Some background to the philosophy of obtaining a medical history
A well-known general dictionary defines medical history as ‘the past background of a person in terms of health’; whereas a well-known medical dictionary gives the definition as ‘information obtained from the patient to aid in establishing a medical diagnosis and developing a treatment plan’. While there is nothing technically wrong with the latter definition, we stick with the first one because its neutrality indirectly carries two important messages about medical histories:
- the process requires active and open-minded engagement from both parties, patient and clinician – it cannot work if the process lacks mutual trust or is in any way prejudiced. One-sided searching of databases for symptoms and solutions is every bit as unhelpful as a clinician hearing or seeing only those signs and symptoms that fit a presumptive diagnosis.
- the process requires the willingness to engage with a degree of open-endedness by both parties, patient and clinician – it cannot work if there are preconceived ideas.
Clearly, the better and clearer the communication between clinician and patient over this process, the better will be the quality of the diagnosis and the mutual understanding of its implications as well as the eventual (informed) decisions about treatment options – where that is relevant. Exploration of the medical history is the biggest single step in arriving at a diagnosis; in combination with a careful medical examination in many cases it is the only necessary step.
It would be wrong to believe that working the way through a medical history and trying to arrive at a diagnosis is a completely pre-determined, formulaic process. In reality, the process necessarily involves elements of uncertainties, intuition, recognition, consideration of probabilities and constant reiterations, often in several steps and supported by medical examination and a more or less extensive range of tests and investigations.
In addition, a comprehensive medical history needs to appreciate, amongst other aspects, the social, cultural and economic circumstances of a person since all of these affect a person’s health and well-being (and, for example, may have impact on suitable care plans).
Below we describe the procedures and processes to obtain a medical history in non-emergency situations. In an emergency, there are neither time nor opportunity for these approaches to evaluation and instead internationally agreed protocols for dealing with emergencies are followed to assess the situation and inform the most appropriate actions.
The process of obtaining a medical history aiming to diagnose a condition
Following our slightly more philosophical considerations above, we are ready to look at the process itself. Your symptoms (your main complaints / problems, as reported by you) will most likely be the reason for your appointment at the clinic. The symptoms will be the primary focus of the dialogue with the clinician who assembles the medical history (clinical signs of a / the condition are addressed in any following medical examination). A review of present and past (possibly including childhood diseases) illnesses and any long-term conditions will be included, as well as family conditions, and any previous surgery (reason and outcome). The medical history will include information about regular and acute medications (prescribed and over-the-counter drugs), known allergies (to medications, latex, food, antiseptics) and use of recreational drugs, including alcohol and tobacco use.
A review of body systems forms a systematic and structured part of the overall enquiry. It is used to assess symptoms and any potential functional limitations that are not covered by the investigation of the main symptom(s). It can reveal any additional undisclosed conditions which may require further investigation: the key for the clinician is to find a systematic approach to enquiry which will not miss major symptoms of disease. For people with complicated medical histories, or those likely to require major surgery, more intensive history taking is necessary. Table 1 summarises the structure and topics of a review of systems in a maxillofacial clinic.
|cardiovascular||chest pain, previous heart attack, hypertension (high blood pressure), palpitations (irregular heartbeat), shortness of breath on exercise, paroxysmal nocturnal dyspnoe (severe shortness of breath at night), orthopnoea (shortness of breath when lying flat), ankle swelling|
|respiratory||cough, sputum, wheeze, haemoptysis (coughing up of blood)|
|gastrointestinal||weight changes, appetite, dysphagia (difficulty swallowing), heartburn, nausea, vomiting, abdominal pain, bowel habit, blood or mucus in stool|
|genitourinary||pain, burning, hesitancy, poor stream, terminal dribbling, incontinence, frequency, nocturia (passing urine during the night), urgency|
|in women||date of last menstrual period, likelihood of pregnancy|
|neurological||fits, faints, blackouts, funny turns, limb weakness, paraesthesia (abnormal sensations), visual problems, hearing problems|
|muscoskeletal||joint pain, stiffness, swelling|
|endocrine||heat, cold intolerance, lethargy, voice change|
|dermatological||rash, itching, bruising, discoloration|
|psychiatric||stress, depression, mood swings, sleep disturbance, suicidal thoughts, anxiety|
If at this stage a definite diagnosis cannot be made, at least a provisional diagnosis may be made and/or some other possibilities may still have to be explored (differential diagnoses) next.
Medical history in preparation for elective (planned) surgery
Clerking is the term used to describe the structured pre-operative assessment by means of history taking, medical examination, and relevant special investigations. It applies to all patients admitted for any procedures.
At this stage, obviously a diagnosis will have been made and the role of medical history investigations is now to focus on fitness for surgery in general, and for general anaesthesia in particular. The process follows similar patterns of assessments and investigations as before, usually with a particular emphasis on assessment of cardiovascular and respiratory systems (see Table 1, above) and aims to identify any relevant aspects that need to be addressed ahead of / for the planned surgery.
Pre-operative assessment clinics, where patients are clerked several days in advance of their operations, allow adequate time to order investigations, review the results, to anticipate and address medical and social problems. Pre-operative assessment clinics are in widespread use as part of the process of maximising ‘efficient’ use of expensive hospital resources, although how efficient the process actually is warrants careful scrutiny.