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Being a doctor is first of all about being able to observe thoroughly and listen well. There needs to be a very good interpersonal relationship between doctor and patient. So a doctor should be able to assess the signs, look for symptoms and arrive at a diagnosis in quite a methodical manner. This is where, taking history helps. It is the beginning of managing and healing patients, devoid of any social, cultural or ethnical variations. It helps the clinician to understand the patient’s state of mind and analyse the signs. Firstly, there should be a friendly greeting between both parties. The clinician should quickly assess a few important things like the mannerism, hearing, way of walking, mood, speech, posture and any obvious abnormalities in the patient during the first few minutes of the meeting. Then we can proceed to take history.
Maintaining good eye contact is crucial. After explaining the patient that we would be following an order by asking some questions, we can cover up the general data collection which includes date of birth, age, occupational history, social status, past medical history, family history, smoking habits and alcohol consumption. Tracking the history along a time frame provides a descriptive picture of the patient’s current state. This first part of history is very important as it sets the foundation for an effective diagnosis. After the basic rituals, the patient should be encouraged to explain why he or she has now come for the consultation, on their own pace without any interruption from us, or any accompanying person. Because even if interrupted a bit, the patient will not be able to convey his or her thoughts effectively and completely. Patients who present in a well-structured manner are in minority. So the clinician should prompt the person by asking questions at the right time without offending them.
Also the clinician should not miss out important clinical clues that the patient may be showing during the conversation. And we should converse using terms that can be easily grasped by the patient, instead of complex clinical terms. Open-ended questions from the clinician make the patients subconsciously to approve of the clinician and want to enthusiastically talk about their issues which may help us to identify what is important to the patient. On the other hand, direct questions will shut them down, making them not share their situation properly. This approach is ‘disease – centred’. The doctor should moderate his need to arrive at the diagnosis and the patient’s experiences and feelings. The clinician should be able to relate the severity of the symptoms to the personal life of the patient. What may seem critical in one person may not be that much of a big deal in another one.
Also the degree of pain perceived by each individual is different. The pain scale assessment is helpful to manage the disease. The patient can be asked to rate the feeling of pain on a scale of 10 and assessed accordingly. Most women rate the labour pain as 10. And although the patient may not be able to put things in an order, the clinician should make note of details, even if out of the blue and attend that later. Each clinician may have their own customized outline for taking history at different situations. Nevertheless it follows a common pattern as follows:- Name, age, occupation, place of birth, any other forms of identity, problem presented, past medical history, specific past medical history, history of the main problem presented, family history, occupational history, smoking, alcohol, allergies, drug and treatment history and direct questions about bodily systems uncovered. Generally diseases have malfunctioning of multiple bodily systems. So a complete assessment should consist of regards to all the bodily systems instead of only the system concerned with the patient’s perception as the problematic zone.
Various systems can be analysed by asking questions relevant to the following aspects:
Analysing the patient’s sayings at the back of the mind without putting them off at face is elementary in taking history. Certain areas need careful clarification. Pain is one such area. It usually confuses the clinicians. So the site, radiation, character, severity, time course, factors aggravating the pain, factors relieving it and symptoms associated can be inquired to precisely pin point the problem related to the complaint. Asking patients directly about the medications they took is not so effective. Instead, encouraging them to realize and remember anything they took by constantly and carefully asking about certain drugs that may have interfered, is beneficial in taking drug history. Similarly taking family history can be tricky as well. Inquiring about any illness that runs in their family, their family tree and occurrence of same problem previously to others in the family can be helpful. A person’s occupation also affects the present condition, especially in non- organic problems induced by exposure to various environmental elements. Alcohol poses major health risks. So it is the best to have a measure of the reported amount of alcohol consumed into units of alcohol per week.
The CAGE assessment is a smart approach to record details of the patient’s alcohol habits. C – cut down; A – Angry; G – Guilty; E – Eye- opener. Taking past medical history without completely giving into what the patient expresses is also important so that any misinterpretation of the past medical ailment by the patient or wrong diagnosis by a previous clinician does not affect our present diagnosis. Every patient is unique; so is the experience of taking history in different patients although we follow a common routine most oftenly. Garrulous, angry, or well-informed patients or people who accompany a patient can pose challenges to the clinician. Garrulous patients talk too much giving very less important details and they need to be handled with a well-balanced set of direct and indirect questions. In angry patients, anger maybe a part of symptomatology or due to circumstances or expressed in response to the diagnosis or a treatment. If this attitude is as damaging as breaking off the contact between the two parties, then it is better to suggest a change of doctor to the patient.
Nowadays doctors should provide as much as possible details of the condition of the patient so they wisely choose the best treatment option and take care of themselves post treatment. But clinicians should also be able to handle well-informed patients who are stubborn about certain perceptions and facts they hold. Also the clinician should be able to assess whether it is important for the accompanying person to stay beside the patient or not depending on language difficulties and relationship of that person to the patient. Questions that demand a negative response from the patient are also equally important to exclude certain things and take a proper history. A clinician should also always try to analyse what the patient actually requires from what the patient presents like whether he or she is unable to tolerate on going symptoms or came because somebody else has noticed the same symptoms or is worried about an underlying cause or if their spouse or relatives are worried. Even the history taken by a clinician from the same patient may vary the next time. This makes the process doubtful or unreliable.
So to arrive at a more accurate diagnosis, the history should be re-taken at different times by different people in different ways. This will fill the gaps and provide a bit more clue. Taking history is an art that has to be polished with time, experience, enthusiasm and commitment. Clinicians should always prioritize their patients, respect them, listen to what they say empathetically, explain them in a language that they can understand, update their knowledge and clinical skills from time to time, know their limits and follow the right ethics to facilitate the process of taking history and making it smooth for both parties involved.
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