THE IMPORTANCE OF HISTORY TAKING
A good history and detailed examination form the foundation of medical practice. Whether you are a physician, a surgeon, an emergency medical technician or a first responder; an extensive, precise and accurate initial assessment sets the pace for further care, evaluation and testing. From a clinical standpoint, the decision making of the patient's treatment depends solely on the information gathered during your history and examination. These are also the skills that a medical professional carries with them till the end of their practice. As one garners more experience, you will become faster, more concise and will be able to derive more information out of less questions.
With more and more emphasis being placed on the integration of health care across specialties; the basics of medical knowledge have become irreplaceable. Each of your patients are going to be different, unique individuals– spanning various ages, gender identities, sexualities, socio-economic backgrounds and ethnicities. The essentials of health care: empathy, listening, clinical reasoning and deduction—are skills that will help you to understand the psyche and the state of every patient. History taking and examination is a vital first step in developing a meaningful therapeutic relationship with your patient.
Detailed Assessments versus Problem-focused Assessments
While encountering a patient for the first time, one should make the decision of doing a detailed assessment or a problem-focused assessment. It is also always prudent to make adjustments into your history as you go along; if a patient presents with a fresh wound, you may start with a problem-based approach. But as you take history, you may find out that the patient is diabetic, in which case you may need to go into further detail.
As students of medicine, it is encouraged to do a detailed history. This helps you develop pace and flow, two very important qualities when interviewing a patient. However, the ground reality is very different. As you become interns and residents, you may have to allocate time and resources to your patient based on the urgency of their problem. This equity of health care is what we refer to as triaging: The patient that needs attention the most gets it first. In such situations, a short, focused history is preferred.
Detailed | Problem-focused |
|---|---|
Essential for forming the initial framework of a patients symptoms | Essential for returning patients, emergent patients or follow-up cases |
Provides a baseline for future reference | Saves time in dire situations for quick intervention |
Holistic approach to the patient as an individual | Assessment of only a particular system with respect to the chief symptom |
Writing a Case Sheet
In the era of evidence-based medicine, documentation has become a skill that doctors need to master. A good, crisp case sheet can make the difference in pattern of care; especially in larger hospitals where a patient is treated upon by a team of healthcare professionals. Even in smaller clinics, it is impractical to expect a doctor or a nurse to remember every detail about every patient. Hence, good documentation paves the way for good clinical outcomes.
Unfortunately for the students, like most things in medicine, a universally accepted format for case sheets does not exist. Keep in mind that it is more important to include everything than to nitpick about the order of the information presented. Students are always encouraged to find a format that is comfortable to them and stick to that while taking history, so that they do not miss out on any vital information. The final case sheet can then be tailored to the hospital, clinic or institutions requirement.
Around the world, different countries practice different ways of case sheet writing. However, the one thing that is always common is the S-O-A-P approach.
The subjective: The first part of the case sheet always consists of the subjective history provided by the patient. These include all the information that is given by the patient verbally and more often than not, cannot be verified by the clinician. A patient might tell you that he feels a rat gnawing away in his stomach. This is his subjective way of expressing his discomfort to you. As a clinician, you have no way of confirming this. The subjective part includes the Chief Complaints, History of Presenting Illness, Past, Personal and Family Histories.2
The objective: The objective part of the case sheet includes all the information that is elicited by the doctor which he can verify. This usually means the examination findings and their interpretations. A patient may tell you that his legs have been feeling weak since a month, this is subjective. However, once you test the power in his lower limbs and verify that he cannot move his leg against resistance, it is an objective finding. The objective part usually includes the General Physical Examination and the Systemic Examination.
The assessment: The assessment is the part of the case sheet which consists of the summarization of the subjective and the objective findings. A concise summary with all the positive findings, a preliminary diagnosis and any recent investigations or reports may be included in the assessment portion.
The plan: The plan is the part of the case sheet which outlines the diagnostic and therapeutic interventions that the patient must receive under your care. This includes all the investigations, interventions, procedures and the drug charting that needs to be done. If the patient is admitted in your facility, then it is of utmost importance to include a daily follow-up note. The follow-up note consists of the patient's general condition, relevant examination findings and any changes to their initial plan that may be recommended as per the patient's prognosis.
Though it is rare that doctors will encounter this terminology in India, in several countries, the case sheet itself is known as the SOAP note. As members of a quickly growing global health network, this was added here in an attempt to sensitize the Indian healthcare community towards this format. It is also good to notice that it is not very different from what we follow in India.
Etiquette during History Taking
More often than not, medical professionals are accused of taking their position of respect for granted. This is definitely not an appreciable quality. As doctors, we must hold ourselves to an extremely high standard especially when we deal with patients and their families. It is imperative that we follow all the general rules of social etiquette: dress well, talk empathetically and use respectful language. It is always recommended to introduce yourself to the patient before the interview, state the purpose of the interview and approximately how long it will take. This is also a good time to ask if the patient has any pressing concern which needs immediate attention. Reassure the patient that all the information provided during this interview is completely confidential.
Components of History Taking
Initial Information
The initial information during history taking entails the date and time of evaluation. In situations where several clinicians are handling multiple cases, it may also be prudent to add the name of the evaluating physician. This is exceptionally important in emergency situations where the physician performing the initial assessment needs to be readily available for assistance.
Personal Details
This includes all the details that help us in identifying the patient. A good rule of thumb to follow is name, age, gender identity, occupation and marital status. In a multicultural society like India, the patient's native village or town is also a good point of identification. If the patient is referred from a different center, that can also be entered here.
Source of History and Reliability
The source of history or reliability is usually a must-have in pediatric cases. Though not always necessary, it is a good practice to mention this in adult history taking as well. This is exceptionally useful when the patient himself is poorly oriented or unable to give clear history. It reflects the accuracy of the information in the case sheet.
Chief Complaints
The chief complaint is the immediate, emergent complaint which brings the patient to you. Try to use the patient's own words when writing the chief complaint. Arranging the chief complaints chronologically can also help to streamline your thought process while interpreting your case sheet at a later time.
A point to keep in mind is that more often than not; it is the history-taker's duty to arrange and make sense out of the information. Do not be afraid to ask leading questions to clarify the time and intensity of each symptom. For example, a patient may present with a fluid-filled abdomen as his chief complaint since one month. It may strike as odd to you that the patient noticed his abdomen enlarging for an entire month and decided to come to the hospital on this particular day. However, upon further probing it will be clear that the patient's family brought him to the hospital because he was somnolent since two days.
History of Presenting Illnesses
This column provides the descriptive aspect of the chief complaints. It is a comprehensive, clear and chronological account of the patient's problems. This includes all the details that come with the famous mnemonic OLD-CHART:
- Onset: Sudden, insidious, immediate or emergent.
- Location: Site of the symptom.
- Duration: How long has the symptom been bothering the patient?
- Character: Any descriptive words that the patient may use to help narrow down the cause of his symptom. A common example is seen in pain, where patients can describe it as stabbing, crushing, burning, dull-aching, etc.
- Aggravating factors: Are there any actions that increase the symptom?
- Relieving factors: Are there any actions that reduce the symptom?
As illnesses affect different parts of the body, and many illnesses may be multi-system, it is important to ask about connected symptoms. You need to cover the following areas:
- Respiratory system: Dyspnea, wheeze, cough, sputum, haemoptysis, chest pain
- Cardiovascular system: Chest pain, orthopnea, paroxysmal nocturnal dyspnea, ankle swelling, palpitations and intermittent claudication
- Gastrointestinal system: Abdominal pain, nausea, vomiting, hematemesis, bowel habit, blood P/R, melena
- Urogenital system: Frequency, nocturia, polydypsia, loin pain, hematuria
- Menarche, menopause, cycle, inter-menstrual bleeding, post coital bleeding
- Central nervous system: Headaches, visual disturbances, sleep, hearing, tinnitus, light headedness, blackouts, fits, unsteady gait, weakness and paresthesias
- Musculoskeletal: Myalgia, arthralgia, back pain, joint swelling
- Psychiatric: The mental state examination will be taught more formally in your psychiatric attachment. Remember, depression is common and may often co-exist with physical ill health.
The best way to round out a good history of presenting illness note is to include relevant positive history and relevant negative history. There are several commonly encountered cases which are diagnoses of exclusions. Noting down these “points of exclusion” (often called negative history in clinical practice) is the mark of a good clinician.
Past (Medical or Surgical) History
Broadly, the past medical or surgical history can be divided into three categories: childhood illnesses, adult illnesses and screening tests. Childhood illnesses are usually not mentioned in the past history, unless there is a significant residual morbidity or chronicity of the condition.
In order to give a complete picture of the patient's health status, adult past history can be divided into medical, surgical, obstetric/gynecological and psychiatric. In each of these categories, always focus on the past illnesses which might give a clue to the patient's current ailment. A great rule of thumb to follow is disease-duration-drug, i.e., name of the ailment, followed by duration, and then the therapeutic intervention that was used.
In elderly patients, screening tests are done to rule out certain predictable age-dependent conditions. The results of these screening tests can be mentioned in the past history. This saves both time and resources for the treating clinician as these tests need not be repeated again.
Personal History
In personal history, we comment on the person's temperament. An additional note on the patient's appetite, sleep, bowel and bladder habits is encouraged, especially if there is any variation from his normal patterns. If the patient is sexually active, the clinician should elicit history about his sexual practices and evaluate whether the patient engages in high risk sexual behavior.
Lastly, it is always prudent to ask the patient about his addictions and allergies. Tobacco usage, drug addictions, alcohol consumption are all commonly encountered addictions which can alter or change the course of both the patient's condition and your treatment. When eliciting such history, it is always important to be open-minded and to make the patient feel safe enough to share that information with you.
A common situation that can be encountered is family members and patient bystanders asking prying questions about the patient's addictions, sexuality or gender identity. Similarly, an employer or manager may contact you in order to gain information about the patient's condition. Handling these situations tactfully is of paramount importance. Trust is the foundation of a good doctor-patient relationship. It is therefore extremely necessary to keep the information furnished in the personal history between the treating doctor and his patient. Learning to intersperse questions about personal details within regular history taking is very helpful to establish the rapport with the patient.
Family History
Under family history, outline the present or past health conditions of any immediate family members. These include but are not limited to hypertension, cardiovascular disease, diabetes, cancer, autoimmune conditions and untimely deaths. If the patient has a known genetically transmitted disease, a pedigree chart may also be added.
Review of Systems
Review of systems is an additional column that can be added when a clinician is evaluating a patient for a routine health checkup. It is very similar to the “head-to-toe” examination part except that questions are asked pertaining to the patient's general health status. Go from the head to the toe of the patient, asking questions that may be significant to his quality of life such as “How is your vision?” and “How is your hearing?” and “Do you have any skin rashes?”
Do keep in mind that when a patient presents with a chief complaint, the history and your line of questions will be streamlined to include all the details that contribute to his current ailment. As such, a review of systems is not necessary in those situations since all those points would have been covered previously.
Examination of the Patient
Setting up the Examination
Before you examine the patient, take your time and prepare yourself for the sequence in which you wish to go about. Approach the patient with calmness and be as professional as one can be. Introduce yourself as a student, ask if they have any urgent discomfort which needs attending and then request the patient to let you examine them.
Once the patient has agreed to the examination, it is both your responsibility and in your best interest to make the patient feel as comfortable as possible. It is very common for patients to feel vulnerable and uneasy during examination. This may be in anticipation of pain or the uncertainty of what the doctor may find. But an uncomfortable patient begets an uncomfortable doctor. Adjust the height of the bed, the lighting and your stance based on the patient's requirement. Take extra steps to protect the patient's modesty. The extra work done in preparation tells a patient that you are genuinely concerned about their health and the patients will show their appreciation in the form of cooperation.4
“A doctor is one of the only jobs where you can ask someone to take off their clothes and they will do it without question”. This trust is a unique aspect of the doctor-patient relationship which is your responsibility to safeguard. Close the doors, place blinds or partitions, ask the patient if they want anyone in the room to leave and comply with their requests. Wash and warm your hands before you touch the patient.
During the Examination
A seasoned clinician completes the physical examination in a quick, thorough and gentle manner. He notices the body language and the mannerisms of the patient, empathizes with his condition and provides reassurance in the best way possible. It is very normal to forget a particular part of the examination during the process. Go back to the patient and request his permission to do the parts that you missed out.
During examination, it might take time for you, as a student, to appreciate certain findings. No clinician expects a second or third year student to properly diagnose a heart murmur. As such, if you find yourself spending some extra time trying to learn the nature of a finding, it is always a good practice to inform the patient that you are doing so because of your desire to learn and not because there is something wrong with them.
Another common happening in the wards is the patient or their bystanders asking you to interpret your findings to them. In the eyes of the patient, you are another doctor and they can use your knowledge as a “secondary opinion”. As an inexperienced doctor who is not the patient's primary clinician, you may find yourself in a situation trying to give information that you yourself are unsure of. Be respectful and mindful of the patient bystanders concerns, but also be gracious enough to accept what you know and do not know. As a student, it is more fruitful to share findings with your peers and your professors. Discuss the diagnosis and plan with them so that you can be an active part of the treating team.
After the Examination
Write down your findings in a streamlined and systemic manner. Go through your pre-examination list and fill in any gaps in your case sheet. It is also a good practice to thank the patient for his cooperation and to offer them some positive reassurance.
Protecting yourself: Hygiene for the healthcare worker.
In a hospital, your chances of being cured of a disease and your chances of contracting a disease are both extremely high. Healthcare workers are constantly at the risk of life-threatening illnesses because of the close proximity with which they work with sick patients. Even after countless years of research, effort and studies, hospital infections are an occupational hazard that we may never be able to completely eliminate due to the nature of our jobs. Hence, it is always important for a doctor to adopt certain practices to put their health and safety first.
Universal precautions are a set of guidelines by the CDC that have been recommended in an effort to reduce the risk of parenteral, mucous membrane and non-contact exposure of healthcare workers to harmful blood-borne pathogens. The following body fluids are considered potentially harmful: blood, blood products, semen, vaginal secretions, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid and amniotic fluid. All healthcare workers must be cautious to prevent injury through needle-stick and exposure to these hazards. Further, with the rise of Sars-Cov-2 or the coronavirus, it is now more important than ever to maintain a strict level of hand and hospital hygiene.
Patient-Doctor Privilege
As a doctor, it is a very natural and expected part of your profession to ask extremely embarrassing, secretive and personal information. Your clinical reasoning relies entirely upon your ability to convince a patient that they can trust you with the most intimate parts of their lives; information which they have perhaps not shared with anyone else. It is very important for you, as a doctor, to be receptive to such information and to accept it with an open mind. These may include sensitive information pertaining to their daily habits, drug addictions, sexual activity, sexuality, gender identity, criminal activity or prior illnesses. The conversation between a doctor and a patient is not the place for prejudice or judgment, especially if it is against your cultural and religious beliefs. If you feel like you cannot get past your inhibition when dealing with a patient, be respectful and ask a peer or colleague to take over.5
Furthermore, if a patient provides you with such information, it is your duty to keep that information a secret. This is exceptionally important when a patient bystander, distant relative or employer asks you for details pertaining to the patient's condition. In the western countries, it is illegal for you to provide confidential details even to the next of kin without the patient's consent. However, in the Indian scenarios, due to the close-knit nature of families and communities, privacy is often taken for granted. As a doctor, it is your responsibility to uphold the patient's dignity.
Always ask for the patient's consent before sharing sensitive information to their family, friends or employers. When the patients are teenagers or under-aged, ask the patient if they need some time to speak alone away from their parents. It is always a good practice to ask the patient bystanders to leave during the examination process. This is the ideal time to elicit sensitive history from the patient.6
PREREQUISITES FOR PRACTICAL EXAMINATION
Clinical skills, such as the physical examination remain an important instrument in the physician's armamentarium and assessment of these skills form the basis of the final clinical examination. Every student appearing for the examination will be under a lot of stress, which even though justifiable becomes detrimental for the performance of the student. Here are some suggestions:
- The first and foremost is preparation. Try to have a timetable and cover all important cases well in advance. You have a set of cases that are usually kept for the examination and most of the questions asked are also predictable. Do not keep any important things pending to read on the day prior to examination.
- Sleep is of utmost importance on the day prior to the examination. You need to sleep for a minimum 4–5 hours on the day prior to the examination. The curriculum being vast, compromising a few hours of sleep would do more harm than good.
- Have a light breakfast. Hypoglycemia hampers your thought process, delays your reaction time and severely impairs the performance. Agreed that the feel of examination may be like undergoing a surgery, but nil per oral (NPO) status is not needed.
- Attire is important. Be neatly groomed and dressed. Wear a clean apron with a number badge.
- Carry all your instruments.
- Write a detailed case sheet. Examine each case thoroughly. Never rely on expert's diagnosis. Make your own diagnosis. Always justify it with your own views.
- Stick to the set time limits. Do not waste time.
- Be gentle to the patient when you examine. The more cooperative the patient is, the better will be your performance. Always take the permission of the patient and explain before examining and do not forget to thank them at the end.
- Never forget to wish the examiner good morning/evening. If you do not know an answer, say sorry! (Most of the examiners will change the question or give you a clue). Always finish with a thank you!
- Confidence is of paramount importance. Practice presenting cases without referring to the case sheet. Be clear in the order of presentation, both history and examination. Stress on relevant important findings. To be expressive is important, but not over expressive. Eye contact is essential. Answer clearly and to the point. Do not speak about rare causes. When demonstrating signs, do it clearly.
- Most importantly, have faith in yourself and your preparation. You shall succeed.
CHECKLIST FOR PRACTICAL EXAMINATION
- Clean apron with roll number tag
- Hall ticket
- Stationery
- Stethoscope with a bell
- Knee hammer
- Key (to test plantar reflex, stereognosis)
- Wristwatch with seconds needle
- Measuring tape
- Two scales
- Pins
- Glass slides
- Two small boxes for testing smell (soap and coffee)
- Four boxes for testing taste (sugar, salt, bitter and sour)
- Four cards with the words “sweet”, “sour”, “bitter” and “salt” written on them.
- Snellen's chart
- Ishihara's chart
- Cotton
- Tuning forks (128 Hz and 512 Hz)
- Divider
- Ophthalmoscope with full batteries
- Torch with full batteries
- Thermometer
- Tongue depressor
- Cotton wick/throat swab stick—gag reflex
- Two test tubes preferably aluminum for temperature testing (glass test tubes may be used if aluminium test tubes are not available)
- Pulse oximeter (not mandatory)
- Gloves
- Mask
FORMAT OF CLINICAL EXAMINATION
The general format of cases in the examination is as follows:
Type of case | Time given for examination of patient | Time for clinical viva | Marks |
|---|---|---|---|
Long | 45–60 min detailed case sheet needed | 15–20 min | 50/40 marks |
Short | 15 min | 7–10 min | 20 marks |
Semilong | 15 min | 7–10 min | 20 marks |
Spotters | 1 min | 2–3 min | 5 marks each |
Charts (laboratory data, clinical) | 1 min | 2–3 min | 5 marks each |
OSCE (any clinical sign) | 5 min | 5 min— observed | 5–10 marks each |
Viva voce | 4 table vivas, each carrying 5 marks, each timed for 5 minutes Topic—X-rays, ECG, instruments, drugs, charts, general viva | ||
COMMON EXAMINATION CASES
Respiratory system | |
|---|---|
Long case | Short case |
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Cardiovascular system | |
|---|---|
Long case | Short case |
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Gastrointestinal system | |
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Long case | Short case |
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Nervous system | |
|---|---|
Long case | Short case |
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Semi-long cases/therapeutic cases | |
|---|---|
Renal |
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Rheumatology |
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Endocrine |
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Hematology |
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General |
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