Hospitalization - Giving a History

The interview is likely to be lengthy, and many of the questions will be reviewed by other members of the staff. The patient must cooperate to the best of his or her ability and should never insist that, because the family physician has already taken all of the details, repetition is unnecessary. Often, the patient forgets to tell his or her own physician about something, and this comes to light only during the interview at the hospital. This medical history is the most important single factor in helping the physician to make a diagnosis. It is more important than the physical examination, the tests, or the X rays, even with the sophisticated equipment available in today's hospitals.

An intern usually comes to see you after you have settled into your room. He or she writes down all the details of your illness.

Giving a History. The resident physician begins the interview by introducing himself or herself and explaining who he or she is. Residents vary in interview technique, but commonly the resident begins by discussing the patient's main symptoms, because obviously this is causing the patient the most concern. When the resident asks you what is wrong, you should explain the most prominent symptom or symptoms, such as shortness of breath or abdominal pain. The resident does not want your estimated diagnosis.

The questions that follow relate to the presenting symptom. For example, if you are complaining of abdominal pain, the resident will ask questions such as: has the pain changed position at all; has the pain become localized (concentrated in one area) or has it spread to other areas of the abdomen; and what type of pain is it (sharp, burning, spasmodic, or a dull ache).

The resident will ask questions relating to the intensity of the pain. A question commonly asked of mothers is whether the pain is as intense as labor pains. The resident will also want to know if anything makes the pain worse, such as moving a limb, or whether anything eases the pain, such as sitting up or lying down. The resident will ask if you notice any other symptoms as the same time as the pain, for instance, gas or flatus.

After the questions concerning the main complaint, the resident will probably ask about your past medical history. The questions will cover areas such as: have you had any major illnesses (do not forget to mention any childhood illnesses you have had); have you had any operations (you should mention even the most minor ones, such as having a mole removed); and have you ever been treated for a disorder (remember to mention minor disorders such as indigestion). The resident will ask a female patient about her menstrual and obstetrical history; how many children she has had; whether all the pregnancies and labors were normal; and if there were any postnatal complications. A female patient must remember to mention any blood pressure problems during pregnancy or complications, such as forceps delivery or induced labor. If you have ever been hospitalized, you will be asked the year and your home address at the time, the name of the previous hospital, and the physician whose care you were under.

The resident will ask you what job you do and whether it exposes you to any particular hazards or emotional tension. A patient's social history plays an important part in the diagnosis.

The physician will ask if your mother and father are still alive. If they're not, he or she will want to know of what they died. If your grandparents lived into their eighties and both parents are alive and well at the age of seventy, there is a likelihood that you will live to the same age. If you are an adopted child, you should mention it. The resident may also ask direct questions about conditions and illnesses in the family: is there any incidence of tuberculosis or has any member of the family suffered from a stroke or heart attack.

The resident will want to know about your drinking and smoking habits. This is not an opportunity for the resident to criticize or pry into your habits, but it is essential that you answer the questions accurately. The resident has no wish to censure you, but he or she must have accurate information in order to reach a correct diagnosis.

The resident will then probably move on to questions related to drugs and medications. A patient often denies taking drugs regularly, only to admit, after closer questioning, that he or she has been taking antacids for indigestion for the past forty years or a laxative every morning for the past month. It is most important that you think carefully before giving your answer. The accuracy of the diagnosis could depend on it. A good example of this is the contraceptive pill. Many women do not regard this as regular medication, but during major surgery it can encourage the formation of blood clots that could prove fatal. The resident will also want to know about any allergies, such as one to adhesive tape.

Many residents make a habit of running through all of the body's systems at the end of the interview, asking direct questions about each. This is a sort of screening that gives the patient a last chance to remember anything that may be important. The questions about the chest may include: how much do you smoke; do you ever have pain in the chest; are you ever out of breath after walking up the stairs; and do you ever cough up mucus. Questions about the bowels may include: how often do you have a bowel movement; have you ever noticed blood in the stool; or do you feel bowel discomfort at any time. Questions about the bladder may include: how often do you urinate; do you ever feel pain or burning on urinating; have you ever noticed any blood or cloudiness in the urine; have you ever suffered from stress incontinence or frequency; and have you ever had trouble urinating. A female patient will be asked questions about her menstrual cycle: is it regular; is the bleeding heavy or light; does she suffer from painful menstruation; or does she ever bleed in mid-cycle.