The case study & Medical history
The content of the history required in primary care consultations is very variable and will depend on the presenting symptoms, patient concerns and the past medical, psychological and social history. However, the general framework for history taking is as follows.
- Presenting complaint.
- History of presenting complaint, including investigations, treatment and referrals already arranged and provided.
- Past medical history: significant past diseases/illnesses; surgery, including complications; trauma.
- Medication history: now and past, prescribed and over-the-counter medicines, allergies.
- Family history: especially parents, siblings and children.
- Social history: smoking, alcohol, recreational drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets and hobbies.
- Systems review: cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, genitourinary system.
There are several consultation models which are useful to frame (and remember) your questions. Medical schools in the UK often use the Calgary-Cambridge model.
It is widely taught that diagnosis is revealed in the patient's history. 'Listen to your patient; they are telling you the diagnosis' is a much-quoted aphorism.
The basis of a true history is good communication between doctor and patient. The patient may not be looking for a diagnosis when giving their history and the doctor's search for one under such circumstances is likely to be fruitless. The patient's problem, whether it has a medical diagnosis attached or not, needs to be identified.
It is important for doctors to acquire good consultation skills which go beyond prescriptive history taking learned as part of the comprehensive and systematic clerking process outlined in textbooks.
A good history is one which reveals the patient's ideas, concerns and expectations as well as any accompanying diagnosis. The doctor's agenda, incorporating lists of detailed questions, should not dominate the history taking. Listening is at the heart of good history taking. Without the patient's perspective, the history is likely to be much less revealing and less useful to the doctor who is attempting to help the patient.
Often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A good example is with the complaint of headache where the diagnosis can be made from the description of the headache and perhaps some further questions. For example, in cluster headache the history is very characteristic and reveals the diagnosis.
To obtain a true, representative account of what is troubling a patient and how it has evolved over time, is not an easy task. It takes practice, patience, understanding and concentration. The history is a sharing of experience between patient and doctor.
A consultation can allow a patient to unburden himself or herself. They may be upset about their condition or with the frustrations of life and it is important to allow patients time to give vent to these feelings. The importance of the lament and how it may be transformed from the grumbles of a heartsick patient to a useful diagnostic and therapeutic tool for both patient and physician, has been discussed in an excellent paper.
