Saturday, 12 December 2009

Diagnosis and The Medical History

The medical history is the most important part of any medical consultation. Taking a good medical history is key to being a good doctor, and the key to a good medical history is listening to the patient.

The medical history lets your patient explain to you what has happened to them and help you understand their problem. Medical diagnosis is the process of working out what has caused the problem.

Doctors ask a series of questions in order to get the information they need to help make a diagnosis. Sometimes the diagnosis, or cause of the problem is obvious, sometimes it can be hard to find.

Medical information is set out in the following way so as to make sense of large amount of information, some of which is relevant and some of which is not.

The Presenting Complaint

This describes the problem. At this stage open questions are best to allow the patient to use their own words to describe what has happened to them.

History of the Illness
This describes the background to the problem

Other illnesses
What else has the person suffered from?

Treatment history
What treatment has the person had, both for the Presenting complaint and for Other illnesses. All too often treatment can be as damaging as the original condition

Family History
What traits, tendencies and conditions run in the family? What do relatives suffer from?

Social and Occupational History
What work does the patient do or not do? what jobs have they had in the past that may have had a significant impact on their health and wellbeing? What kind of company does the person keep? do they live relatively separate life or are they always surrounded by friends?

and finally a
Systems Inquiry

This is a detailed inquiry into each system of the body, for example, the cardiovascular system, the respiratory system - that is how well do their heart and lungs function?, the genito urinary system, for women a gynaecological history, for men, the male equivalent asking how well their urinary system works and whether their sexual function is satisfactory, mental health and psychiatric symptoms, and gastrointestinal symptoms

These questions are more intimate and need to be handled much more sensitively than general questions. It is important before asking intimate questions that the patient and doctor trust each other. Although many people can quickly build an illusion of trust, if someone is going to trust you with the honest and intimate details of their bodily functions, they know they can trust you or whoever is asking the questions. Most people still feel that doctors can be trusted, although when people rarely see the same doctor twice, such trust is reasonably being eroded.

Future posts will look at each of these questions so as to explain exactly what information is medically required at each point in the process of making a diagnosis. As a medical student, "taking a history" was a ritual, I hated doing it, and couldn't understand why we were doing it. Now it is the most interesting part of the consultation and I understand what I am looking for and why I am doing it.

Recording a medical history

The questions above give a lot of information, which takes effort, experience and discipline to record accurately and in a way that is useful. At all times it helps for the doctor to make clear what they are thinking about and why they have made their decisions and taken action. We were taught as medical students "No notes, no Defence!"

More often patients are given a handout and asked to tick boxes instead of talking to a doctor.

There are good and bad points to a "tick the box" approach

Good points

"Tick the box" medical histories allow doctors etc to focus on important problems immediately

Useful to screen large numbers of people and record data on a computer.

The recorded data can be manipulated to produce research papers which enable the government and other official bodies to show how much the health of the population is improving year on year

Bad points
Patients tick the wrong box - I have yet to meet anyone who answers "Yes" to the question "Are your bowels normal?", largely because people do not know what is normal bowel function.

"Tick the box" only allow Yes and No answers. It is useful for specific questions, such as "does it hurt everytime you pass urine?" but even this does not allow for the answer "sometimes"

"Tick the box" questions are almost completely useless for broader questions, such as "Are you satisfied with your consultation, town council, or the way the government communicates with you".

"Tick the box" questions do not allow a person to give background to their problem. On the other hand there are only so many hours in the day, and the amount of information that any specific doctor or expert can manage is limited.

Finally, it is easier for people to make a mistake completing a form, compared to answering questions directly. Not because the person is lying but because they may not have understood the form correctly, or because they may be embarrassed or think something is not relevant.

The role of experience

An experienced doctor can take a history quickly because their experience tells them what is important. With time, doctors develop a range of styles and it is important both for doctors to find what type of patients they can help the most. Equally, patients need to find a doctor whom they can trust and whose style suits them.

Traditional diagnosis follows the path

1 - Medical History
2 - Examination, both of the problem area and of the person generally
3 - Differential diagnosis - or list of possible diagnosis
4 - Tests and Investigations - both general and specific tests
and finally
5 - The Diagnosis, that is what has caused the problem
6 - Management plan, this includes specific treatment and general plan of how best to manage this person's medical problems

Nowadays tests and investigations are often more reliable and cheaper than doctors. It is often quicker and more efficient to go straight to the tests and come back and ask further questions depending on the results of the tests.

Even so, the pathway

History -> Examination -> Differential Diagnoses -> Tests and Investigations -> Diagnosis

remains firmly embedded in medical culture. This pathway was started by Galen, over 1,500 years ago and it remains a useful way to organise medical information.

However it cannot be easily computerised! because at each step there are mental processes going on which cannot easily be recorded on a computer. I find written notes more useful than notes on a computer - because I see a page of medical notes as a "picture" which tells me about the doctors' state of mind, their reaction to the patient, as well as the patients responses.

If you are familiar with a doctor's style, it is possible to understand what they meant, where their concerns were and how best to deal with a particular patient. This is harder if not impossible with computerised records. Personally I prefer hand written notes, scanned into a computer at the end of the consultation.

This has been a long post, well done if you have reached the end! no one said studying medicine was easy, but I hope it can also be fun

Copyright (c) Dr. Liz Miller

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