Tuesday, 5 January 2010

Medical History

The Medical History is key to diagnosis
I remember ageing professors telling me this as a student and thinking - what do they know? I just want to get on and scan the patient. However scans, tests and investigations only tell half the story. They tell you what is going on at this moment in time, but they don't tell you how it happened.

If you imagine the patient who comes to see you in distress as a car crash, looking at the car crash does not tell you what happened to the car and its occupants. To know this, you need the story. Just looking at the car crash, is like just doing tests, investigations and scans. Yes you need to look at the car crash but you also need to know the story that goes with it, otherwise it is just another bent car.
With the story, you know where to look for damage and how best to straighten it out. For example, the car may look fine but have a bent chassis. But unless you know that the car was dropped 30 foot from the top of a building, you are unlikely to look at the chassis.
For that reason, history is important. Patients should be wary of a doctor who does not ask questions, listen to the answers and examine them to see the damage.

A good medical history means you walk in the patients shoes and understand what has happened to them, from a medical viewpoint. There is no need to include what your aunt's cat died of! The story explains how the patient came to be in the state they are. The story assumes a rational explanation for what why the patietn feels the way they do. Without the story, symptoms mean very little, you cannot find the cause of the problem and it is difficult to straighten the patient out, without causing further damage.

For example

[All patients are assumed to be 35 year old men, unless there are medical points that relate to age or gender]

Mr Xa came to see me three months after an operation for carpal tunnel syndrome (compression of the nerve to the hand at the wrist). The surgeon had listened briefly to his complaints of numbness and tingling in the fingers and three days later operated to relieve pressure on the nerve at the wrist.

The surgeon cuts the white band crossing the nerve, which is the carpal tunnel ligament. This releases any pressure there may  be on the nerve at the wrist.  

This begs the question - what has happened to the patient that there is pressure on the nerve because at the very least you want to stop it happening again. 

The operation was a disaster. Mr Xa had a painful stiff hand, with barely any movement at the wrist. The patient was right handed and could not even help their children tie their shoe laces.

The history was key. Before the symptoms started Mr Xa had had an extremely busy period at work, with a lot of extra typing and pressure. This was not a simple case of carpal tunnel syndrome - which typically comes on gradually, worse at night and associated with pregnancy and increasing age. This was a case of Work related Upper Limb disorder which needed physiotherapy to help Mr X change the way he typed (imagine you are sitting down a Grand Piano and playing Rachmaninov's fifth!)

Click here to read more about Work Related Upper Limb Disorder and Carpal Tunnel Syndrome

I also knew from the circumstances of his visit what kind of a person he was. He had battled cancelled trains and freezing cold to keep his appointment. This person did not make up symptoms, nor to complain lightly. 

This is a typical surgical scar from carpal tunnel syndrome.

I wish I had taken a picture of Mr X's hand because it showed a "tethered scar" and the muscles in his palm had wasted, the scar was pulling badly and was tender. (this is the link for the picture)

In many cases massage helps the scar heal. In Mr Xa's case, the scar looked so badly tethered that I believe Mr Xa needed a specialist hand surgeon's opinion with a view to revising the scar and releasing the tethering. His symptoms were getting worse not better.

A good medical history would have told the surgeon, who does "operations for money" privately, that this was not just Carpal Tunnel Syndrome, but part of a Work related Upper Limb disorder. It did not need surgery, or at best, only as a last resort. Mr Xa needed a Work Place Assessment, physiotherapy - anything but quick surgery.

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Copyright (c) Dr. Liz Miller


  1. Another case of treating the immediate symptom and not the patient !
    I relate the case of a young man I employ who had a car accident where he was thrown out of the open top and the vehicle rolled on his left leg. Doctor at the scene told him it was just bruised but told him to go A&E once he was home. He did so with same result. A week later once his leg had swollen, turned blue and was very painfull he was urged to return and was nearly turned away again except for his father, my friend insisting a second opinion. A wordly wise elderly Consultant took one look, ordered an immediate X-ray and found no pulse at the ankle. He was rushed on blue lights to a vascular unit and the pulse was reinstated but he then had a further week of waiting that culminated, when he at last saw an orthpaedic Consultant, in an emergency operation to repair his fratured tibia and reattach his torn ligaments. The surgoen openly stated that a further 24 hrs could have lost him the leg. He had then to wait a further 2 months for a second procedure for which I had to pay, to jump the queue which otherwise would have been a further 6 weeks. He now has a painfull and rigorous physio regime to follow to restore function. It is likely the delays have caused this to be much longer than would otherwise have been the case. Knowing as I do, much about leg trauma that it is unlikely he will recover his previous level of function.
    What a travesty ! It's all basic stuff; possible fracture, get X-ray, check blood supply, treat accordingly and yes he told them repeatedly his leg ahd a car roll on it. The history would have told them that, but they were too distracted by their own knowledge to do the proper thing and treat the patient. Then they failed to give priority to his need to get back to work as a young man with a family to support.
    This is a sad reflection on an NHS costing billions to run that cannot achieve even a basic level of care.

  2. This is exactly right - the purpose of the medical history is to find out what has happened. To understand fully the nature of the injury. Patients don't make this stuff up!

    There are guidelines that state unless bruising and swelling are present, then you should not Xray an ankle. The problem with following guidelines is they can stop people thinking. Independent professionals must use their knowledge, experience and wisdom to judge when to follow guidelines and when to step outside the rules.

    In peace time, unless you are in the Armed Forces, mindlessly obeying orders (following guidelines) can be a disaster!

    Sherlock Holmes is, of course, a great inspiration should anyone doubt where accurate observation and reasoned analysis can lead you!

    This case is tragic. At the very least, a letter of complaint is in order, whether or not you get any further I don't know.