of Department of Medicine, Pune, India Institute of Post Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Medical Dr Vivek Chauhan College, Kolkata, India Assistant Professor, Medicine, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Dr E Prabhu Himachal Pradesh, India Senior Consultant and Head, Institute of Nuclear Imaging and Molecular Medicine and Chief Professor Md. Abdul Jalil Chowdhury Coordinator, Institute of Advanced Research Professor of Internal Medicine, Bangabandhu in Health Sciences, Tamil Nadu Government Sheikh Mujib Medical University; Honorary Multi Super Speciality Hospital, Omandurar Secretary, Bangladesh College of Physicians and Government Estate, Chennai 2, Tamil Nadu, India Surgeons (BCPS), Dhaka, Bangladesh Professor Dr T. Ravindran Dr D Dalus Professor of Medicine, Government Kilpauk Professor and Head, Department of Internal Medical College, Chennai, India Medicine, Medical College and Hospital, Trivandrum, India xii International Advisory Board Professor M.D. Selvam Professor I. Uthman Professor of Medicine, Sri Muthukumaran Medical Professor of Clinical Medicine, Head, Division of College Hospital and Research Institute, Chennai; Rheumatology, Department of Internal Medicine, Former Professor of Medicine, Stanley Medical American University of Beirut Medical Center, College and Government Stanley Hospital, Beirut, Lebanon Chennai, India  Acknowledgements The Editors would like to acknowledge the contribu- Prakriti Gupta; Nishedh Gyawali; Riffat Humayun; tion of all past authors to this textbook. Each Mobin Imtiaz; Vibhu Jain; Ruwandika Jayawickrama; new edition builds on the expertise of the many Govind Jha; Tushar Jha; Kaushal Raj Kafle; writers whose work has shaped this book over more Sowmyashree Mayur Kaku; Pavan Kamble; Kiran than a century. In particular we would like to Kanchankoti; Vivekanand Kattimani; Abhishek acknowledge the following who stepped down after Kaushik; Muneeb Khalid; Sharoj Khan; Zahila Khan; the last edition to allow new authors to take their Supreet Khare; Balaram Krishna; Anita Kum; Akshay place: Runa Ali; Andrew Archbold; David D’Cruz; Kumar; Amit Kumar; Deepak Kumar; Manish Kumar; Jayne Gallagher; Robert Ghosh; Beng Goh; John Praveen Kumar; Vivek Kumar; Dhairya Lakhani; Mirza Monson; John Moore-Gillon; the late Alan Naftalin; Umm E Laila; Manikho Lawrence; Jin Xiang Lui; Serge Nikolic; Ruth Taylor; Adam Timmis; and Raj Mohd Luqman; Surjeet Kumar Malakar; Aaron Thuraisingham. Mascarenhas; Abhishek Mittal; Patel Mrugank; The Editors and Publishers would like to thank all Abhishek Mittal; Sudeb Mukherjee; Vineet Nair; the students and doctors who have provided valuable Naren Srinath Nallapeta; Dilip Neupane; Patel Nida; feedback on this textbook and whose comments have Avinash Pallav; Anup Pandeya; Ambikapathi helped shape this new edition. We hope we have Panneerselvam; Sabin Parajuli; Ashwin Singh Parihar; listed all those who have contributed and apologise Kishor Pokharel; Arun Prasad; Nikhil Prasad; Varun if any names have been accidentally omitted. Venkat Raghavan MS; Vishal Raj; Pradhum Ram; Jai As part of the publishers’ review, students from Ranjan; Piyush Ranjan; Amuda Regmi; Sudeep Regmi; numerous medical schools supplied many innovative Sudip Regmi; Peter Richards; Arpit Rustagi; Simrina ideas on how to enhance the book. We are indebted Kaur Sabharwal; Sujit Kumar Sah; Shreyas Samaga; to the following for their enthusiastic support: Emir Bipin Sapkota; Priyanka Satish; Somya Saxena; Abadi; Suhel Abbas; Shaik Kariuddin Abdullah; Deeksha Seth; Sakhi Shah; Syed Mohammad Usman Santosh Acharya; Mamun David Ebne Ahamed; Shah; Anmol Sharma; Anurag Sharma; Bhanu Sharma; Salsabil Alfadly; Nouman Safdar Ali; Hemant Atri; Dhan Bahadur Shrestha; Jeevan Shrestha; Suhana Keerthi Ananthula; Noah Anvesh; Sumant Arora; Shrestha; Veena Shriram; Amber Tahir Siddiqui; Ankita Mohan Babu; Pirmal Bachani; Suranjana Banik; Ankit Singh; Arashdeep Singh; Avinainder Singh; Bishnu Bansal; Siddhartha Barnawal; Suranjana Basak; Singh; Jeevika Singh; Nidhi Singh; Chopperla SK SK Manognya Bethapudi; Sunil Bhardwaj; Ifrah Binyamin; Dattatreya Sitaram; Sakar Raj Sitaula; Soundarya Sagnik Biswas; Sugandh Chadha; Subhankar Soundararajan; Amit Srivastava; Shashank K. Chatterjee; Prajwal Dahal; Amrutha Denduluri; Ugur Srivastava; Sepuri Bala Ravi Teja; Priyesh Thakurathi; Demirpek; Mansi Dhingra; Shubham Dixit; Arpan Akhilesh Tripathi; Subhrajyoti Tripathy; Mohammad Dutta; Mohammed Omar Farooq; Samreen Fathima; Yousuf Ul Islam; Rajiv Vasusumi; Ashwin P Vinod; Neil Dominic Fernanes; Priya Gala; Vikash Gautam; Farhan Khan Virk; Waiz A. Wasey; Rajat Kumar Yadav; Apeksha Ghai; Spandita Ghosh; Akanksha Grover; Saroj Yadav; and Vikrant Yadav.  Contents SECTION 1 11. Patients in pain 157 General patient assessment Richard M. Langford and Shankar Ramaswamy 1. Doctor and patient: General principles of history taking 3 SECTION 3 Michael Glynn Basic systems 2. General patient examination and 12. Respiratory system 167 differential diagnosis 15 Veronica L.C. White William M. Drake and Tahseen A. Chowdhury 13. Cardiovascular system 189 Ceri Davies 3. The next steps: Differential 14. Gastrointestinal system 241 diagnosis and initial Andrew Rochford and Michael Glynn management 31 15. Locomotor system 273 Michael Glynn Stephen Kelly 4. Ethical considerations 37 16. Nervous system 309 William M. Drake Rodney W.H. Walker SECTION 2 17. Urogenital system 355 John Peters, James Green and Lina Hijazi Assessment in particular groups 18. Endocrine and metabolic 5. Women 45 disorders 379 Rehan Khan Tahseen A. Chowdhury and 6. Children and adolescents 63 William M. Drake Anna Riddell 19. Skin, nails and hair 403 7. Older people 85 Rino Cerio Adam Feather 20. Eyes 419 8. Psychiatric assessment 99 Andrew Coombes Trevor Turner 21. Ear, nose and throat 439 9. Patients presenting as Michael J. Wareing emergencies 121 Geraint Morris Index 465 10. Patients with a fever 141 Caryn Rosmarin and Ali Jawad SECTION 1 General patient assessment 1. Doctor and patient: General principles of history taking 2. General patient examination and differential diagnosis 3. The next steps: Differential diagnosis and initial management 4. Ethical considerations  SECTION ONE GENERAL PATIENT ASSESSMENT Doctor and patient: General principles of history taking Michael Glynn 1 There are two main steps to making a diagnosis: Introduction 1 To establish the clinical features by history and If asked why they entered medicine, most doctors examination – this represents the clinical would say that they wish to relieve human suffering database. and disease. In order to achieve this aim for every 2 To interpret the clinical database in terms of patient, it is essential to understand what has gone disordered function and potential causative wrong with normal human physiology in that indi- pathologies, whether physical, mental, social or vidual and how the patient’s personality, beliefs and a combination of these. environment are interacting with the disease process. This book is about this process. This first chapter History taking and clinical examination are initial introduces the basic principles of history taking but crucial steps to achieving this understanding, and examination, while more detail about the history even in an era in which the availability of sophisticated and examination of each system (cardiovascular, investigations might suggest to a lay person that a respiratory, etc.) is set out in individual succeeding blood test or scan will give all the answers. In addition, chapters. Throughout the book, the patient is referred even though many diseases are now curable, the relief to as ‘he’, the editors preferring this to ‘he/she’ or of symptoms is usually what the patient expects from ‘they’ (except in specific scenarios involving female the medical process. patients). The phrase ‘Clinical Methods’ is used less than it used to be. It can be defined as the set of skills doctors use to diagnose and treat disease and the manner in Setting the scene which doctors approach clinical problems and relate to patients. The skills that make up Clinical Methods Most medical encounters or consultations do not are acquired during a lifetime of medical work, and occur in hospital wards or Emergency Departments they evolve and change as new techniques and new but in primary care or outpatient settings. Whatever concepts arise and as the experience and maturity the setting, a certain familiarity to the context of of the doctor develop. Clinical methods are acquired the consultation, including the consulting room by a combination of study and experience, and there itself, the waiting area and all the associated staff, is always something new to learn. makes the process of clinical diagnosis easier. Patients The aims of any first consultation are to understand are less often assessed in their own home than previ- patients’ own perceptions of their problems and to ously, and many doctors now find this a strange start or complete the process of diagnosis. This double concept. aim requires knowledge of disease and its patterns Meeting the patient in the waiting room allows of presentation, together with an ability to interpret the doctor to make an early assessment of his a patient’s symptoms (what the patient reports/ demeanour, hearing, walking and any accompanying complains of, e.g. cough or headache) and the findings persons. It is good to offer a greeting and careful on observation or physical examination (called physical introduction and to observe the response unobtrusively signs or, often, simply ‘signs’). Appropriate skills are but with care. It is important to remember that needed to elicit the symptoms from the patient’s patients are easily confused by medical titles and description and conversation and the signs by observa- hierarchies. All of the following questions should be tion and by physical examination. This requires not quickly assessed: only experience and considerable knowledge of people Does the patient appear relaxed and smiling or in general, but also the skill to strike up a relationship, furtive and anxious? in a short space of time, with a range of very different Does the patient make good eye contact? individuals. Is he frightened or depressed? 4 1 Doctor and patient: General principles of history taking Are posture and stance normal? Beginning the history Is he short of breath or wheezing? In some conditions (e.g. congestive heart failure, The process of gathering information about a patient acute asthma, Parkinson’s disease, stroke, jaundice), often begins by reading any referral documentation the general nature of the problem is immediately and with the immediate introduction of doctor and obvious. It is very important to identify the patient patient. However, once the social introductions correctly, particularly if he has a name that is very are achieved, the doctor will usually begin with a common in the local community. Carefully check single opening question. Broadly, there are two ways the full name, date of birth and address and any to do this. numerical identifier used by the local health system A single open-ended question along the lines of (in the UK, the hospital registration number or the ‘Tell me about what has led up to you coming here NHS number) today’ gives the opportunity for the patient to begin Pleasant surroundings are very important. It is with what he feels to be most important to him and essential that both patient and doctor feel at ease, avoids any prejudgement of issues or exclusion of and especially that neither feels threatened by the what at first hearing may seem less important. encounter. Avoid having patients full-face across a However, at this stage the patient may be very anxious desk. Note taking is important during consultations and nervous and still making his own assessment of while being able to see the patient and establish eye how he will react to the doctor as a person. A begin- contact and to show sympathy and awareness of his ning which focuses on issues which may be more needs during the discussion of symptoms, much of factual and less emotive can be more rewarding and which may be distressing or even embarrassing. If lead to a more satisfactory consultation. Box 1.1 lists the doctor is right-handed and the patient sits on the some of the areas of questioning that can be usefully doctor’s left, at an angle to the desk, the situation is included at the beginning of the history. It is important less formal, and clues such as agitated foot and hand to inform the patient that this is going to be the movements are more evident. If other people are order of things so that he does not feel that his present, arrange the seating to make it clear that it pressing problems are being ignored. A statement is the patient who is the centre of attention rather along the lines of ‘Before we discuss why you have than any others present. Increasingly doctors are come today, I want to ask you some background entering information directly into a computer, rather questions’ should inform the patient satisfactorily. than writing, and this affects positioning. There is a particular logic in taking the past medical history at this stage. For many conditions, the distinc- tion as to what is a current problem and what is past Emergency presentations history is unclear and arbitrary in the patient’s mind. A patient presenting with an acute exacerbation of If the patient is being seen as an emergency, the chronic obstructive pulmonary disease may have a whole process of history taking is altered according history of respiratory problems going back many to the surroundings and the degree of illness. No years. Therefore, taking the history along a ‘timeline’ history may be obtainable from a severely ill or will often build up a much better picture of all of unconscious patient, but collateral history from the patient’s problems, how they have developed and bystanders, relatives or emergency medical personnel how they now interact with life and work. should not be ignored. In retrospect this information Once these preliminaries have been completed, can be hard to get later on in the patient’s illness the doctor should use a simple and open-ended and can be crucial to diagnosis (e.g. was the patient question to encourage the patient to give a full and seen to have a grand mal seizure, or did he complain free account of the current issues. Say something of sudden pain, before a collapse). along the lines of ‘Tell me about what has led up to you coming here today’. This wording leaves as open as possible any question about the cause of the History taking Having overcome the strangeness of meeting and talking to a wide variety of people that he might not Box 1.1 Areas of questioning that can be covered at the ordinarily meet, the new medical student usually beginning of history taking feels that history taking ought to be fairly simple but Confirm date of birth and age that physical examination is full of pitfalls such as Occupation and occupational history unrecognized heart murmurs and confusing parts of Past medical history the neurological examination. However, the experi- Smoking enced doctor comes to realize that history taking is Alcohol consumption immensely skilled, and that the extent to which this Drug and treatment history skill goes on increasing with experience is probably Family history greater than for clinical examination.  SECTION One 5 Doctor and patient: General principles of history taking patient’s problems and why he is seeing a doctor, and Box 1.2 Particular gestures useful in analysing specific could give rise to an initial answer beginning with pain symptoms such varied phrases as ‘I have this pain …’, ‘I feel depressed …’, ‘I am extremely worried about …’, ‘I A squeezing gesture to describe cardiac pain don’t know but my family doctor thought …’, ‘My Hand position to describe renal colic wife insisted …’ or even ‘I thought you would already Rubbing the sternum to describe heartburn know from the letter my family doctor wrote to you’. Rubbing the buttock and thigh to describe sciatica All of these answers are perfectly valid but each gives Arms clenched around the abdomen to describe mid-gut a different clue as to what are the real issues for the colic patient, and how to develop the history-taking process further for that individual. This part of history taking is probably the most important and the most dependent on the skill of Box 1.3 Words and phrases that need clarification the doctor. It is always tempting to interrupt too early and, once interrupted, the patient rarely com- Ordinary English words pletes what he was intending to say. Even when he Diarrhoea appears to have finished giving his reasons for the Constipation consultation, always ask if there are any more broad Wind areas that will need discussion before beginning to Indigestion discuss each in more detail. Being sick Dizziness Headache Developing themes Double vision Pins and needles This stage of the history is likely to see the patient Rash talking much more than the doctor, but it remains Blister vital for the doctor to steer and mould the process so that the information gathered is complete, coherent Medical terms that may be used imprecisely by patients and, if possible, logical. Some patients will present a Arthritis clear, concise and chronologically perfect history with Sciatica little prompting, although they are in the minority. Migraine For most patients, the doctor will need to do a Fits substantial amount of clarifying and summarizing Stroke with statements such as ‘You mean that …’, ‘Can I Palpitation go back to when …’, Can I check I have under­ Angina stood …’, So up to that point you …’, ‘I am afraid I Heart attack am not at all clear about …’ and ‘I really do not Diarrhoea understand, can we go over that again?’ If a patient Constipation clearly indicates that he does not wish to discuss Nausea particular aspects of the history, then this wish must Piles/haemorrhoids be respected and the diagnosis based on what informa- Anaemia tion is available, although it is also important to Pleurisy explain to the patient the limitations that may be Eczema imposed by this lack of information. Urticaria Warts Non-verbal communication Cystitis Within any consultation, the non-verbal communica- tion is as important as what the patient says. There may be contradictions such as a patient who does Vocabulary not admit to any worries or anxieties but who clearly It is very important to use vocabulary that the patient looks as if he has many. Particular gestures during will understand and use appropriately. This under- the description of pain symptoms can give vital clinical standing needs to be on two levels: he must understand clues (Box 1.2). While concentrating on the conversa- the basic words used, and his interpretation of those tion with the patient, the doctor should keep a wide words must be understood and clarified by the doctor. awareness of all other clues that can be gleaned from Box 1.3 lists words and phrases that may be used in the consultation. These include the patient’s demean- the consultation that the doctor needs to be very our, dress and appearance, any walking aids, the careful to clarify with the patient. If the patient uses interaction between the patient and any accompanying one of the ordinary English words listed, its meaning people and the way that the patient reacts to the must be clarified. A patient who says he is dizzy developing consultation. could be describing actual vertigo, but could just 6 1 Doctor and patient: General principles of history taking mean light-headedness or a feeling that he is going Box 1.4 Example of a history that leads to to faint. A patient who says that he has diarrhoea a poor conclusion could mean liquid stools passed hourly throughout the day and night or could mean a couple of urgent A GP is seeing a 58-year-old man who is known to be soft stools passed first thing in the morning only. hypertensive and a smoker. The receptionist has already Therefore, the doctor needs to use words that are documented that he is coming in with a problem of chest almost certainly going to be clearly understood by pain. The GP makes an automatic assumption that the pain the patient, and the doctor must clarify any word or is most likely to be angina pectoris, because that is phrase that the patient uses to avoid any possibility probably the most serious cause and the one that the of ambiguity. patient is likely to be most worried about, and therefore starts taking the history with the specific purpose of Indirect and direct questions confirming or refuting that diagnosis. GP: I gather you’ve had some chest pain? Broadly, questions asked by the doctor can be divided Patient: Yes, it’s been quite bad. into indirect or open-ended and direct or closed. Indirect or open-ended questions can be regarded as GP: Is it in the middle of your chest? an invitation for the patient to talk about the general Patient: Yes. area that the doctor indicates to be of interest. These GP: And does it travel to your left arm? questions will often start with phrases like ‘Tell me Patient: Yes – and to my shoulder. more about …’, ‘What do you think about …’, ‘How GP: Does it come on when you walk? does that make you feel …’, ‘What happened Patient: Yes. next …’ or ‘Is there anything else you would like to GP: And is it relieved by rest? tell me?’ They inform the patient that the agenda is Patient: Yes – usually. very much with him, that he can talk about whatever is important and that the doctor has not prejudged GP: I’m afraid I think this is angina and I will need to refer any issues. If skilfully used, and if the doctor is sensitive you to a heart specialist. to the clues presented in the answers, a series of such The GP has only asked very direct and closed questions. questions should allow the doctor to understand the Each answer has begun with ‘Yes’. The patient has already issues that are most important from the patient’s been quite firmly tagged with a ‘label’ of angina, and point of view. The patient will also be allowed to anxiety has been raised by the specialist referral. describe things in his own words. Alternatively, the GP keeps an open mind and starts as Many patients are in awe of doctors and have some follows: conscious or subconscious need to please them and GP: Tell me why you have come to see me today. go along with what they say. If the doctor prejudges Patient: Well – I have been having some chest pain. the patient’s problems and tends to ‘railroad’ the GP: Tell me more about what it’s like. conversation to fit their assumed diagnosis too early Patient: It’s in the centre of my chest and tends to go to in the process, then the patient can easily go along my left arm. Sometimes it comes on when I’ve been with this and give simple answers that do not fully walking. describe his situation. Box 1.4 illustrates this extremely GP: Tell me more about that. simple, common and important pitfall of history Patient: Sometimes it comes when I am walking and taking. sometimes when I’m sitting down at home after a long walk. Disease-centred versus patient-centred GP: If the pain comes on when you are walking, what do An interview that uses lots of direct questions is often you do? ‘disease centred’, whereas a ‘patient centred’ interview Patient: I usually slow down, but if I’m in a hurry I can will contain enough open-ended questions for patients walk on with the pain. to talk about all of their problems and be given GP: I am a little worried that this might be angina but enough time to do so. This will also help to avoid some things suggest it might not be, so I am going to refer the situation in which the doctor and the patient you to a heart specialist to make sure it isn’t angina. have different agendas. There can often appear to be The GP has asked questions which are either completely a conflict if the patient complains of symptoms that open-ended or leave the patient free to describe exactly are probably not medically serious, such as tension what happens within a directed area of interest. Clarifying headache, while the doctor is focusing on some questions have been used. While being reassuring, the GP potentially serious but relatively asymptomatic condi- expresses some concern about angina and is clear about tion, such as anaemia or hypertension. In this situation, the exact reason for the specialist referral (for clarification). a patient-centred approach will allow the patient to air all of his problems and will allow a skilled doctor to educate the patient as to why the other issues are also important and must not be ignored. A GP may rightly refuse a demand for antibiotics for a sore  SECTION One 7 Doctor and patient: General principles of history taking throat that is likely to be viral but should use the many women will be the pain of labour. The pain opportunity to educate and inform the patient about scale assessment is useful in diagnosis and in monitor- the true place of antibiotic treatment and the risks ing disease, treatment and analgesia. Assessing a patient of excess and inappropriate use. The doctor needs to with pain is discussed in more detail in Chapter 11. grasp the difference between the disease framework (what the diagnosis is) and the illness framework Which issues are important? (what are the patient’s experiences, ideas, expectations A problem for those doctors wishing to take the and feelings) and to be able to apply both frameworks history in chronological order – ‘Start at the beginning to a clinical situation, varying the degree of each, and tell me all about it’ – is that people usually start according to the differing demands. with the part of the problem that they regard as the most important. This is, of course, entirely valid from Judging the severity of symptoms the patient’s viewpoint, and it is also important to Many symptoms are subjective and the degree of the doctor, since the issue that most bothers the severity expressed by the patient will depend on his patient is then brought to attention. Curing disease own personal reaction and also on how the symptoms may not always be possible, so it is important to be interact with his life. A tiny alteration in the neurologi- aware of the important symptoms since, for example, cal function of the hands and fingers will make a pain may be relieved even though the underlying huge impression on a professional musician, whereas cause of the pain is still present. It is very common most others might hardly notice the same dysfunction. for the doctor to be pleased that one condition has A mild skin complaint might be devastating for a been solved, but the patient still complains of the professional model but cause little worry in others. main symptom that he originally came with. Trying to assess how the symptoms interact with the patient’s life is an important skill of history taking. A schematic history A simple question such as ‘How much does this bother you?’ might suffice. It may be helpful to ask A suggested schematic history is detailed in Box 1.6. specific questions about how the patient’s daily life There will be many clinical situations in which it is affected, with comparison to events that many will be clear that a different scheme should be fol- patients will experience. Box 1.5 illustrates some of lowed. An important part of learning about history the relevant areas. taking is that each doctor develops his own personal Medical symptomatology often involves pain, which scheme that works for him in the situations that he is more subjective than almost anything else. Many generally comes across. Nevertheless, it is useful to patients are stoical and bear severe pain uncomplain- start with a basic outline in mind. ingly whereas others seem to complain much more about apparently less severe pain. A simple pain scale Direct questions about bodily systems can be very helpful in assessing the severity of pain. Within the variety of disease processes that may The patient is asked to rate his pain on a scale from present to doctors, many have features that occur in 1 to 10, with 1 being a pain that is barely noticeable many of the bodily systems which at first may not and 10 the worst pain he can imagine or the worst seem to be related to the patient’s main complaint. pain he has ever experienced. It is also useful to A patient presenting with back pain may have had clarify what the reference point is for ‘10’, which for Box 1.6 Suggested scheme for basic history taking Name, age, occupation, country of birth, other Box 1.5 Areas of everyday life that can be used as a clarification of identity reference for the severity, importance or Main presenting problem clarification of symptoms Past medical history – ‘Before we talk about why you Exercise tolerance: ‘How far can you walk on the flat going have come, I need to ask you to tell me about any at your own speed?’, ‘Can you climb one flight of stairs serious medical problems that you have had in the slowly without stopping?’, ‘Can you still do simple whole of your life’ housework such as vacuum cleaning or making a bed?’ Specific past medical history – e.g. diabetes, jaundice, Work: ‘Has this problem kept you off work?’, ‘Why exactly TB, heart disease, high blood pressure, rheumatic fever, have you not been able to work?’ epilepsy Sport: ‘Do you play regular sport and has this been History of main presenting complaint affected?’ Family history Eating: ‘Has this affected your eating?’, ‘Do any Occupational history particular foods cause trouble?’ Smoking, alcohol, allergies Social life: ‘What do you do in your spare time and has Drug and other treatment history this been restricted in any way?’, ‘Has your sex life been Direct questions about bodily systems not covered by the affected?’ presenting complaint 8 1 Doctor and patient: General principles of history taking some haematuria from a renal cell carcinoma that Box 1.7 Bodily systems and questions relevant to taking has spread and is the cause of the presenting symptom. a full history from most patients. If the specific For this reason, any thorough assessment of a patient questions have been covered by the history of the must include questions about all the bodily systems presenting complaint, they do not need to be and not just areas that the patient perceives as included again. If the answers are positive, the problematic. This area of questioning should be characteristics of each must be clarified introduced with a statement such as ‘I am now going to ask you about other possible symptoms that could Cardiorespiratory be important and relevant to your problem’. A list Chest pain of such question areas is given in Box 1.7. Intermittent claudication In addition, during any medical consultation, Palpitation however brief, it is the duty of the doctor to be alert Ankle swelling to all aspects of the patient’s health and not just the Orthopnoea area or problem that he has presented with. For Nocturnal dyspnoea example, a GP would not ignore a high blood pressure Shortness of breath reading in a patient presenting with a rash, even Cough with or without sputum though the two are probably not connected. This Haemoptysis function of any consultation can be regarded as Gastrointestinal ‘screening’ the patient. In health economic terms, a Abdominal pain true screening programme for a particular disease Dyspepsia across a whole population (such as for cervical cancer) Dysphagia has to be evaluated as being useful, economic and Nausea and/or vomiting with no negative effects. However, once the patient Degree of appetite with a complaint has attended a doctor, a simple Weight loss or gain screening process can be incorporated into the Bowel pattern and any change consultation with little extra time or effort. The direct Rectal bleeding questions (and full routine examination) encompass Jaundice this screening function as well as contributing to solving the patient’s presenting problems. Genitourinary Haematuria Clarifying detail Nocturia Frequency One of the basic principles of history taking is not Dysuria to take what the patient says at face value but to Menstrual irregularity – women clarify it as much as possible. Almost all of the history Urethral discharge – men will involve clarification but there are specific areas Locomotor where this is particularly important. Joint pain Pain Change in mobility Whenever a patient complains of pain, there should Neurological follow a series of clarifying questions as listed in Box Seizures 1.8. Of all symptoms, pain is perhaps the most subjec- Collapses tive and the hardest for the doctor to truly compre- Dizziness hend. A simple pain scale has been described above. Eyesight The other characteristics are vital in analysing what Hearing might be the cause of pain. Some painful conditions Transient loss of function (vision, speech, sight) have classic sites for the pain and the radiation Paraesthesia (myocardial ischaemia is classically felt in the centre of the chest radiating to the left arm). Pain from a hollow organ is classically colicky (such as biliary or renal colic). The pain of a subarachnoid haemorrhage Box 1.8 List of clarifications for a complaint of pain is classically very sudden, ‘like a hammer blow to the Site head’. Some pains have clear aggravating or relieving Radiation factors (peptic ulcer pain is classically worse when Character hungry and better after food). Colicky right upper Severity quadrant abdominal pain accompanied by jaundice Time course suggests a gallstone obstructing the bile duct, and a Aggravating factors headache accompanied by preceding flashing lights Relieving factors suggests migraine. It is always worth making sure that Associated symptoms any symptom of pain has been clarified in this way,  SECTION One 9 Doctor and patient: General principles of history taking Box 1.9 Clarifying questions in the drug history Box 1.10 Detail of the family history Can you tell me all the drugs or medicines that you Are there any illnesses that run in your family? take? Occasionally this will reveal major genetic trends such as Have any been prescribed from another clinic, doctor or haemophilia. More often there will be an answer such as dentist? ‘They all have heart trouble’. Do you buy any yourself from a pharmacy? Basic family tree of first-degree relatives Are you sure you have told me about all tablets, capsules and liquid medicines? This should be plotted on a diagram for most patients, What about inhalers, skin creams or patches, including major illnesses and cause and age of any deaths. suppositories or tablets to suck? Specific questions about occurrence of problems similar to Were you taking any medicines a little while ago but the patient’s stopped recently? Ask the patient about items in the developing differential Do you ever take any medicines prescribed for other diagnosis, for example ‘Does any one in your family have people such as your spouse? gallstones/epilepsy/high blood pressure?’ if these seem a Do you use herbal or other complementary medicines? likely diagnosis for the patient under consideration. and while some of the points will come out in the toxic exposures, are now extremely rare in developed open-ended part of the history taking, others will industrial countries, but accidental exposure continues need specific questions. to occur. Other problems, such as asbestosis or silicosis, produce effects many years after exposure, and a Drug history careful chronological occupational history may be At first glance, asking a patient what drugs he is required to elucidate the exposure. For patients with taking would seem to be one of the simplest and non-organic problems, the work environment can most reliable parts of taking a history. In practice, often be the trigger for the development of the this could not be further from the truth, and there problem. are many pitfalls for the inexperienced. This is partly because many patients are not very knowledgeable Alcohol history about their own medications and also because patients The detrimental effects of alcohol on health cause a often misinterpret the question, giving a very narrow variety of problems, and the frequency of excess answer when the doctor wants to know about medica- alcohol use means that up to 10% of adult hospital tions in the widest sense. The need for clarification inpatients have a problem related to alcohol. To make in the drug history is given in Box 1.9. The drug an accurate estimate of alcohol consumption and any history, almost more than any other, benefits from possible dependency, it is essential to enquire carefully being repeated at another time and in a slightly and not to take what the patient says at face value different way. For example, in trying to define a but to probe the history in different ways (Box 1.11). possible drug reaction as a cause of liver dysfunction, For documentation, the reported amount should then it is not unusual to find that the patient has taken a be converted into units of alcohol per week (Box few relevant tablets (such as over-the-counter non- 1.12). If the reported amount seems at all excessive steroidal anti-inflammatory drugs) just before the then an assessment should be made of possible onset of the problem and only remembered or realized dependency for which the CAGE questions are very it was important to say so when asked repeatedly useful (Box 1.13). and in great detail. Retrospective history Family history The concept of retrospective history taking is a Like the drug history, the family history would seem refinement of taking the past medical history and at first glance to be simple and reliably quoted. In develops the theme of never taking what the patient general this is true, but it can be dissected into sections says at face value. Many patients will clearly say that that will uncover more information. These are set they have had certain illnesses or previous symptoms out in Box 1.10. using medical terminology. This information may not be accurate either because the patient has misinter- Occupational history preted it or because they were given the wrong It is always useful to know the patient’s occupation information or diagnosis in the first place. This area if he has one, as it is such an important part of life becomes particularly important if any new diagnosis and one with which any illness is bound to interact. is going to rely on this type of information. For In some situations, a patient’s occupation will be instance, in assessing a patient presenting with chest directly relevant to the diagnostic process. The classic pain at rest, a past history of angina of effort will be industrial illnesses, such as lead poisoning and other considered a risk factor for acute myocardial infarction 10 1 Doctor and patient: General principles of history taking Box 1.11 Probing the alcohol history period of heavy work and not a clear central chest pain coming on during exertion. Doctor: Do you drink any alcoholic drinks? Clearly the possibility of retaking the history for Patient: Oh yes, but not much – just socially. everything the patient says about his medical past Doctor: Do you drink some every day? may not be practical in the time available, but the Patient: Yes. possibility and value of doing this should always be Doctor: Tell me what you drink. borne in mind and can completely alter the developing differential diagnosis. Patient: I usually have two pints of beer at lunchtime and two or three on my way home from work. Doctor: And at the weekend? Particular situations Patient: I usually go out Saturday nights and have four or It is true to say that while there are many themes, five pints. patterns and common areas to history taking and Doctor: Do you drink anything other than beer? some areas of history taking might seem routine, the Patient: On Saturdays I have a double whisky with each process of history taking for different patients will pint. never be identical. There are some particular and often challenging situations that deserve some further The first answer does not suggest a problem, but based description. on the figures in Box 1.12, the actual amount adds up to 70 units per week which clearly confers considerable health Garrulous patients risks to this patient. A new medical student will soon meet a patient who says a huge amount without really revealing any of the information that goes towards a useful medical Box 1.12 Units of alcohol (1 unit contains 10 g of pure history. This will be in marked contrast to some other alcohol) patients who, from the first introductory question The units of alcohol can be determined by multiplying the (e.g. ‘Tell me about what has led up to you coming volume of the drink (in ml) by its % alcohol by volume here today’), will reveal a perfect history with virtually (abv) and dividing this by 1000. For example, 1 pint no prompting. A fictitious but typical history from (568 ml) of beer at 3.5% abv contains: (568 × 3.5) / 1000 the former type of patient is given in Box 1.14. When = 1.988 units. faced with such a patient, the doctor will need to It is important to bear in mind that alcohol strength significantly alter the balance of open-ended and varies widely within each category of drink, but here is a direct questions. Open-ended questions will tend to guide to the most common alcoholic drinks: lead to such a patient giving a long recitation but Standard-strength beer (3.5% abv): 1 pint = 2 units with little useful content. The doctor will have to Very strong lagers (6% abv): 1 pint = 3.5 units use many more clear, direct questions which may Spirits (whisky, gin, etc., 40% abv): 1 UK pub measure just have yes/no answers. The overall history will (about 25 ml) = 1 unit inevitably be less satisfactory but it is not possible Wine (12%): 1 standard glass (175 ml) = 2 units to get the ‘perfect’ history in every patient. The UK Government now recommends that to minimize Angry patients alcohol-related health effects, both men and women should keep to less than 14 units of alcohol per week. Only a few patients are overtly angry when they see a doctor, but anger expressed during a clinical consulta- tion may be an important diagnostic clue while at the same time get in the way of a smooth diagnostic Box 1.13 The CAGE assessment for alcohol dependency process. Some patients will be angry with the immedi- C – Have you ever felt the need to Cut down your alcohol ate circumstances such as a late-running outpatient consumption? clinic. Others will have longer-term anger against the A – Have you ever felt Angry at others criticizing your surgery, department or institution which will be more drinking? difficult to address. It is always important to acknowl- G – Do you ever feel Guilty about excess drinking? edge anger and to try to tease out what underlies it. E – Do you ever drink in the mornings (Eye-opener)? Even if it is not the doctor’s immediate fault that Two or more positive answers could indicate a problem of the clinic is running late or there have been other dependency. problems, it is always worth apologizing on behalf of the unit or institution. For some patients, anger may be part of the symp- and will increase the likelihood of that as the current tomatology or expressed as a reaction to the diagnosis diagnosis. However, on closer questioning, it might or treatment. This will be particularly true in patients become clear that what the patient was told was with a non-organic diagnosis who insist that there is angina (perhaps by a relative and not even a doctor) ‘something wrong’ and that the doctor must do was in fact a vague chest ache coming on after a something. Many types of presentation will fall into  SECTION One 11 Doctor and patient: General principles of history taking Box 1.14 A typical ‘garrulous’ history of a doctor to give the patient as much information about his illness as possible, particularly so that he Doctor: Tell me about what has led up to you coming here is able to make informed choices about treatments. today. This change of approach has led to many patients Patient: Well doctor, you see, it was like this. I woke up one seeking out information about their problems from day last week – I am not quite sure which day it was – it many other sources, particularly the Internet. It is might have been Tuesday – or, no, I remember it was not unusual for a patient to come into the first Monday because my son came round later to visit – he consultation with a new doctor, armed with printouts always comes on a Monday because that’s his day off from various websites that he feels are relevant or college – he’s studying law – I’m so pleased that he’s information on their smart phone. settled down to that – he was so wild when he was younger The doctor must take all this in their stride, go – do you know what he did once …? through the information with the patient and help Doctor (interrupting): Can you tell me what did happen him by showing what is relevant and what is not. when you woke up last Monday? Many medical websites are created by individuals or Patient: Oh yes – it was like this – I am not sure what groups without proper information for a sound basis woke me up – it may have been the pain – no, more likely of knowledge, but it can be difficult for the patient it was the dustmen collecting the rubbish – they do come to make a judgement about this. Being able to inform so early and make such a noise – that day it was even patients of a few relevant and reliable websites can worse because their usual dustcart must have been broken be very helpful. In general, it is easy and more reward- and they came with this really old noisy one … ing to look after well-informed patients, provided Doctor (interrupting): So you had some pain when you they do not fall into the very small group that have woke up then? such fixed and erroneous ideas about their problems that the diagnostic and treatment process is impeded. Patient: Yes – I think it must have been there when I woke up because I lay in bed wondering where on earth there might be some indigestion remedy – I knew I had some Accompanying persons but I am one of those people who can never remember Some people come to consultations alone and others where things are – do you know what I managed to lose with one or more friends or family members. Always last year …? spend time during the initial exchange of greetings Doctor (interrupting): Was the pain burning or crushing? identifying who is present and getting some idea of Patient: Well, that depends on what you mean by … the group dynamics. If the patient appears to be Doctor (interrupting): Yes, but did you have any crushing alone, ask whether there is someone waiting outside. pain? There is always a reason people come accompanied, The doctor gradually changes from very open-ended to but if there appear to be too many people present very closed questions in order to try to get some information or if the presence of others might threaten the that is useful to building up the diagnostic picture relationship with the patient at any time in the – eventually a question is asked that just has a yes/no consultation, it is appropriate to consider asking answer. the others to leave, even if only briefly. It is reasonable, if in doubt, to ascertain why others wish to be present, and certainly whether this is also the patient’s wish. It is very important to be certain that the patient is this group, including tension headache, irritable bowel happy for any others to be present and to be as and back pain. There may be obvious secondary gain certain as possible that the patient does not wish to for the patient (such as staying off work and claiming object but feels unable to do so. This is particularly benefits) and challenging this pattern of behaviour difficult if the doctor does not speak the patient’s may provoke anger. language but can speak to those accompanying. It is the duty of a doctor to attempt to work with Consider whether specific questions about the history and help a wide variety of patients, and those who should be asked of those accompanying, either with are angry are no exception. However, occasionally it the patient or separately, with specific consent. may be best to acknowledge that the doctor–patient Beware of a situation in which the accompanying relationship has broken down and that facilitating a people answer all the questions, even if there is not change to another doctor may be in the best interests a language difficulty. Many clues to diagnosis may be of the patient. masked if direct communication with the patient is not possible (using an interpreter/advocate for patients The well-informed patient who do not speak the same language as the doctor In the last century, doctors often looked after patients is discussed below). There may be many reasons that for a long time without really explaining their illness the patient does not speak for himself. These may to them, and patients were reasonably happy taking include embarrassment in front of those accompanying the attitude that ‘the doctor knows best’. This (such as a teenager with his parents). In such cir- approach is no longer acceptable and it is the duty cumstances, it may be necessary to leave parts of the 12 1 Doctor and patient: General principles of history taking history until those accompanying can reasonably be myriad data gleaned on taking a history, he is often asked to leave, such as during the examination. baffled as to how to start the analysis, but inevitably Occasionally it is clear that the patient will not talk the process becomes easier as more medical knowledge for himself, in which case the history from those is acquired. An analysis of symptoms from a medical accompanying will have to be the working student is more based on facts learned from textbooks, information. whereas an experienced doctor will tend to base the analysis more on patterns of disease presentation that Using interpreters/advocates they have encountered many times. While the analyti- Particularly in the inner cities of Western countries, cal process is largely acquired through this type of there will often be a large immigrant population who experience, some principles can be described. This do not speak the first language of the country, even topic is discussed further in Chapter 3. if they have been resident for some years, and it is impractical for each patient to be looked after by ‘Hard and soft’ symptoms health professionals who speak their language. In A detective analysing evidence of a crime will put a these circumstances, the medical consultation has to lot of weight on fingerprint or DNA evidence and be undertaken with an interpreter. The most immedi- less weight on identification evidence. The same ate solution may be to use a family member, but if principles apply to analysing symptoms. A ‘hard’ the issues are private or embarrassing, this often does symptom can be thought of as one which, if clearly not work well. It is also unethical to use an underage present, adds a lot of weight to a particular diagnosis. family member as an interpreter (under 16). A ‘soft’ symptom may be thought of as one which The best solution is to have available an independent is either reported by patients so variably that its true interpreter/advocate for the consultation, although presence is often in doubt, or one which is present in areas where many patients are not native speakers, in such a variety of conditions as to not be useful in many interpreters will be needed for a range of confirming or refuting a diagnosis. Examples of these languages. Another solution for infrequently encoun- two groupings are given in Box 1.15. tered languages is a telephone interpreting service. When taking a history via an interpreter/advocate, the overall style usually has to change. The breadth Time course of history and the clinical clues that can be obtained A simple epithet states that the character of the from a good initial open-ended question may well symptom suggests the ‘anatomy’ of the problem and be lost in the double translation, and the doctor often the time course the ‘pathology’ of it. For instance, a changes to a much more direct style of questioning vascular event such as a myocardial infarct, stroke or for which the answers will be unambiguous even subarachnoid haemorrhage usually has a sudden onset, when going through the double translation. It is also whereas something that gradually progresses or for not unusual for the interpreter/advocate and the patient to have a few minutes of conversation fol- lowing an apparently simple question from the doctor, Box 1.15 ‘Hard’ and ‘soft’ symptoms but then a very short answer is returned to the doctor. ‘Hard’ symptoms This leaves the doctor bemused as to what is really going on with the patient. Finally, history taking via Pneumaturia: almost always due to a colovesical fistula an interpreter/advocate usually takes much longer Fortification spectra: if associated with unilateral than when the doctor and the patient speak the same headache, strongly suggests classical migraine language. Rigors: strongly suggests bacteraemia, viraemia or malaria A bitten tongue: if associated with a seizure, strongly Analysing symptoms suggests a grand mal fit A sudden severe headache ‘like a hammer blow’: The objective of the history and examination is to strongly suggests a subarachnoid haemorrhage begin identifying the disturbance of function and Pleuritic chest pain: strongly suggests pleural irritation structure responsible for the patient’s symptoms. This due to infection or a pulmonary embolus is done by analysis of the symptoms and signs leading Itching: if associated with jaundice, indicates intra- or to a differential diagnosis (a list of possible diagnoses extrahepatic cholestasis that will account for the symptoms and signs, usually ‘Soft’ symptoms set out in descending order of likelihood). This list of Dizziness possibilities is then often refined by the use of special Light-headedness investigations, but in up to 80% of patients the likely Tiredness diagnosis is reasonably clear after the initial history. Back pain The process of analysis can be likened to detective Headache work, in which the symptoms and signs are the evi- Wind dence. When a medical student is first faced with the  SECTION One 13 Doctor and patient: General principles of history taking which the onset cannot be exactly dated by the Box 1.16 General reasons that patients come to see patient, such as weight loss or dysphagia, may be a doctors (other than for a severe or acute malignant process. There are some pitfalls in this type problem) of analysis which must be borne in mind to avoid confusion. Cannot tolerate ongoing symptoms and wants to be rid Disease processes that gradually progress may start of them off by being asymptomatic and the patient may only Someone else noticing specific problems (e.g. jaundice) notice symptoms when they start to interfere with Another doctor noticing specific problems (e.g. high his lifestyle and activities. For example, exertional blood pressure) breathlessness in a largely sedentary patient may Worry about underlying diagnosis (often induced by develop late in a cardiorespiratory disease process, relatives, friends, books, media or Internet) whereas a patient who actively exercises is likely to Spouse or relative worried about patient notice symptoms much earlier. This phenomenon is Cannot work with symptoms also seen where the relevant bodily organ or system Colleagues/bosses complaining about patient’s work or has a lot of reserve and the symptom may show itself time off only when the reserve is used up. This could be true Requirement of others (insurance, employment benefit, for a relatively chronic liver disease such as primary litigation) biliary cirrhosis apparently presenting acutely. The proverb of the ‘straw that broke the camel’s back’ is a good analogy of this sort of situation (a camel presenting complaint is exertional chest pain can is steadily loaded up with straw until suddenly it immediately be asked if the pain is worse on increased appears that a single piece of straw is sufficient to exertion and how long a period of rest is needed to make the camel collapse). In addition, the disease relieve it. Pain that is not predictably produced by process may have a step-wise worsening rather than a exertion and is not reliably relieved by rest may well linear decline, such as in a situation of multiple small not be angina pectoris. However, it remains very strokes when the patient may not present until a single important that interjected questions of this type do small stroke makes a big difference to his functional not spoil the flow of the patient’s story. ability. Pattern recognition versus logical analysis What does the patient actually want? It is important to realize that in some clinical situ- If a patient comes to a doctor with a long history, it ations the diagnosis may be clear based on previ- is always worth trying to find out why he has come ous experience, and in others the diagnosis has to for medical help and what he actually wants from be built up through a process of logical analysis the consultation. There may be various scenarios as of symptoms, signs and special investigations. The listed in Box 1.16. It is always worth trying to find fact that the process of gaining information from out which might apply to the individual patient, symptoms, signs and special investigations is never because it sets the scene for giving advice and treat- completely exact must also be borne in mind so ment, particularly if an exact diagnosis or a complete that the patient with an atypical presentation is not treatment cannot be provided. It is often much easier assigned the wrong diagnosis. The area of medicine to reassure a patient that there is nothing seriously that probably most often uses pattern recognition wrong than to give him an exact diagnosis or fully is dermatology, but recently skin biopsies are used relieve his symptoms. much more to clarify diagnoses that were previously assumed. A patient presenting with chest pain and signs of underperfusion may easily be thought to be Retaking the history having a myocardial infarction but a brief history of the character of the pain (tearing and going through to It is clear that history taking is an inexact process, the back) may prompt a search for a dissecting aortic heavily influenced by the doctor and by the patient. aneurysm. The logical conclusion of this is that no two histories taken from the same patient about the same set of symptoms will be identical, even if the same doctor Negative data repeats the process. Given two slightly or significantly An experienced history taker will begin the analysis different histories, it may be hard to know on which from the outset of the clinical encounter. This means one to base the diagnosis, or whether to regard history that during the initial process and without the need taking for that patient as so unreliable as to be useless. for so much later review, questions can be asked for The main message is that a single attempt at the which a negative answer is as important as a positive history may not suffice and repeated histories taken one. These questions are usually very specific and at different times by different people and in different direct, often with a yes/no answer. A patient whose ways may provide just as much extra information on 14 1 Doctor and patient: General principles of history taking which to base a diagnosis as more and more detailed Box 1.17 Duties of doctors registered with the UK General special investigations. When a patient is seen for a Medical Council (2013) second or alternative opinion, the doctor usually spends more time on retaking the history than on Knowledge, skills and performance repeating the examination. Make the care of your patient your first concern Keep your professional knowledge and skills up to date Recognize and work within the limits of your competence Note taking Safety and quality Take prompt action if you think that patient safety, When making notes, it is important to keep eye dignity or comfort is being compromised. contact with the patient. Notes should not be made only at times that might suggest to the patient what Communication, partnership and teamwork items of information are regarded as important. It is Protect and promote the health of patients and the better to listen carefully and just record enough to public help remember the important points later. A fuller Treat patients politely and considerately account can be written up afterwards or dictated for Respect patients’ right to confidentiality typing later. In this, the exact history, the weight Listen to, and respond to, patients’ concerns and placed on various items and, most importantly, what preferences the patient actually said can be recorded. What Give patients the information they want or need in a patients say, word for word, is often as important as way they can understand any later reconstruction of the history. Increasingly Respect patients’ right to reach decisions with you doctors are entering information directly into comput- about their treatment and care ers, rather than writing, during a consultation. If an Support patients in caring for themselves to improve experienced doctor starts this for the first time, it and maintain their health can feel intrusive, but can soon be mastered so as to Maintaining trust become second nature. Patients will generally accept Be honest and open and act with integrity the presence of the computer as being part of the Never discriminate unfairly against patients or colleagues fabric of modern life. Never abuse your patients’ trust in you or the public’s