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
http://www.lizmiller.info/
www.moodmapping.com
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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
www.lizmiller.info

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