How to tell your doctor what’s wrong with you.

eliciting the HPI through an interpreter can be challenging
eliciting the HPI through an interpreter can be challenging

When I see a new patient I may ask why they left their previous doctor. One of the most common reasons I hear is, ” My doctor wasn’t listening to me.” Accurate communication between doctors and patients is vital for effective diagnosis and treatment but can be difficult to achieve for many reasons. One is that doctors and patients may approach the medical encounter from different viewpoints and have different goals. Patients already know what is “wrong” and want to know what can be done to help or fix their problem as quickly as possible. The physician’s focus is on getting an accurate medical history to help narrow down the possible diagnoses so they can proceed to testing and then treatment.

Medical students are taught to take a “history” from a patient, one of the first skills taught in medical school. The history is the most important part of the medical encounter because, as we are taught,

“Listen to the patient and the patient will tell you what is wrong.”

This doesn’t mean the patient should  give the doctor a diagnosis, although that is what often happens.

Physician: “Hello, I’m Dr. Oglesby. Why are you here today?”

Patient:” I have a ________.”

Fill in the blank with any number of diagnoses that patients believe they have- a bladder infection, the flu, bronchitis, a sinus infection, pulled muscle, poison ivy, ankle sprain, etc.

What it does mean is that the history of the patient’s problem– how and when  it started, how it has progressed, what the current status is- gives the doctor the necessary information to develop a “working diagnosis”- in other words, the most likely explanation for the symptoms. Then the doctor can proceed with further evaluation to confirm or refute that diagnosis, and possibly lead to an alternate diagnosis to explore.

This process is called obtaining the HPI- the History of Present Illness. That distinguishes it from the PMH- the Past Medical History. (Medicine loves acronyms.)

We want to hear from patients a description of the symptoms in their own words. Then we ask questions to clarify and expand.

Here is an example:

Patient comes to me with complaint of headaches. And says-

“Dr. Oglesby, I have terrible headaches all the time. I think I have a brain tumor and want an MRI as soon as possible.” 

But what I need to hear is –

“Dr. Oglesby, I have headaches. The headaches are brought on by stress. Loud noise aggravates the pain. Lying in a dark room improves them. There is a throbbing pain in one of my temples and it shoots to the top and back of my head. The headaches are so severe that I cannot take care of my family. I have a headache once a week, and it lasts for at least 2 hours.”

It may sound simple, but I find that patients often have difficulty describing how they feel. They may say they hurt, cough, itch or get short of breath, but give few details. Maybe we have become too used to text messaging with its brevity, abbreviations and emoticons. We have forgotten how to use descriptive words.

patient encounter in VietNam

There are various mnemonics used to organize the elements of the HPI .(Medicine also loves mnemonics.)This is the one I learned in medical school- PQRST. The letters stand for the the different types of information we try to elicit in the HPI.

P- Precipitants- what happens to make the symptom begin or recur; Provocation– what makes it worse, increase, more frequent, etc: Palliation– what makes it better, less intense, less frequent

Quality- sharp, dull, cramp, piercing, numbing, tight, burning, tingling, throbbing,

Region and Radiation- where on the body does it occur and where does it move to

Severity– how bad is it- mild, severe, disabling, tolerable, unbearable, worst ever; can also rate  1-10,

Timing- when in the past did it start, how often does it occur now; how long do episodes last; length of intervals between occurrences

Now we can apply this to the above example:

“Dr. Oglesby, I have headaches -region

that are brought on by stress-precipitant

Loud noise aggravates the pain-provocation

Lying in a dark room improves them-palliation 

There is a throbbing pain in one of my temples and it shoots to the top and back of my head.-quality, region, radiation 

The headaches hurt so much that I cannot take care of my family- severity 

I  have a headache once a week, and it lasts for at least 2 hours.” -timing 

With this description, I would feel confident that the patient has migraine, not a brain tumor. If  the physical examination is normal, she likely will not need an MRI and we can proceed to planning management of her headaches.

I don’t think we doctors expect our patients to always recite a rehearsed narrative  about “why I came to the doctor today.” But it does help if you come prepared to answer questions as specifically as possible. You might try thinking about your problem using the PQRST mnemonic. It will help your doctor identify possible causes for your symptoms, and may also help you understand your problem and even suggest ways you can help yourself.

 

Here is an entertaining story about how some people tell a “country doctor ” what’s wrong.

“I have finally come to realize that Hedda carries with her more than a lifetime’s worth of grief, which now and then erupts as a sensation she has no words for. ”

 

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