Patient Profile and Case History
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Chiropractic Physical and Spinal Diagnosis”
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If one had to sum up the doctor's role in one term, it would probably be "decision maker". In practice, decisions involving diagnostics, therapeutics, economics, and human relations must be made throughout each day. Every telephone call and every direct conversation entail decisions of one sort or another which can have far-reaching effects.
Part One: Case History Methodology
Every clinical procedure conducted is started because some decision had been made. The quality of the decisions made are determined essentially upon knowledge, experience, practice goals, data collection and retrieval, interpretation and clinical skill, and personal interest.
It is the privilege of any physician to set his own practice goals. Such goals usually take one of two major directions: comprehensive care or specific care. Comprehensive care implies the discovery of all the patient's problems, forming a plan of action for each problem, putting that plan of action into effect, and monitoring the progress results and revising the plan as necessary. On the otherhand, specific care is restrictive care in which a doctor of specialized skill and interest concentrates on only a part of the patient's problem or problems. Family practice is an example of comprehensive care; chiropractic orthopedics is an example of specific care.
The point to be made here is that both comprehensive care and specific care require an accurate diagnosis. Comprehensive care requires the discovery of all the patient's problems to direct problem-oriented therapy. Specific care also requires the discovery of all the patient's problems so that all problems can be considered in relation to the specific area of interest. Obviously, one cannot be specific unless he has an appreciation for the whole. To do so would be like the story of the blind men examining the elephant: all describing the animal according to the parts (ears, tail, tusk, legs, etc) they were near without understanding the relationship of the parts to the whole.
Good decisions are the result of accurate, complete facts being at hand from which a logical course of action can be planned. This means that the health of the practice is determined to a great extent by the quality of the doctor's data gathering and retrieval systems. Every office requires certain basic information on every new patient.
To be aware of the patient's problems is the first step in logical health care. The second step is to have systematically developed complete records of the patient's problems and the care administered to monitor progress. More is needed besides a comprehension of the problems for it is extremely doubtful if all the problems could be remembered without a written record. Total recall from visit to visit of existing problems and their ramifications over a period of weeks or months is incredible. Quality health care is the result of accurate observation, analysis and synthesis of information, and appropriate action. Good records safeguard the quality of these functions.
Clinical records concern the health-care aspects of the practice. Examples are the entering patient data form, the patient history form, the case history and examination form, case progress records, clinical laboratory reports, and x-ray reports. Administration records concern the business side of the practice.
Entering Patient Data
When new patients enter the typical chiropractic office, they are greeted, seated comfortably, handed a clip board to which has been attached a card or slip, and requested to fill out the necessary information. Much of this information is for administrative purposes such as the patient's address and telephone number, employer's name and address, referral and insurance data. However, some of the information is of a clinical nature and will be transferred to other records such as date of birth, chief complaint, number and ages of children, and occupation.
Patient History Form
After the entering data are obtained, the next step is to obtain a record of the patient's health history. A chiropractic assistant may be responsible for the initial gathering of this information which records when symptoms first appeared, how long the disorder has existed, what the patient has previously done about the condition, and other facts helpful in case evaluation.
Such information may be gathered by an assistant, and is usually restricted to that concerning the patient's chief and minor complaints;
the patient's medical, surgical, obstetrical histories;
family, social, and accident histories.
Other points covered are:
record of past patient illnesses,
drug or food sensitivities,
past medical and chiropractic care and the results obtained.
Family history will concern:
the health status of siblings and parents, offering possible clues to hereditary influences.
The patient's social history relates to where the patient lives, marital status, number and ages of children, type of work and work environment, smoking and drinking habits, activity excesses and inhibitions. The history of accidents and their effects are recorded. The doctor will later go over each point in detail with the patient during the interview.
Programmed questionnaires and direct questioning comprise the two most common methods used in gathering a case history. A screening device such as a preprinted form does not minimize the doctor's role in taking the history. It is just an efficiency means of supplying non-critical data and serving as reference points from which the doctor will investigate further. The time saved in asking routine questions can be used in more personal aspects of the case.
To save patient and office time, many doctors utilize a type of personal history form which requires only a simple "Yes" or "No" answer which can be checked or encircled by the patient. These forms are usually designed so that a group of questions refers to a particular body system.
A questionnaire gives the doctor an opportunity to review the data prior to seeing the patient so that he may formulate some of the basic questions in his mind prior to contact. The person whose duty it is to instruct the patient in how to fill out a questionnaire must be sure to stress the importance of the information to the patient so that the form will be completed with sincerity. The patient should be assured that all information will remain in confidence. If a question is not clear to a patient, there should be someone available to help.
Obviously, a patient that is severely ill should not be asked to fill out a multi-page questionnaire. An acutely ill patient is far too disturbed to be confronted with a printed form.
Many doctors feel that a questionnaire should be presented to the patient only after the initial history has been obtained and a positive rapport has been established between doctor and patient. The approach must be designed to the patient and problem at hand as well as to office philosophy.
Case History and Examination Form
The doctor's actual examination has begun with a review of the initial data. During the interview, the doctor will further investigate this information, probing deeper and wider, and arrive at a judgment as to what type examination procedures would be best suited for the particular patient and complaints involved.
At the completion of the patient interview, the doctor will propose the type of examination necessary; and upon patient agreement, the examination will proceed. After examination, the doctor will record or dictate the results of his physical examination, spinal analysis, laboratory findings, and other data necessary to profile the patient's condition.
In a simple acute case, this whole process may be completed in a matter of minutes. In a severe chronic condition of an obscure nature, the process may take from several days to several weeks before a working diagnosis and prognosis is arrived at. Regardless, after the examination and evaluation of the patient's history and examination findings, the doctor will meet with the patient to discuss his opinions and recommendation for treatment or referral.
Although professional printing houses have a large selection of case history forms to choose from, many doctors prefer to design their own to meet personal goals and specifications. Still other doctors do not desire a restricted format and prefer to develop clinical records on an open basis through dictation which is later typed.
Case Progress Records
Once a patient enters therapy, his condition is recorded, together with changes in treatment or to previously given instructions. Progress notations constitute a permanent record of what was done and offer a chronological patient status. While the patient's history indicates the patient's status at the time of the initial visit, the progress records indicate the patient's state of health at subsequent points in time.
Elements in the Diagnostic Process
In the broad sense, the word symptom is used to label any manifestation of disease. In the diagnostic sense, however, symptoms are thought of as being only subjective, appreciated only by the affected person. Pain and itching are pure symptoms. Signs are detectable by another person and sometimes by the patient himself. Faint cardiac murmurs and pulmonary rales are pure signs. Some features are symptoms and signs as the same time such as fever and swelling. Conditions vary in classification. Alcoholism, for instance, may be a diagnosis or it may be a symptom and/or sign of a severe neurosis.
There is one basic reason for studying signs, symptoms, and, for that matter, the case history: to determine the pathophysiological processes involved. Memorizing specific symptoms of specific disease entities has little clinical value unless the processes involved are understood. Knowing "why" a certain sign or symptom is present is vital for comprehension and competent therapy.
A sign or a symptom is never an isolated phenomenon but has multiple interrelationships, some physiological and some psychological, which can be of a major or minor importance. The patient's problems can only be interpreted and a diagnosis made possible when the clinical significance of the patient's signs and symptoms are understood.
The structure of the diagnostic process in the typical chiropractor's office consists of:
(1) developing a patient profile,
(2) recording the history,
(3) conducting the physical examination and spinal analysis, and
(4) interpreting necessary laboratory reports and x-ray films.
These procedures may be directed either to specific problems such as low back pain, hypertension, asthma, or they may be directed in a comprehensive manner which identifies all the patient's problems even if some are not a concern to the patient at the time. Thus, the direction that these procedures will take will be determined by both patient and practice goals. It is these first two elements, patient profile and history, that are the major subject of discussion in this chapter. These two elements are the components of the patient's initial interview with the doctor.
The Art of Clinical Inquiry
Several years ago, Dr. David C. Pamer offered a description of the need for the case history in an article which appeared in "The Chiropractic Internist":
"An accurate, complete, usable, and at times laborious and exhausting case history is the essential foundation that all practitioners must first obtain before they can build piece by piece the true diagnosis. And only after a diagnosis has been reached should therapy be initiated. The case history must be accurate and complete, thus warning the physician of conditions and protecting the patient from possible detrimental diagnostic procedures which may be encountered within the realm of a diagnostic 'work-up'. A complete case history will protect the fetus of a young 'surprised' female with 'low back pain' from x-ray irradiation. An accurate case history will protect the traumatized patient from possible further injury or aggravation of injury during physical examination. A 'good' case history of patient data must regulate and mandate diagnostic studies and aid in the interpretation of the same. McBryde and Blacklow (SIGNS & SYMPTOMS, Lippincott, 1970) state that 50% of the diagnoses made are possible solely on the data obtained from a complete case history. Another 25% of the diagnoses are based on the physical examination alone. Laboratory, x-ray, and other procedures contribute 20%, with 5% of the cases nondeterminable."
An understanding of the goals of the interview, how to handle the presenting symptom and present illness during the interview, how to develop communications leadership and control, how to cope with patient anxiety, what notes to take, and recognition of the pitfalls in interviewing are prerequisites to developing the art of clinical inquiry.
Goals of the Interview
The patient's first interview is the first part, as well as the foundation, of the doctor-patient relationship. This vital interview can be considered to have three basic content objectives: an emotional substance, a factual substance, and a therapeutic substance. Thus, feelings, facts, and direction are the primary goals of the interview.
The emotional substance is that atmosphere of developing good human relations. Interest, courtesy, understanding, the development of rapport, and all the other social manners and arts of interpersonnel communications will be tested here as they are in any meaningful social contact. Shewd assessment of various personalities and the ability to adapt to a wide variety of personalities offer an optimal climate for the doctor to gain knowledge of the individual and the person's full cooperation. This is the time when first impressions and most lasting impressions are made. This is the period when doctor and patient "size up" one another. The emotional substance is human reality. However, balance is the key. One can show not enough interest in the emotional substance, or show too much.
The factual substance is that information about the patient's problem and its history. Here, the doctor's knowledge of the basic and clinical sciences help the examiner to direct his questions with skill, correlating the patient's symptoms with his clinical knowledge and experience. If backache is the chief complaint, for instance, what is its possible pathophysiology and etiology? If the complaint is chronic in nature, the doctor will reflect on what he has learned of the natural progression of such a syndrome in a similar situation. The factual substance is one of data gathering, sifting, correlation, and evaluation --without prejudgment that could cloud objectivity.
In the text CLINICAL METHODS, H.K. Walker, MD, states: "Therapy begins when the patient and physican first set eyes on one another." There can be little therapy if there is little desire to cooperate. Thus it is important that the examiner establish and cultivate a climate which informs the patient that the doctor is interested in the person first as a human being, and second as a patient; and the patient is instilled with the conviction that the doctor knows what he is doing. These factors are the product of the emotional and factual substance of the interview.
The value of this first interview and the patient's history cannot be overestimated. It is the point in which doctor and patient first have contact and attempt to construct a bond. It elicits valuable information about the person as an individual and establishes the first steps toward the later diagnosis. It designs the physical examination which is to follow and makes certain signs to be found more meaningful. It provides an index to the seriousness of the illness. It indicates probable laboratory tests, and it begins to direct the role of future therapy. In the majority of instances, following physical and laboratory examinations will:
(1) confirm an accurate case history, or
(2) indicate case history inadequacy.
The value of a case history is directly proportional to its completeness and accuracy. Thus, in questioning a patient, the doctor must accomplish two tasks:
(1) convince the patient of the importance of the interview and questioning, and
(2) establish the complete sequence and relationship of events up to the present illness. Unless the first task is accomplished, the second can never be achieved. As the history-taking develops, the doctor must begin to formulate tentative ideas about the pending diagnosis.
The Presenting Symptom
The presenting symptom is the chief complaint or major problem for which the patient is seeking help. It is the response to such questions as "What seems to be the matter?" or "How can I help you?"
Deep probing into the patient's chief complaint will frequently uncover diseases and disorders that were predestined in years past and could have been avoided or minimized if an efficient case history had been obtained at that time. The doctor's role should be as much preventive as it is therapeutic.
Once the chief problem has been defined, the patient should be encouraged to offer more details of the situation. Most patients will do this spontaneously. After the patient has "told his story", the doctor is in a position to direct specific questions to profile the patient's problem in greater detail.
Remember that the patient's symptoms represent what the patient feels to be wrong and what the patient is concerned with. The doctor may find a very severe problem that is asymptomatic, but this should not be an excuse to minimize the patient's concern.
If the patient is in pain, then the doctor will limit his questions at this time by asking something to the effect, "What's bothering you the most?" In most instances of pain, it is practical to concentrate on the acute condition during the first visit.
The Present Illness
If the patient is not in pain, then the doctor should proceed to ask, "What else has been troubling you lately?" Your goal is to encourage the patient to relate all his problems so that you can arrive at a description of the present illness. It is also good to have the patient describe his symptoms on following visits. The re-telling will invariably add new facts not previously revealed or recently remembered. It takes time to build trust --and almost impossible to obtain a thorough case history in the first visit. If the patient has been involved in trauma, shock, or a crisis, it is not unusual for a degree of amnesia or faulty recall to be present.
At the end of the interview, you should feel confident that the emotional and factual substance of the interview was to your liking and confident that the patient has been open and truthful with you. If not, the data are most likely incomplete or misleading.
You now have a list of the patient's problems--some possibly related to the chief complaint and others that are probably not. Clinical judgment will determine their priority consideration. The quality of this judgment is determined to a great extent in how thoroughly you understand the beginning and course of the problem, where the problem is located and its radiation, the problem's quantity and quality, what circumstances aggravate or aid the problem, and what manifestations are associated. Answers to these questions should be at hand for each complaint.
Leadership in Communicating
After the doctor is introduced to the patient and before the formal interview begins, it is always good practice to start the conversation with a few social comments not related to health or sickness to put the patient at ease. Don't be in a hurry to begin the actual interview. Let the person first understand that you recognize him as an individual. Inquire into the patient's comfort, then explain your professional role: family practitioner, specialist, practice goals.
Good answers come from tactful questions that are asked in a manner the patient understands. If you ask most lay people, "Have you ever had jaundice?", most will respond, "No". If you then ask them, "Do you understand what jaundice is?", most will reply, "Not exactly". And of those who say they do understand, most will have an erroneous understanding. Thus, be sure to speak in terms that are understandable and descriptive, and watch the responding body language as well as listen to the words. Use similes and analogies whenever you think you might be misunderstood otherwise.
Time will be saved and continuity will be maintained by avoiding hopping between unrelated areas. Poor transitions result in a disorganized picture.
Try to avoid Yes-No patient answers to your questions. They relate little information. Spontaneous paragraphs are what you are seeking for they will most likely be closer to the relevant truth you seek.
A good rule of thumb is that three-fourths of the talking should be done by the patient. You can keep the patient talking by:
(1) keeping silent when the patient pauses,
(2) ask, "Go on!" or nod in agreement,
(3) have the patient reaffirm his own words such as asking "It hurts only in the right leg, right?" or
(4) have the patient clarify something he said earlier.
Your job is to lead the patient so that he will not leave anything important out of his story. Such control usually necessitates privacy and enough quiet so that both patient and doctor can concentrate. Relatives and friends should not be present except in situations such as a pre-adolescent, mental retardation, or when language interpretation is necessary.
You can lead the patient in several ways and maintain control of the situation; for example, by frequent eye contact, offering undivided attention, changing the subject when the patient wanders, and in the manner in which you frame your questions. Non-threatening questions as "Tell me more about your...." or "Would you say your pain is sharp or burning?" elicit more information than simple direct questions that require a mere yes or no response. A simple "Anything else?" or "What do you mean by ...? often brings forth important information.
The facts you gain during the interview will become your basis for making a therapy decision when they are correlated with physical and laboratory findings. And of all these procedures, most diagnosticians feel that the history during the initial interview is the most important. It should never be rushed.
Science and humanity are not incompatible. There is no substitute for a physician's interest, acceptance, recognition, and empathy, from the patient's viewpoint. Studies have shown that these qualities are more important to the patient in selecting a doctor than the physician's technical and scientific ability. Galen told us centuries ago: "He heals the best in whom the most people have the greatest confidence."
To understand why a patient thinks and acts as he does, the doctor must first learn why he thinks and acts as he does. Each physician has a unique "anatomy and physiology" in his decision process, and each has its own strengths and weaknesses.
The interview is not complete unless you are confident that you understand:
(1) the beginning and course that the patient's problem has followed,
(2) where the problem is located and its nature,
(3) the quality and quantity of the problem,
(4) under what circumstances the problem is aggravated and relieved, and
(5) the problem's associated manifestations.
Every illness has an emotional component. Sometimes this component is slight, and sometimes it may amount to an emotional crisis. Health and well being cannot become complete unless there is both physical and emotional recovery. Young and inexperienced physicians have a tendency to negate, minimize, and sometimes even ridicule psychological manifestations. This is probably the result of academic over-emphasis upon objective technical data rather than upon the patient as a whole. It is also much easier to interpret laboratory data than it is to evaluate subjective responses during the diagnostic work up.
The technical and scientific aspects of health science can be learned through books and courses; however, the art of clinical practice can only be learned in the doctor-patient relationship of heath "care". For this reason, the diagnostic process can never become fully computerized. To diagnose means to thoroughly understand, and one cannot fully understand unless the human elements are taken into consideration. A computer may be helpful in the accumulation and sorting of data, but it can never be programmed to interpret correctly in light of human problems.
An individual becomes a patient when he or she seeks health care from a professional. The term "patient" comes from the Latin word "pati" which means to suffer. This suffering, mental or physical, must be remembered at all times.
Self-preservation is one of our strongest urges. Thus, in matters of health, every patient feels emotional discomfort. There is not always pain, but there is always anxiety. In the wake of any illness, there is a flood of fears --some based on fact, many on assumption or unwarranted beliefs. There are fears of personal survival, financial concerns, social worries. There are fears of pain from examination or therapy, of the doctor's competency, and of embarrassment in exposing private areas to a stranger. Recognize these fears: they deserve understanding and recognition, never a minimizing "put-down".
Quite often, delicate topics will have to be explored such as in sexual difficulties, menstruation disorders, a history of venereal disease, or signs of illegal drug use. Such areas should not be covered too early. Let a rapport be developed first, and the information will be more open and credible. Anxiety is expressed in a wide variety of behavioral patterns --the angry patient, the hostile patient, the dependent patient, the crying patient, the embarrassed patient, the depressed patient, the affectionate patient, the uncooperative patient and the overly cooperative patient. A cultured sympathetic objectivity is the best way to calm the angry and hostile, avoid dependency attachment, sublimate the affectionate, ease the embarrassed, give hope to the depressed, and maintain necessary cooperation in a professional atmosphere.
Take care not to act too friendly or not friendly enough. The doctor must be sincerely concerned, yet he must maintain a degree of detachment. If objectivity is lost, judgment becomes biased, and acts become controlled by emotions rather than by reason. By being calm, sympathetic, showing interest and acting human, the doctor tends to reduce those anxiety forces within the patient that would not be in the best interests of case management or honest communications.
One of the easiest methods of revealing unwarranted anxiety is one of the most overlooked; that is, to simply ask the patient how he interprets his symptoms. If the patient's beliefs are in error, never imply that he's ignorant. ust state your interpretation and how you will determine the facts.
Each patient has his own way of coping. Regardless of it's expression, it is the doctor's responsibility to try to understand why the patients feels and thinks the way he or she does. This is the first diagnosis --and the act, the first therapy. Complacency and a "matter of fact" or judgmental attitude are negative forces in the doctor-patient relationship.
As a general rule, organic diseases present clear-cut symptoms, while emotional or mental disorders are apt to be poorly defined and presented as seemingly unrelated complaints until the trouble for the organ language is discovered. Today we realize that there is a close relationship between psyche and soma. While one aspect may be far more important in a particular case, it is never alone and the other aspect should not be neglected.
It is important to realize in both diagnosis and therapy that symptoms in chronic cases may have become a fixed part of the personality and sublimated to have certain positive benefits. For instance, a crutch may have been developed into an instrument to gain attention and sympathy. Periodic episodes of pain may be used to keep a spouse nearby and restricted to the house. Thus, the doctor must consider not only a symptom or sign and its pathophysiologic consequences but also question what a symptom or sign means to a specific patient.
Note Taking During the Interview
Except for specific dates, numbers, and key-word reminders, note taking during the interview is poor practice for several reasons. It distracts the doctor in giving careful concentration to the patient. It makes it appear to the patient that the doctor is more interested in cold data than the warm person who is undoubtedly hurting.
Although the information gathered during the interview will be a basis for the development of the case record, interview information is far from suitable as it is presented. When entered into the case record, this information must be greatly condensed, sifted and filtered, and put in proper sequence and professional terminology before it is formally recorded.
Errors in Technique
The interview conversation should be designed to be subjective; that is, an account of the patient's feelings and beliefs. A symptom can never be a diagnosis: a headache is a symptom, even if you call it cephalgia. Anything that is an effect of something such as pain, immobilization, dystonia, myopia, and so forth, cannot be a diagnosis. The cause of the effect is the diagnosis, and this is arrived at by analysis and evaluation of all symptoms, signs, and findings. To seek the cause of the ailment is to seek the diagnosis. Thus, to fail to arrive at a diagnosis or arrive at a wrong diagnosis is to fail to determine the cause. Since chiropractic's inception, practitioners have been directed to "look to the cause". To seek the cause is to seek the diagnosis.
Many errors in diagnosis can be traced to errors in data collection such as:
(1) failure to ask important questions,
(2) failure to obtain adequate patient response to questions,
(3) failure to adequately explore important leads, or
(4) failure to place information in proper perspective. Some patients over-emphasize symptoms while others tend to de-emphasize them depending upon their emotional state and motivations.
Only is most rare instances can a few symptoms arrive at a clear diagnosis. Most clinical diagnoses will be comprised of a syndrome, supported by physical signs observable to or elicited by the examiner, and correlated with laboratory and roentgenological data interpretations. It is frequently stated that a good clinician is a good observer, critic, communicator, decision-maker, and a good student --now and throughout his career.
One symptom by itself usually means very little. It is its relationship to other symptoms that is significant. For instance, vomiting accompanied by abdominal pain in the lower right quadrant may indicate appendicitis, while vomiting with headache and failing vision would lead one to suspect something causing intracranial pressure. The art of diagnosis is developed by learning to recognize characteristic symptom and sign groups and their anatomical and pathophysiologic relationships.
Biorck reminds us in THE PROBLEM-ORIENTED SYSTEM that good clinical communications require awareness that any one patient is three patients in the practical sense: there is the patient as he is; the patient which develops within the doctor's mind; and the patient that develops in the doctor's records. The patient within the doctor's mind may be quite different from the patient as he really is. This is because patients will never tell you everything. They may be withholding information, they may have forgotten something, or they might not understand what information is important to you. In addition, doctor's are human beings, and human beings cannot help but project, identify, and rationalize in error at times. The doctor may be able to identify with a patient's story, but his experience can never be exactly similar. The doctor's mental image of the patient might contain information that is not in the records. In the same token, the records might contain facts that have been forgotten by the doctor.
Both patients and doctors are often guilty of prejudice. A patient's previous experiences with doctors affect his perception of every doctor. A doctor's reaction to a patient of a certain age, sex, lifestyle, or ethnic group can influence his clinical decisions. Such factors should not be a part of health care; but they are, because patients and doctors are human.
Symptoms usually appear quite early before marked physical signs of disease are evident and before laboratory data are useful in detecting malfunction. For this reason if for no other, a high-quality gathered and interpreted case history is necessary to lead the doctor to correct conclusions.
The presence or lack of a symptom may be of great interest during the case history just as the presence or lack of a sign may be of great interest during the physical examination. For this reason, both the presence of or the lack of symptoms and signs should be recorded. To record only positive symptoms and signs is to record only half the facts and may falsely indicate an ommission of inquiry.
A doctor may have certain routines he uses in certain situations in taking a case history and conducting a physical examination. However, there should be no such process as a "routine" examination, and routine or mechanical recording of data does not constitute a case history.
Regardless of how carefully an impersonal inquiry into a patient's illness has been designed (eg, a questionnaire or routine procedure), it can never take the place of personal interest in the uniqueness of the patient. Several studies in teaching hospitals have revealed that there is a direct correlation between therapeutic results and the amount of effort and time spent with the patient during the initial interview.
In recent years, there appears to be an over-emphasis in both the undergraduate and postgraduate levels in teaching the mechanical aspects of physical diagnosis such as of the various neurological and orthopedic signs and reflexes and methods of muscle testing. While these methods are vital to complete assessment of the patient, there is danger that the doctor will become more concerned with the study of disease than the study of patients. Scientific knowledge without wisdom in application is folly.
Our technical knowledge is expanding at a rapid rate. This is well, but we must be alert that it should not be at the expense of the ill person, else we become better technicians and poorer physicians. The most important diagnostic skill is that which is the least taught and most difficult to learn: how to talk with patients and obtain not just adequate but significant information.
Elements in Diagnostic Logic
Before the doctor can take rational action, such action should be preceded by careful observation and description, interpretation and verification, and diagnosis and review.
Observation and Description
The first two steps are to observe and describe. Much of the purpose of the doctor's observation is to understand and appreciate the patient's background, habitus, note the degree of functional difficulties and pathological processes evident, and grade the scope and pertinence of abnormal findings found within the interview, physical examination, and associated laboratory studies. The doctor describes when he tabulates his obervations. This is a sifting of pertinent facts from irrelevant information that results in condensed, logically organized, patterns of data. A typical patient will present a number of abnoralities that will be non-related to his present illness, and a decision must be made as to what is pertinent and what is not.
Interpretation and Verification
The next two steps are interpretation and verification. When information about the patient has been tabulated, it must be reviewed in light of the doctor's basic science knowledge and clinical experience. The doctor must weigh and differentiate the pattern of the patient's problem with the pattern of known disease processes. Once an initial and possible determination(s) is made, logical diagnostic procedures are selected, given a priority, and scheduled to verify this opinion. As the examinations and tests are conducted, their findings must be tabulated, interpreted, and judged against the particular patient and his situation at hand.
Diagnosis and Review
Diagnosis means more than applying a label to a disease process. While it means to identify disease(s) accounting for a patient's illness, it means to a greater extent to determine the nature of the patient's distress. While a label helps in identification and is necessary for various legal and communications reasons, it may not always accurately predict therapy or prognosis even if it predicts the course of initial therapy. If, however, patient progress does not show expected results, then the working diagnosis and course of treatment based upon it must be modified.
The tendency to jump to conclusions based upon a few facts must be avoided. For many reasons, interpretation of history, physical, and laboratory findings may be faulty. The patient may not be perfectly open and honest during the interview. Symptoms being subjective are a mixture of emotional and physiological factors. Physical findings may be misleading. Positive or negative laboratory tests are not always accurate. All standard diagnostic procedures are helpful, none are perfect.
Dr. Richard H. Tyler tells the story of how diagnostic procedures, in this instance a physical sign and lab work, can indicate that something is wrong, yet not specifically identify the cause. He reports in an article titled "Thinking Before Diagnosing" which appeared in the May 1979 issue of THE CHIROPRACTIC FAMILY PHYSICIAN the following account. It is not unfamiliar to that experienced by many doctors of chiropractic.
"Several years ago I had a patient come to me complaining of severe pain on the right side of the lower thoracic--upper lumbar spine. She had been a patient of mine for quite some time but I had never seen her in such distress as she was this day. The adjustments that I usually made in that region couldn't be performed due to the acute pain. I examined the abdominal area and found McBurney's point exceptionally sensitive. Something was radically wrong. Appendicitis was the first condition I thought of. 'It's probably just gas', said my patient. 'Why don't I just go home', she continued, 'and call you in the morning'. I hesitated. I had a full schedule of patients so such a plan would be easier on me. I looked at her for a long time. No, I decided to send her to the lab in the building for a CBC. I put a stat on the order and within the hour the report came back with an extremely high WBC count. I referred her immediately to the surgeon in the building. Soon he was on the phone asking me for the CBC differential. 'I believe it's a hot appendix', he said. 'I'd like to put her in the hospital right away.' That evening my patient underwent surgery for appendicitis. The following morning the surgeon called me and told me that we both had made a misdiagnosis. 'We found that she had a ruptured ovarian cyst and was bleeding to death internally. Had she gone home to call you in the morning, as she wanted, she undoubtedly would have died in her sleep.'"
The patient profile is the opening statement in the patient's record. It usually consists of a brief narrative about the patient's way of life:
(l) life history, including usual day's activities, and education,
(2) marital status,
(7) hobbies and special interests,
(8) religion, and last but not least,
The purpose of the patient profile is for the doctor to form a picture of the patient's present lifestyle: home, work, and recreational activities to see:
(1) if anything therein may be the cause of or contributing to the patient's health status, and
(2) gain insight into the impact of the patient's problems on his daily activities.
Any of these factors may be a contributor of stress leading to lowered resistance and disease. Life history may indicate certain socioeconomic burdens or recent relocation frustrations. Marital status may present a mate incompatibility or a divorce maladjustment. The occupation may contain peer or superior friction, postural strains, or chemical or physical work hazards. A financial strain may be causing abnormal tension in a personality that is habitually "high strung" without the added pressures of money worries. Habits in diet, sleeping, or exercise may be a factor. Habits and addictions to tobacco, alcohol, diet fads, laxatives, and drugs may be causative or contributing factors. Religion may have an influence on diet, on fears behind anxiety, or on guilt behind depression.
By inquiring into a patient's usual day's activities, you deepen rapport with the patient and gain additional insight into specific problem areas. Such knowledge gives an understanding of how the patient is coping with his or her environment: physically, mentally, emotionally. Inquiries should be directed to the patient's quantity and quality of sleep; how he feels upon arising; evacuation problems; ability to dress one's self, prepare meals, drive a car, do housework or yardwork; difficulty of work activities and amount of overtime worked; amount of recreation and exercise; and other such factors of lifestyle.
Occupation is often associated with physical and mental stress. Inquire as to how the patient perceives his job, future career, and rapport with associates. Explore specific tasks and responsibilities. Try to determine if there is any link between the patient's symptoms and occupational hazards. Chemicals, dust, gases, postural strain, physical abuse, inadequate lighting or temperature control should be discussed. Excessive noise, arc lights, job boredom, stymied promotion, salary level, poor job benefits, and deadline pressures may also be pertinent.
Postural strains peculiar to the patient's line of work are always vital to a complete case history. Probe to see if musculoskeletal symptoms are related in any way to other somatic or visceral problems. Are any occupational stresses being superimposed on other complaints?
Automobile seats have a tendency to place the pelvis lower than the knees and to flatten the lumbar curve. The smaller and lower cars create awkward stooping and bending motions upon entering and leaving. These factors must be considered in people who drive a lot such as traveling salesmen.
Farmers who drive tractors and other large farm equipment, as well as workers who operate large construction equipment, frequently steer with one hand and twist their torso to view behind. This contributes to both lumbosacral and cervicodorsal strain, almost as much as shoveling and tossing dirt, gravel, or snow.
Dentists are taught to work in the sitting position, but many still stand and work in a bent position causing lumbosacral strain and with their upper thorax rotated to one side causing middorsal strain. Forward bending and rotaion is also a common problem with barbers and beauticians.
Each occupation has its postural features. Rare is the energetic housewife who does not complain of a nagging backache. Making beds, ironing, carrying groceries, vacuuming the rugs, picking up the children's toys, amount to about every bending, twisting motion imaginable. Assembly line workers maintain a stressful forward bending of head, neck, and upper dorsal spine. Typists and writers often assume the same posture while sitting. Packing and loading workers must constantly pick up a load from one side of their body, rotate their spine, and place the load on the other side.
Musicians commonly have postural defects peculiar to their instrument. The cello player rotates his trunk slightly to the left. The violinist must hold his instrument by force of his rotated flexed neck. The pianist sits for hours on end in practice with his trunk and shoulders flexed. The bass viol player bends his thorax to the right and rotates left with the right shoulder anterior.
Loosening of pelvic supports and the adominal weight of pregnancy is a well-recognized cause of backache. Less recognized is the awkward position during ottle feeding resulting in mid-dorsal strain. Bending from the waist and lifting the growing child frequently causes sacroiliac involvement if not lumbosacral strain. Carrying a toddler on one hip results in abnormal side bending and lower spine rotation with compensatory curves above.
Some practitioners such as Nelson feel strongly that posture and position is not the cause of most musculoskeletal problems: "Experience indicates the muscle sensitized by reflex irritation and prolonged or repetitive effort merely raises the irritability to exceed the threshold. Functional visceral irritations are a frequent cause of a low-level unconscious hypertonicity waiting to be further irritated."
Inquiries into a patient's educational background may indicate a low intelligence level which would make it difficult to follow normal instructions or to comprehend their significance. If normal explanations appear too complex for the patient, drawing pictures and using stories are helpful to get your points across. There also appears to be a relationship between educational level and effectiveness of treatment. The more a person comprehends his disorder, the more he is motivated to modify behavior.
Money worries can contribute significant stress, especially if a sudden loss or burden is recent. Questions regarding income must be asked with great tact and assured confidence. Once income level has been determined, inquiries as to size of household and debt responsibilities will help to profile the situation.
Nelson feels that "Worry of considerable magnitude but of short duration does not seem to be as hard on the nervous system as long, continued, but lower-level anxiety. Our primitive nervous system is well-suited for 'natural' or catastrophic stresses, but has difficulty with long drawn-out stress found in modern civilization."
While poor nutrition is usually regarded as the outcome of poor habits and conditioned tastes, other factors must be considered. Diet habits may be associated with income, poor storage or cooking facilities, ethnic food preferences, lack of planning or preparation knowledge, or anorexia associated with disease.
While obtaining a dietary history appears burdensome, it is necessary in obtaining a complete patient profile. If a 24-hour recall appears inadequate, have the patient develop a food diary for a week so that you may assess caloric, vitamin, mineral, and protein intake. Inquire into snacks and "junk" food habits. Frequent use of peanuts, popcorn, and chips may be associated with sodium imbalance contributing to hypertension, for example. Food allergies, sensitivities, and food fads should be discussed.
Nutrition commonly denotes food ingestion. While intake is important, facors of digestion, assimilation, transport, the regulation of metabolic end products, and elimination of metabolic and bulk wastes are also significant. The nutritional picture is complicated because almost all systems have some influence on nutrition. A comprehensive systems review helps to clarify the problems as long as it is recognized that the digestive, musculoskeletal, nervous, urinary, endocrine, circulatory, respiratory systems and psyche are interrelated.
Hobbies and Special Interests
Hobbies and recreational interests often give clues to emotional interests, intellectual level, and motor skills. Athletic participation assesses heart, lung, muscle, joint function, and coordination. Particularly significant is a recreational activity recently stopped such as an avid golfer who has recently given up the game. Inquire if any regular activity has recently been abandoned and why. Many hobbies require certain degrees of stamina, dexterity, visual acuity, and other functions that help to profile the patient. A lack of interests may indicate a physical impairment or be a barometer of emotional health (eg, depression). Such knowledge is often helpful in establishing therapeutic goals.
Inquiries should be made about the patient's typical posture while lying, sitting, or standing. Occupational postures have been previously discussed, but may be probed into further if it is felt necessary. Discuss the amount of time spent in these positions and whether or not symptoms are eased or aggravated by certain positions and motions.
Ask about the patient's mattress and the degree of rest noticed in the morning. Is the patient sleeping in a twisted position that would cause a pelvic torsion? Are the arms placed over the head, thus contributing to a brachial plexus condition? Are large pillows used in the supine position which tend to aggravate a dorsal kyphosis or strain the cervico-dorsal junction? Are the pillows too soft or too small to support the neck and head in the side position? If so, lateral cervical strain may be present.
Does sitting ease or aggravate any discomfort? Discuss the type of chair used at home and at work. Is there firm back support? Discuss chair height to desk height. Desk height should be level with the undersurface of the forearm flexed 90 degrees. Chair height should allow 90-degree knee flexion with thighs parallel to the floor. It's best that knees be slightly higher than hip than below hip. Does poor lighting affect sitting posture?
While standing, is weight shifting excessive? Is weight borne more on one side than the other? Which side? Does the heel of one shoe wear more or differently than the other? Do slacks or skirts have to be tailored so that they hang equal? Does one hip appear larger or one shoulder higher during tailoring? Women are often aware that one brassiere strap or slip strap seems to slide off a low shoulder frequently.
The patient history consists of the:
(1) presenting symptom,
(2) present illness,
(3) personal history, including past sicknesses, hospitalizations, medications,
(4) family history,
(5) accident history, and
(6) a systems review. The goal of the patient history is for the doctor to have an accurate record of, understanding of, and appreciation for these factors.
The presenting symptom is the chief complaint; that is, the major problem for which the patient has sought relief. A detailed description of the patient's current problems developed chronologically is called the "present illness". Every symptom and sign has a beginning and a course of development that may be progressive or fluctuating. Symptoms and signs are products of the body that produced them. Each body creates symptoms and signs in an unique way, and each personality adapts to them in an unique way.
The chief complaint consists of a brief statement, preferably in the patient's own words, concerning his reason for seeing the doctor. It also portrays the patient's sense of priorities about his problems. Actually, the term "present illness" is a relic of the past in which a patient saw a physician for a single illness. Years ago patients rarely sought relief for chronic, multiple, interacting problems as they do today. Thus, "active problems" would be a better descriptor, but "present illness" is commonly used today with a more modern interpretation. Ascertaining the presenting symptom and present illness has been previously discussed.
To assess the patient's personal health history, inquiries should be directed toward childhood diseases, major illnesses, operations, pregnancies (deliveries and abortions), allergies (air-borne, contact, medications, food), serious accidents, immunizations and reactions to such.
Previous hospitalizations may give clues to active conditions. Surgery for a ruptured appendix several years ago may result in adhesion troubles today, for example. Record dates of surgery, hospitalizations, length of confinement, and complications. Chronic diseases may be superimposed upon an acute condition. For example, infections hamper diabetes control, a sudden rise in blood pressure may bring out a cardiac weakness, an acute abdominal strain may interfere with a compensated lordosis, or sneezing may aggravate a chronic cervical disorder.
Medications direct attention to problems presently being treated or controlled. It is also well to remember that medications interact with other drugs. Some patients do not know what medications they are taking or why they are taking them. If this is the case, note the prescriptions and look up the drugs, their actions and side effects. Determine if the patient is following the instructions on the bottles. Inquire into use of non-prescription drugs. Overuse of aspirin, for example, is a common cause of gastritis, especially compounded with alcohol intake. Many drugs interfere with gastric pH, enzyme quality, normal renal excretion, intestinal bacteria, and normal blood chemistries. Drugs may also confuse the significance of certain signs and symptoms. For instance, a black tarry stool may be the result of bismuth powders or an iron tonic.
Genetic factors are sometimes involved in diabetes, renal disease, hypertension, mental illness, heart disease, cancer, and allergies. Inquiries should be directed toward the health status of grandparents, parents, and siblings. Ages and causes of death are important information. Determine if one or more members of the family is or has experienced symptoms similar to those presented by the patient. Genetic counseling may be advisable later with presymptomatic members of the family, and reproduction risks should be discussed if appropriate.
A detailed accident history is vital to a complete patient history. Discuss in detail the where, when, and how each accident or severe strain occurred. Ascertain the care administered, the scope and degree of trauma, the diagnostic tests taken and the care administered. For example, many allopathic whiplash cases are dismissed upon the relief of pain. Joint stiffness and fixation often result because of compensatory connective tissue effects of the over mobilization, similiar to traumatic arthritis effects. Proper manipulation would prevent this: if not completely, then to a large extent.
In an automobile accident, for instance, it is important to know from which side the force came, the position of the patient at the time of impact and after. Was a seat belt or shoulder harness fastened? Did the patient's head strike anything? Was there unconsciousness? What were the immediate symptoms? What were the later manifestations? These and many more similar questions must be deeply probed.