The History is the Patient telling us the Diagnosis, The Physical Examination is the Body telling us the Diagnosis.

Saturday, March 31, 2012

Written by Professor Dr Wong Yin Onn The Start of a Diagnostic Process The History

History taking is the foundation of the Clinical Art and the heart of the diagnostic process in Medicine. The medical history is the grand centerpiece, the big picture that provides a panoramic overview of the patient's entire illness - how it originated, how it grew and developed, and how it is at present.
It is primarily the medical history that tells the doctor which specific signs to look for, and what other subsequent investigations are needed to obtain the information he seeks. All other methods of diagnosis can be seen as auxiliaries to the medical history, which is the principal, or core diagnostic method.

Prof TJ Danaraj demanded a highly detailed history from his students, and a sloppy history will be met with a severe reprimand. Prof KK Toh recalled how a student who did a particularly poor job will be exiled from the Bedside teaching until he has personally apologised to the teacher and each student in the group, for he has wasted the precious learning time of the entire group and himself; and insulted the patient.

TJD will typically draw a long line across the blackboard with his chalk; the student will be asked as to describe in detail what happened on the Day1 when the first symptom appeared and then Day2 etc etc. Then what brought the patient to hospital, that precipitating event which made the patient seek admission, and subsequently what happened Day1 of admission, etc all the way to the present day.

We must pay close attention to the time course of the symptoms. How has symptom complex changed over time?

The natural history of the illness, its progression is of utmost importance in diagnosis. Today I am saddened that most students take lightly this "History of Present Illness (HPI)". In this era of instant coffee and maggi mee, the students compressed all this HPI into a few brief statements, losing much that it tells us. Always remember that The History is the Patient telling us the Diagnosis!

I tell my students to at the very least think of 5 common conditions that can explain for the Chief Complaint and HPI. For eg if the Complaint has been Chest Pain, then at the very bare minimum, think of 5 Common or Important conditions that can cause or fit the HPI. The Common include Ischaemic Heart Disease, the NOT TO BE MISSED include Acute Myocardial infarct, Aortic Dissection, Pulmonary Embolism, and Pnemothorax. The long list of others from GERD to Oesophageal spasm to Zoster is at the back of our minds. With this we review the Systems and LOOK at each system one by one comprehensively for possible symptoms and disorders that may not be spoken of by the patient in the HPI. In the HPI the patient volunteers his data, in the systemic review we enquire!

The focused review of systems bring out information that supports a certain diagnosis or helps gauge the severity of the disorder, or exclude the likelihood of a pathology.

Today, the systemic review often consists of mindlessly repeating a few lines that goes.... "Patient does not smoke, drink or take drugs of abuse. He has no sexual indiscretion". This is one extreme.
Any book on Clinical Methods will have a list of symptoms that comprised the definitive "Review of Systems." Some students actually memorized this list. This is the other extreme! But the Mindless recitation of this list is rather stupid: "I know that you are having chest pain, but I need to know if you have ever had an extra marital affair."
I smile to myself everytime I hear such well parroted lines at the wards, and realise that the student still has Not grasped the Art.

The Diagnostic process is time honoured, refined by the passage of time,
a distillate of Medical wisdom.
History taking and Physical examination remains the pillars of sound practise,
no matter how the machines have advanced.
The human touch, both the spoken word and the touch of the hand is as important as the pharmacopeia.
Even if the superb diagnostician may not need it, the suffering man does.
he consults a doctor, not a machine,
he seeks help, not the beeps of computers.

On complicated machines we now rely,
and use ear, tongue, eye and hand far too little.
We scan and sound everything,
and await with pious resignation the decree of the computer.
Clinical methods we tend to damn,
and the doctor now becomes a stranger to the patient.

The modern doctor is at ease with ECHOs and Scans,
but he forgets the symptoms and signs of diseases,
the patient now a nameless collection of body parts to be referred to organ specialists,
where once on a clinician's skills the matter rests.
But we have yet a machine that can measure Human pain and distress,
nor a computer that can counsel and relieve.

What ails a man from the symptoms and signs, a clinician can tell,
at the bedside he truly shines,
his conversation reassures the patient that he is the most important suffering being to this doctor,
his touch a soothing balm to the aching body.

TJD warned us that we are Doctors, NOT Technicians; and unless we continue to act as Human Doctors healing the sick Human being, the Technician will take over!

The History is the Patient telling us the Diagnosis,
The Physical Examination is the Body telling us the Diagnosis.
Both must be Complete.

The History is in a language both the Doctor and Patient understands,
The Physical Examination is in a language only the well trained doctor understands.

The Mathematics of Diagnosis is the Mathematics of PROBABILITY; what is the probability of disease A causing the symptom complex of this patient?
In the OSCE system of evaluation of our medical students at the end of the year, the student is asked at the end of his history taking... "What is your Provisional Diagnosis and Differential Diagnosis at the end of this interview?"

Effectively we are asking, what is the Probability of the diseases causing this illness from the highest to the Lowest!

Some symptoms provide us with valuable clues to the diagnosis, for eg

Fever, Chills, and Rigors! People! pls give me 5 important common causes.

One of my students saw a patient come in with Fever, Chills and rigors with abdominal discomfort and unilateral flank pain. From the history, he was able to quite accurately localise the source of infection which took the attending doctors a CT Chest and Abdomen to diagnose! The history and physical examination should give us a Working Diagnosis based on which we order the appropriate Investigations. It should not be that we do the Investigations to give us the working diagnosis!

The medical history and dialogue between the patient and his doctor is the heart of the doctor - patient relationship. It is here that the doctor establishes a rapport with his patient, and communicates to him/her his sincere caring and commitment to their recovery. This caring in itself has great therapeutic value.
The cold impersonality of modern medicine is anti-therapeutic, and dehumanising.