CHAPTER 2

The Patient's History

Taking a history from a patient is the single most important interaction that occurs between doctor and patient. The history is a description of the events and conditions that led to the patient feeling sick and seeking medical assistance.

It includes the condition for which the patient may have come to the doctor, as well as any previous illnesses or medical conditions that may be relevant to the present problem. It is the history that gives the most useful information for the doctor and gives the best clue of what is troubling the patient. In fact, the history is so important that correctly obtaining and recording it is an art in itself. It is not just asking a series of questions, but also recognizing subtleties such as the patient's demeanor, which may reveal unspoken concerns.

When certain disease processes are suspected, doctors are taught to ask relevant questions in a certain order and manner. This order and manner standardizes the recording of the history which allows for easier and more consistent communication between doctors.

For example, the history is often recorded in the following manner:

Chief Complaint: this is the main concern that troubles the patient and is usually stated in the patient's own words.

History of Present Illness: this records the chronological order of the patient's symptoms and complaints as the patient remembers them. This should begin with the first symptom or disturbance that was noticed and the day and time when it occurred. This should be followed by a story of all that has happened in the mean time, up to and including the day of the appointment to see the doctor.

Past Medical and Surgical History: this should include all significant past medical information that the patient provides as well as any surgery that has been performed and also if there were any complications during the surgical procedures.

Medications: this should include all medicines being taken by the patient at present, including non-prescription drugs. All drugs taken in the last six months should also be included.

Allergies: this should include all drug allergies and previous drug reactions (including exactly what reaction occurred) as well as any known food allergies.

Social History: this part of the patient's history includes the patient's profession, marital status, living arrangements, and whether or not the patient smokes, consumes alcohol, coffee, or uses illegal drugs. It is also important to question everyone regarding risk factors for contracting diseases such as hepatitis (inflammation of the liver) and Human Immunodeficiency Virus (HIV, the virus that causes AIDS), as well as other sexually transmitted diseases (STDs).

Review of the Body's Systems: this is a mental checklist that a doctor keeps in mind and reviews with the patient. It contains several questions that are related to each major organ system of the body and allows a quick assessment of the overall health and well-being of a patient. For example, in reviewing the pulmonary system (lungs), a doctor might ask if the patient has been exposed to tuberculosis or had other lung diseases such as asthma. Many of the questions in a complete review of the body's systems are good for screening about diseases that may have gone unnoticed by the patient.

This recorded list completes a thorough history. Obviously, such a thorough history is not taken every time a patient comes to the doctor, but complete histories are always recommended the first time a patient is seen by a new doctor or whenever a patient is being admitted to the hospital. When a doctor sees a patient for a relatively uncomplicated problem, it is often not necessary to be so complete. The chief complaint and history of the current illness are usually sufficient.

1. The Importance of the Physical Exam: Second in importance only to taking a history from the patient is the physician's examination of the patient. Simply by looking at a person a skilled physician will often be able to quickly assess how sick the patient really is, and, after completing a thorough physical examination, the doctor should have a good idea about what the diagnosis is. In fact, if the history and physical examination does not leave the doctor with a pretty good idea about what is going on, it is often unlikely that additional expensive laboratory tests and diagnostic studies will be of much use.
   
   Conducting the physical examination is much like taking the history. Doctors are required to learn very detailed ways of examining the body and to know the difference between what is normal and what is not normal. The physical examination is conducted in a particular order and each major organ system is examined separately. Most doctors prefer to use the same order in examining each patient so that no important parts of the exam are left out. The order most often followed goes from head to foot.
   
   The physical examination itself will not be discussed any further at this point since it is the subject of the rest of the book, but suffice it to say that a doctor needs to examine each patient carefully and thoroughly on each visit. Remember, when a doctor sees one of his or her regular patients for an uncomplicated and common problem (like a cold), it may not be necessary to conduct a complete physical examination each time. The doctor may choose to make the examination shorter and perform only those parts that are relevant to the patient's complaint at that time.
2. The Doctor's Methods: When performing the physical exam, there are several methods of observation which doctors have been trained to use in a particular order. These methods involve the use of the doctor's eyes, ears, and sense of touch. Each of these methods provides different types of information, all of which are useful in determining what the problem is. For each of these, a doctor must know what is normal, what is abnormal, and learn to judge what might be wrong when abnormal findings are noticed.

1. Looking (Inspection): One of the most valuable tools that a doctor has is simply looking at the patient. A doctor's eyes provide him or her with a wealth of information which cannot be gained in any other way. As you know, doctors are often unwilling to treat people "over the phone" and the reason for this is a good one -- without seeing the patient, much less information can be gathered about the patient's condition.
   
   Doctors are taught to carefully inspect the patient's body. The obvious places that need to be seen are the skin, the hair, and the nails -- each can reveal clues as to the cause or presence of certain disease processes. A doctor must also, at certain times, carefully inspect each of the openings to the body, such as the mouth, ears or anus. The observation skills of a doctor are important; for example, when a doctor is examining the chest and lungs of a patient, it will be important to observe the movements of the chest wall during breathing and to see which of the muscles for breathing the patient is using. It is also important to observe whether or not the chest wall is symmetrical and moves equally on both sides while breathing.
   
   Finally, and probably the most important observation that the doctor makes is the overall appearance and condition of a patient. People, whether they know it or not, reveal a great deal about themselves just by the way they dress and groom and by the way they behave in certain situations (for example: sitting, talking, walking). Doctors are trained to pick up on these clues and to use each observation to form a more accurate view of the patient. Usually, an experienced doctor is able to accurately assess how sick a person really is just by observing them for a few minutes. This overall assessment is an art which is not only perfected through years of experience, but is essential to good clinical judgement. The next time you visit your doctor, remember that by the time you have finished telling him or her what is wrong, she or he has not only been listening to you, but has also been gathering additional information by observing even the finest details about your appearance and the way your body looks.
2. Listening (Auscultation): Listening is probably the second most valuable tool of examination that the doctor uses. If you consider how important listening to the patient's complaint and history is, then listening is, by far, the most important tool which the doctor has. But here, we are referring especially to the type of listening that doctors call "auscultation". Doctors use stethoscopes on a daily basis to listen to the body's internal organs. A stethoscope is the instrument which the doctor places in his ears while placing the other end on a part of the body to listen. What cannot be seen can often be heard: so doctors spend much time at the end of a stethoscope listening to what is going on inside. Most of us know that doctors use stethoscopes to listen to the heart to hear if it is beating normally and whether there are any abnormal sounds present. Many of us have probably had a doctor put a stethoscope to our chest and ask us to breathe deeply. Here, the doctor is listening to the lungs. These two uses of the stethoscope are invaluable to the doctor in making an assessment and have never been replaced by any modern technology or test.
   
   Other uses of the stethoscope involve listening over certain blood vessels in the head, neck, abdomen and groin to see if there are any abnormal "swooshing" sounds which indicate that blood is flowing unevenly around diseased arteries or veins. Doctors also frequently listen to the abdomen to hear what sounds the intestines are making (bowel sounds). We have all heard our stomachs grumble from time to time, but actually our stomachs and intestines are constantly moving (called peristalsis) and making faint noises that we usually cannot hear. Doctors use these sounds to help determine if the intestines are blocked, irritated, or moving much faster or slower than usual. If you put your ear to someone's stomach and listen carefully for about 30 seconds, you will hear noises which are probably caused by the normal movement of the intestines.
3. Feeling (Palpation): There are many sayings about the doctor's hands which emphasize the importance of touch in the diagnostic and healing process. What cannot be seen or heard can often be felt, and it is for this reason that a doctor's fingers and hands are of such use to him or her. Doctors use their sense of touch daily, especially in examining the head and neck, the heart, the chest and lungs, and the abdomen. In addition, the hands are often used to help examine the arms and legs, the sex organs, and even the inside of the mouth or rectum.
   
   The hands are often used in combination with the visual inspection which the doctor does. In fact, almost everything that appears abnormal requires an examination by palpation because it will often feel abnormal as well. For example, if the doctor sees an unusual red spot in the mouth of a person being examined, the next step is to feel for consistency (how hard or soft it is). This will give clues that help the doctor to decide whether the spot is a tumor (abnormal growth) or just an irritated area and whether further tests are needed.
   
   In general, doctors should carefully palpate all abnormal growths and try to determine three things: (1) whether the tumor is soft, firm, or very hard; (2) whether the tumor is solid, fluid-filled, or hollow (cystic) (3) whether the tumor is attached to the tissue below it, or whether it moves freely.
   
   Feeling can sometimes be uncomfortable for the patient. When a doctor conducts an examination which requires palpation, remember that this palpation is an important part of the information being gathered. By taking the time to feel carefully, a doctor is providing you with the best care and trying to avoid expensive and unnecessary tests and procedures.
4. Tapping (Percussion): Tapping (or percussing) is done less today than in years past because today we have technology available which provides much of the same information that tapping provided to doctors many years ago but with much more accuracy. By tapping on or over an organ, a doctor is trying to determine the relative similarity of the organ or tissue being percussed as compared to the organs of other patients. Percussion is done in a fairly specific manner: the middle finger of one hand is placed over the area being examined while the middle and index fingers of the other hand are used to tap firmly several times. The sounds produced are described as being either dull, flat, or tympanic. Dull is the sound made when tapping over a relatively hollow organ such as the lungs or intestines. Flat is the sound heard when tapping over a solid organ such as the liver or kidneys. Try tapping on someone's back. Start up at one of the lungs and see if you can hear a dull sound, then move downward as you continue tapping and see if you can tell where the sound becomes flat. If you can, you have identified where the lung ends. If, for example, the bottom part of the lung was partially filled with fluid (as in pneumonia) you might hear the flat sound higher up in the chest than normal and suspect that there must be an abnormal collection of fluid there. Tympanitic percussion is the sound that you hear over areas where there is air which is under pressure. This is normally not heard, but it may be present when the abdomen is abnormally distended with air, or when air has collected under pressure inside the chest wall but outside of the lungs.
   
   Percussion is used primarily in examining the lungs and abdomen. It is generally useful for determining the size and amount of expansion of the lungs as well as whether or not there are collections of fluid around the lungs. Percussion is most useful during the abdominal exam when estimating the size of the liver and spleen.

Chapter 3