The medical history of a
patient is the most useful and important element in making an accurate
diagnosis, much more valuable than either physical examinations or
diagnostic tests.
'Listen to your patient
they are telling you the diagnosis' is a much quoted aphorism
On Majority
of occasions diagnosis is revealed in the patient's history.
The medical interview is
the process of gathering data that will lead to an understanding of the disease
and the underlying physiological process.
History taking is a
skill which every Doctor has to learn, the basis of History taking is good
communication between doctor and patient. The history is a sharing of
experience between patient and doctor.
It is important for
doctors to acquire good consultation skills which go beyond prescriptive history
taking learned as part of the comprehensive and systematic clerking process
outlined in textbooks. A good history is one which reveals the patient's ideas,
concerns and expectations as well as any accompanying diagnosis. The doctor's
agenda, incorporating lists of detailed questions, should not dominate the
history taking. Listening is at the heart of good history taking.
Often the history alone
does reveal a diagnosis. Sometimes it is all that is required to make the
diagnosis. A good example is with the complaint of headache where the diagnosis
can be made from the description 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.
A complete medical
history consists of an account of: (1) the present illness; (2) past medical
history; (3) family history; (4) occupational background; (5) psychosocial
history; and (6) a review of body systems.
1. An account of the present illness, which
includes the circumstances surrounding the onset of recent health changes and
the chronology of subsequent events that have led the patient to seek medical
care, is essential to understanding the course of the disease process.
Medications are listed in the medical history because they may play a role in
the current illness.
2. The past medical history is an overall view of
the patient’s health prior to the present illness. It should include previous
hospitalizations, injuries, operations, and any significant illness that may
not have required hospitalization. Allergies are
included here if not listed separately.
3. Included in a family history are the age and
state of health of each immediate family member as well as the cause of death
of any parents, grandparents, and other close relatives. Of particular
importance are genetic or environmental diseases that have known risks. If a
close relative such as a father died of aheart attack (acute
myocardial infarction) before age 60, all his children are at greater risk of
suffering an early heart attack. This risk increases if other factors such
as hypertension (high
blood pressure) or elevated serum cholesterol are
present. Similarly, a history of some cancers (e.g., colorectal cancer)
increases the risk that offspring will develop that type of cancer. The
development of lung cancer in
a person provides even greater impetus for close relatives to avoid smoking.
Examples of other diseases that may have hereditary roots are diabetes
mellitus, schizophrenia and
other forms of mental illness, and arthritis.
In fact, any disease that arises in two or more members of a family suggests a
possible predisposing factor, and the patient should be considered to be at
increased risk for this condition.
4. The occupational history is important because
the workplace may be a source of toxins, such as chemicals, asbestos fibres,
or cigarette smoke, that place one at higher risk of cancer or other diseases.
5. The psychosocial history—information on
education, lifestyle, marital status, and religious beliefs—may influence
future medical decisions, as may the patient’s smoking history, alcohol intake,
and use of controlled substances, such as marijuana or cocaine.
6. The review of body systems allows the physician
to identify any other symptoms that have not been noted previously and that may
influence the patient’s current state of health or provide subtle clues to the
diagnosis. All major body systems are reviewed in an orderly manner, usually
from the head down to the extremities. The intent is to uncover any past
illnesses or problems that have not been previously identified and that may now
or later influence the patient’s health. For example, the patient may describe
leg pain while walking, which could be an early indication of blood vessel
occlusion and increase the physician’s concern about possible coronary artery
disease that otherwise may not have been suspected.
