The History of More or Less
By Marcos Otero, Gulf Coast Immediate Care Center, Fort Walton Beach, FL
The history of an illness is essential. It helps us ascertain the possible differential diagnosis and allows us to delineate treatments.
Last month we discussed expectations some people have of medicine which are unrealistic. This month we will discuss – why the history of the illness is so important?
Many patients have presented with a very unclear history of why they have come into the office. When questioned about when the symptoms started, the response is “for some time” or “more or less.”
“For some time?” or “more or less?” What does that mean? As you can imagine, more is needed to help the provider.
So today, we will discuss history.
History of Present Illness (HPI): This is usually a chronological description of the condition’s progression from when first sick up to the time of the visit. It is subjective, as it is when you tell us about your symptoms. The history of the current condition is essential in our detective acumen.
Questions will be asked that help paint the picture for differential diagnosis.
Some basic questions are:
- When did the problem start?
- What were you doing when it started?
- What type of pain do you have, sharp or dull. Pulsing, intermittent, or continual.
- Where is the pain?
- How bad is it?
- When does the problem occur?
- What makes it better or worse?
- What other symptoms do you have with it?
- Previous treatments or workups?
Further questions are added to elucidate some additional information. The list can be extensive or short, depending on the suspected diagnoses or answers given.
The information must be forthcoming and as precise as it can be. Holding back or exaggerating information only clouds or delays the assessment.
Let us use abdominal pain as an example of why clear history is essential.
A 30-year-old man presents at the clinic with a complaint of severe abdominal pain. The following is the history obtained. C is for the clinic, and P is for the patient.
P – “my stomach hurts.” he points to the abdominal area.
C – “When did it start?”
P – “More or less.”
C – More or Less when.
P – sometimes
C – Where does it hurt?
p – Everywhere
C – When does it hurt?
P – Everyday
C – Does something make it hurt?
P – “No”
C – “Describe the pain.”
P – ” it hurts.”
C – sharp or dull constant or comes and goes.
P – all of that
C – What makes it better or worse
P – Nothing.
C – have you had any problems like this before
P – NO
C – Have you been seen for this before or taken any treatment
P – NO
Different causes of abdominal pain are considered depending on whether the pain started an hour ago, a day ago, a month ago, or a year ago. So more or less does not help! The choice to begin treating the most common ailments was discussed.
When the patient returned after several weeks, he informed the clinic that the same treatment had been tried before and did not work. His wife accompanied him and was upset that nothing was done. She gave us the true, complete history.
His wife says he drinks and consumes large amounts of spicy foods daily. He has diabetes and was told he had GERD in the past but never takes his medication. then complains
His workup was delayed because he was not forthcoming or with the history. He had chronic problems, and not telling us he was diabetic and alcoholic with GERD changed the differential workup.
With appropriate history, he would have been sent earlier to a specialist, where he was found to have severe gastritis and the beginning of an ulcer.
