The history of the presenting complaint used to be one of the biggest enigmas in all times for me. It still is, mind you. But unlike in the bygone days of utter ignorance, I'm kinda confident that i can at least steer not completely blind. Maybe not along the chartered mapped and established course in the smoothest manner.... but i can be pretty sure that i would somehow or other end up where I'm supposed to do.
The world is full of misleading advices. Most directions given by reputed books were more confusing rather than very informative. For example some doctors kept saying that all the symptoms should be documented in the chronological order as the patient describes it. No place for fancy words like dyspnea.... just simple terms, 'difficulty to breathe'. Still other books and consultants would mock you until you wish either you or him would annihilate just then if you use simple language that everyone can understand.
Still others would recommend that you proceed not in the chronological order, but in the order of importance of symptoms. Now this, although may suit the grizzled veterans of medicine,may be quite impossible for a total minion like me, because i just can't decide which symptom is more important. For example, a 55 year old lady may present with a ulcer on her foot following minor trauma, but in the cause of conversation she might mention passing very frothy urine since about one week. It ain't causing her discomfort, so she doesn't consider it a big deal. But we know the implications.
Life is complicated. So the best method is obviously personalized. You tell it the way you like and make sense to you.
So how do 'i' do it??
I usually go with a big smile and start gossiping. Well i mean literally. I try to sound as much as possible like some concerned and slightly curious person than some nerd who go scavenging for"exam cases".
I ask the patient what happened and let them talk a bit. Now the first few minutes will decide whether you are in for a bad day or not. Some patients are excellent storytellers. They begin from the beginning and go on just like a well told story ought to go. They quench your curiosity with just the right answers and do Sheherzad proud.
Others, well the least that you can do is to resist the terrible urge to write a psychiatry referral for the others. They begin from the end and refer to obscure event in the past, and when you ask about it look at you as if you are the biggest idiot not to know about it. These type of patients are unfortunately the more common.
So what i do is to listen and somehow or other get the whole history in order they happene. For example, in a patient comming with a pelvic pain, i would inquire and dig up her previous year diagnosis of a right sided polycystic ovary. My history would begin with that. " ... Sir, a 17 year old female, previously diagnosed with a right sided polycystic ovary presenting with a RIF pain of three days duration..."
Then i would go on and relate the events that led up to her current hospital admission.
Now remember, a history is unique. You only get one history once ever. No two histories are alike.
Before proceeding to the next level of history presenting i tried to master this art. The most difficult art of relating things in the way they happened in the order they happened.
So for my 17 year old patient that would be,
"....Sir, a 17 year old female, previously diagnosed with a right sided polycystic ovary presenting with a RIF pain of three days duration.. She had initially undergone USS of abdomen which hadn't revealed any significant abnormalities."
This is what she told me. And if i repeat the same thing,
1) The consultant,the registrar and all the buggers would openly laugh at me. Or there's an equal possibility of them descending on me like a pack of dragons and scaring me speechless.
2) The story so meticulously planned would be a senseless idiocy. It won't make sense to anyone.
3) Princess scherazad would be ashamed of me.
4) The story won't help to form any diagnosis.

So like someone who is a diciple of Sherlock Holmes should do, i make some very specific inquiries and form my own story based on the patient's experience.
That of course will be the content of my next post.
And a big thank you to all of you guys reading me. I would so like to hear what you have to say!