Post 24 Taking a patient's clinical history. A tutorial from an expert

William Wetherall, the hospital's senior surgeon, laid aside the journal he was reading and looked at the clock on the wall of his office.    It was one minute before ten o’clock.     He smiled, he had a surprise planned for the new group of  students who were waiting for him on the ward.  
He eased himself from his chair, stretched his back, then set off down the corridor.  

  He vowed, as he always did on these occasions, not only to teach them to be good doctors but to impart to them the common sense and good manners he felt should be the hallmark of all who practised in the caring professions.

“Good morning,” he said, as he entered the room.

The students stood and reciprocated the greeting.

“Now let’s start at the very beginning,”  William said, having learned the names of the students.   “Being a doctor is like being a detective.   A crime is solved by interrogating suspects, by examining the crime scene looking for evidence and, if necessary, by undertaking some forensic tests.   
To make a diagnosis, a doctor takes the same three steps.   Firstly, we take the patient’s medical history, in other words we ask them to describe their symptoms.   Then we undertake a physical examination and finally we  perform some tests, perhaps blood tests or maybe x-rays.   Of the three, listening to the patient is by far the most important.   You should be able to make a good working diagnosis in 70% of cases from the history alone.   Your clinical examination will solve the problem in perhaps 20% of cases and various investigations will give you the answer in a further 5%.”  

He paused and waited for the inevitable question.

 “And the last 5%, Sir?”

 “In the last 5% you will never find out,” William responded with a smile.    “Most will simply get better on their own, though just occasionally you may need the pathologist to solve the mystery for you with a post mortem.

Now,” he continued as a nurse wheeled a lady of about fifty into the room, “your very first patient.” 

She was wearing a pink dressing gown over her nightdress and had white slippers on her feet.    “I want you to meet Mrs Bradshaw, a lady who has been with us for some time.”

He invited the patient to move from her wheel chair to the examination couch.  He made sure she was sitting comfortably then thanked her for agreeing to meet them.

“Now in a moment we’re going to take Mrs Bradshaw’s history but before we start I wonder if any of you have already made any observations about her?    I’m sure you would normally be too polite to voice them in her presence but Mrs Bradshaw has assured me she doesn’t mind.”

His enquiry was met with silence.   “Well did any of you notice how she walked?”

After a pause, one of the girls volunteered hesitantly.  “As she left the wheelchair I though perhaps she moved with a slight limp, Sir.”

“Well done, Miss Seddon, she does indeed walk with a limp and I’m sure Mrs Bradshaw won’t mind telling us why.”

“Aye, I suffered with polio as a bairn,” Mrs Bradshaw responded. “Ma bonny wee sister died of it, poor mite.   I was luckier.   I dinna die, but it left me with this weakness in ma leg.”

“Any other observations?” Sir William asked.

“I think Mrs Bradshaw is Scottish,” Mr Morris offered, having heard her strong accent.

 “Indeed I am, young man. I’m from Glasgow,” the patient confirmed with a smile.

 “Anything else?” William wanted to know.

 There was silence, so the surgeon prompted them.  “Mr Solanki, would you care to look at Mrs Bradshaw’s hands.”

The student walked to the front and examined her hands.   “I think she does much work,” he volunteered, at which Mrs Bradshaw smiled broadly. “Aye, indeed I do,” she confirmed.

“What kind of work do you think?” 

Mr Solanki looked at Mrs Bradshaw’s hands again, turning each one over in turn.  “Physical work,” he suggested, “probably many hours spent with her hands in water.”

“Well done Mr Solanki, anything else?”

“I  think she probably smokes many cigarettes.” 

“Right again, well done. Mrs Bradshaw has some nicotine staining on her fingers, doesn’t she, and I think we can smell the faint whiff of her last cigarette on her dressing gown.    She also has the face of a chronic smoker.    Note those many deep facial skin creases.    Now, has anyone made any observations of her general demeanour?     What about you Miss Croft?”

Miss Croft was tall, blond with an attractive figure not disguised by the utilitarian white coat she wore; a young lady who was likely to catch the roving eye of Dr Potts, William’s  colleague! 

“Well”, the student began cautiously, “Mrs Bradshaw seems to be quite confident and comfortable sitting talking to us.    It’s almost as if she was enjoying it.    She doesn’t seem in the least bit anxious.    If it were me, I’d be worried to bits.    It’s as if she were used to being in hospital.”

 “Excellent work young lady.   That’s a very astute observation and one that is spot on.    Mrs Bradshaw has indeed been with us for quite a long time.

Now it’s time for us to take our first history.    Our patient has a pain in her abdomen; it’s under her ribs on the right hand side.”

The senior surgeon looked round and at the back of the group he spotted a slightly built, brown haired student, who seemed to be attempting to make himself invisible.  “Mr Booth, I’d like you to come to the front and ask Mrs Bradshaw a few questions.  To begin with, we need to discover how severe the pain is.” 

Reluctantly the student dragged himself to the front.  “Is the pain severe?” he asked in a voice that was barely audible.

“Severe doctor?  Aye, it’s terribly severe! Cuts me like a knife it does and it’s with me all the time.”

 Mr Booth took a step back satisfied that he had elicited the required information and eager to return to his place.
“Well. Mr Booth, how bad is the pain?” 

 “It’s very severe, Sir.”

 “Well let’s just tease that out a bit shall we,”  William said.   He turned back to the patient.    “Tell me Mrs Bradshaw, what do you do when you get the pain?    Suppose you were at work when the pain came on?”

“Well I just have to keep working don’t I?   You don’t get paid if you don’t work, do you?   I just take my pain killers and crack on.”
“And what pain killers do you normally take?”

 “Maybe an aspirin or two but I’m not really a tablet taker.  As often as not, I just struggle on.” 

“I believe you’ve had a baby or two,” Sir William said, “is it as bad as labour pains?”

 Mrs Bradshaw laughed.   “One or two, Doctor?   I’ve actually had five bairns but no, it’s nothing like as bad as labour pains.   They’re in quite a different league.” 

“So Mr Booth, how severe is the pain?”
The young student looked annoyed.  “But she said it was severe and it obviously isn’t!” he protested.

The consultant  smiled patiently.  “Yes, that is indeed what Mrs Bradshaw said.”   He emphasised the words ‘Mrs Bradshaw’ to indicate that he wished patients to be formally addressed and not referred to as ‘she’.  Then he turned to the rest of the group.   
“Let that be your first lesson,” he said.  “You can’t always take the things patients say at face value.   If you’re to fully understand their symptoms, you have to probe a little deeper.    You see, some patients are tougher than others; some are stoical and minimise their symptoms, whilst others exaggerate their problems, eager for them to be taken seriously.   You probably recognise from your own experience that some people take a few days off work, several times a year, with what they call ‘flu’ whist others, with the same infection, simply call it ‘a bit of a cold’ and carry on working.” 

 And so it went on, William demonstrating to the students how to elicit the precise site of the pain, its character, severity and duration; all the while impressing on them the need to treat their patients gently and courteously.

 “Before you go though,”  William concluded, “We must thank Mrs Bradshaw for helping us today.   I think Miss Croft you observed that she looked at home on the ward.    Full marks to you; Mrs Bradshaw is actually the domestic on this ward.   You will see a lot of her in the weeks to come.   She was kind enough to agree to act as our patient this morning.   And Mr Solanki, you were quite right too, she does indeed work extremely hard keeping the ward so beautifully clean and tidy.   We’d be lost without her.”

Mrs Bradshaw left the room delighted to have helped the consultant whom she and the rest of the staff admired and respected so much, and glowing with the praise he had heaped upon her.  

This story is adapted from THE FIRST CUT by Peter Sykes. It’s available from Amazon as a paperback or ebook

 Comment    It is true that in  William Wetherall’s day, a working diagnosis could be made from the history alone in 70% of cases. With the advent of detailed three dimensional scanning, the use of investigations has become of greatly increased importance but it would be a mistake to underestimate the value of a good clinical history.

Quotation of the day.

   ‘I am putting old heads on your young shoulders’

   Muriel Spark   1918 - 2006   The prime of Miss Jean Brodie

Extract from letter written by a plastic surgeon:  Both her new and old noses have been placed in our album.

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