History Taking Through Heart

I was trying out the Daily Rounds app on Android and came across a case description "Unilateral limb swelling in a 51 year old lady. No comorbidities. KFT normal. How to proceed to diagnosis?"

This reminded me about how clueless I was about history taking during medical school. I think if I've learnt anything well by now, it is on how to take a detailed history. And looking at this question made me realize how much that helps me in coming to diagnoses. So here are some super simple tips to take detailed history while building a personal connection - which doesn't require any knowledge of pathology or medicine.

Start with the person

You might have learnt that asking for name is the way to build rapport. But that's a lie. Asking for name is so you can write it in your notes. If you want to build rapport, talk to the person in front of you (and not the patient). I've found that the question "have you had breakfast?" in their language (adjusted for the time of the day) is a super simple way to build rapport. And the reason is that this is what regular people usually ask each other casually when they are on the road.

This lets the patient relax and breathe free. With just one sentence you're telling them that you're a human like them and you respect them like another human. That their sickness is secondary to their human existence.

Move to the patient

Now you let them talk. Unless they're experienced, they will not have arranged in their mind what to tell you. For the first few minutes, let the patient speak without interruption. Let them figure out what their problem is while they're talking to you. Use only head nods, and "hmm" to communicate that you're listening. Make sure you're looking at the patient and don't give off an impression that you're not listening.

If the patient stops after describing just one symptom, just give it back to them as a question. 

"I have headache" Long pause.

"Headache?" with a puzzled, but caring face.

Awkward long pause.

"Yes. The right side of my head feels like it is exploding, since yesterday"

"Hmm. Tell me."

"That's it. I'm unable to get up from bed."

Pause.

"And everything becomes dim and dark to see"

...

Once you let the patient figure out that you're there to listen, they'll tell you everything you need to know without asking.

Get the timeline right

Once you know the presenting complaints, it's time to arrange them in the right order with dates. Ask specifically about when they were completely alright. Get as specific a date as possible about when things started. (The longer people have been having symptoms, the less specific you can get. But still.) Retrace the course of their illness from day 1 of symptom. Find out the order of symptoms. Find out the progression of illness. Find out what they've been doing (I betcha they've gone to another doctor already or tried something). Find out why they decided to come to you. (That needs a point of its own)

Find out why they came to you

There's a reason the patient has come to you. This is not the same as the chief complaints. Some are scared and are coming for reassurance. Some are tired and want relief. Some have been referred by someone else for a specific reason. Confirm the reason why the patient has come to you. This becomes super helpful when you're figuring out the management. As a bonus, it allows you to address the exact concern the patient has.

Let them know you are on their side

This is the turning point in the consultation. You have heard the patient. You have understood their concern. You now win their trust by telling them that you are there to help them. And then you start talking a bit.

Ask your questions

You should have held the questions in your mind till now. The time to start asking them is now. Start with clarification of symptoms. Ask for negative history. Ask about comorbidities. Ask about past history, family history, socioeconomic history, and so on.

Asking negative history

For asking specific negative history, you'll need to know about diseases. But there is a way to avoid that pre-requisite. Go from head to toe. (You'll need some anatomy, physiology knowledge). 

 

Look at the head and ask about all the organs that you see. Bonus point if you touch their head when talking about the head. (But that's not always appropriate. Use your gut sense). Ask how their sight has been, how their hearing, taste, smell has been. Have they had cough, cold, throat ache? Then look underneath the skull. How has their memory, sleep, thoughts, etc been? (There is hair, tongue, teeth, and so many finer details I've skipped for brevity. You will have to be careful not to ask too many questions too. This is just an algorithm to generate questions mindlessly. Filter those questions by applying your mind.)

Then go down to the chest. There are lungs, heart, esophagus, neck + thyroid. Ask questions about things that could go wrong there. Then the upper limbs.

Then the abdomen/pelvis. These have so many organs. Liver, spleen, kidneys, adrenals, pancreas (endocrine, especially), and the alimentary tract per se. And depending on your patient, uterus, ovaries, so on. It is easy to forget the back with spinal cord.

Then there are genitals and lower limbs.

 

Then there are some general things like fever, bodyache which don't really fit into this organ by organ thing but they usually come up somewhere in between.

This is only one way to generate questions. Depending on how much differential diagnoses you have in your mind based on chief complaints, you might be able to come up with questions without using this algorithm.

Other histories

The best way to take history like past history, socioeconomic history, etc is to imagine yourself in the patient's life. What is this person? Where are they coming from? Where are they going? What do they do in their daily life? How's their life like? What's their family? What do they do after getting up from their bed till they go back to bed? Do they take some medicines? Do they go to hospitals? Do they drive a tractor? Do they work in three houses?

This part of the history should ideally go like a conversation that has become really interesting and you "want to know everything about" the other person. But often we don't have a lot of time to spend here. And it is inappropriate to spend a lot of time here. Just get a fair sense of each slice of your patient's life.

What has their relationship with themselves been? Do they treat their body and mind well? Do they consume alcohol or use tobacco? Do they eat well? Do they exercise? Do they work too hard?

 

What has their relationship with their family been. Who is their caretaker? Could someone in the family be giving rise to their sickness? What's the family dynamics?

What has their relationship with the society been. Are they generally happy with life? What do they do in their life?

What has their relationship with the medical system been. Do they have any diagnoses? Do they have any other doctors? How many times have they had significant medical care in the past and why?

Summarize your idea of pressing issues back to the patient

By this time you have gone far away from chief complaints and to bring the attention (the patient's and yours) back to it, you can summarize what you think is the problem the patient is going through to them. And then after you get the patient's confirmation you can proceed to examination.

Advantages and disadvantages of this method

What I've described here, like other ways of history taking, is just a template. This one is focused on getting a whole picture of a patient's life without using a lot of knowledge about diseases. Another advantage is that you can build a lot of empathy. But it is also very time consuming. It often takes 45 minutes to an hour just with the history if done this way.