2. Personal Information and Presenting Complaint

“As a medical doctor, it is my duty to evaluate the situation with as much data as I can gather and as much expertise as I have and as much experience as I have to determine whether or not the wish of patient is medically justified.” Jack Kevorkian. Personal information Understanding a patient’s personal information is crucial in developing an effective diagnosis and treatment plan. It serves as the foundation for building rapport, contextualizing medical conditions, and tailoring healthcare interventions. Name Purpose Establishes rapport by addressing patients respectfully and personally Ensures accurate record-keeping and identification. Additional insights Names may reflect cultural or regional contexts, providing indirect information about potential genetic predispositions or sociocultural factors. Age Importance of age is as follows: Age-dependent diseases: Many diseases are age-dependent. Congenital anomalies are present usually at birth. Wilson disease usually does not present before 3 years.[1] Insulin-dependent diabetes mellitus (DDM) is a disease of children while noninsulin DDM is usually present at older age, and maturity-onset diabetes of young at younger age. Maternal age is a known risk factor for Down’s Syndrome, and its risk increases as age of the mother increases.[2] 2. Type of infection also varies according to age. Early onset neonatal pneumonia is usually due to bacterial pathogens present in the maternal birth canal such as group B streptococci, Klebsiella, Escherichia coli, and Listeria monocytogenes, while late-onset neonatal pneumonia is due to Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. Viruses are the main cause of pneumonia in older infants and toddlers between 30 days and 2 years old. In children of 2–5 years of age, respiratory viruses are the most common cause whereas Mycoplasma pneumonia is frequently seen in children who are 5–13 years old.[3] At older age again viral pneumonia and bacterial pneumonia are more common. 3. Severity of disease: The newborn and older age group have more severe disease than children and adolescents 4. Doses of drugs: When weight is not known, drug doses can be given as per age. Antitubercular drug dosages in the national program in India prescribed as per age[4] 5. Contraindication: Some drugs are contraindicated in specific age group. Trimethoprim and sulfamethoxazole are not given below 6 weeks of age.[5] The risk of developing fluoroquinolone-associated tendinitis and tendon rupture is further increased in older patients usually over 60 years of age.[6] Gender Knowing the gender helps in the following ways: Females usually have a good prognosis compared to males for the same disease with the same severity In sex-linked diseases (X-linked recessive) such as Duchenne muscular dystrophy and Hunter syndrome, males are commonly affected than female Turner’s syndrome is seen only in females while Klinefelter Syndrome is seen in males Diseases associated with sex-specific genitalia are seen in the same sex group only. Like vaginitis, oophoritis, and salpingitis in female while orchitis and balanoposthitis in male Hormone-related: Coronary heart diseases are more common in males compared to females. Premenopausal symptoms are seen more frequently in females. Birth order Importance of birth order is as follows: Behavioral pattern: Usually if parents have only child it gets more attention and is more pampered, making behavioral issue like tantrums more common in 1st over subsequent children If there are many children then it may be due to some social belief in family planning methods are considered to be against religion It may be due to want of male child if all previous children are female. In this case, usually, females will not get proper attention at home Death of previous child: If previous children die at very early age or if the mother has repeated abortions then obviously they continue to plan pregnancy till they get a healthy unaffected baby Rh incompatibility usually does not affect 1st baby whereas untreated maternal syphilis more often leads to congenital syphilis in the first child and severity may be less in the next child Care of children: If more children are there then proper care, education, etc., may be difficult for the family. Community Knowing the community of the patients may help doctors to guess their beliefs and reason behind the particular disease and their approach to acceptance or rejection of treatment. Sickel cell is common in schedule caste, schedule tribe, and Adivasi while Thalassemia is common in Sindhis, Bhansali, Panjabis, etc In some communities, consanguinity is very common leading to high incidence of autosomal recessive disorders In the Muslim community, burka may lead to more incidence of Vitamin D deficiency while circumcision in childhood leads to decrease incidence of penile cancer Jehovah’s Witnesses lead to refusal of blood transfusion even in emergency and may lead to death.[7] Similarly, religious beliefs in some may lead to delay in seeking treatment as they primarily visit ojha, traditional healers, etc. Place of residency This is important in following aspects: Environmental influence: Diseases like malaria are common in sub-Saharan countries. In India, Odisha, Chhattisgarh, Jharkhand, Meghalaya, and Madhya Pradesh are highly affected with malaria Healthcare accessibility: Patients from far regions may not have proper access to healthcare facilities. Sometimes due to unavailability of transport services, many patients may succumb to potentially treatable disease Follow-up care: When to admit or discharge/advise on discharge to patients may vary according to where they reside and availability of health services in their area. Informant Usually adolescent/adult give their history by themselves, but in children, mentally incapable person, in person with neurological impairment informant is the person who gives history. The reliability of informant is very crucial in every such case. In adults mentioning occupation and marital status may be important in personal information.[8] Presenting complaint and history of presenting complaint Defination Presenting complaints are the primary symptoms or concerns that prompt a patient to seek medical care. These complaints should be documented verbatim in the patient’s own words to preserve accuracy and avoid interpretation bias. Presenting complaint/s History of presenting illness and negative history. Some key points which must be remembered during this are: It should be always in patient’s own language – so yellowish discoloration of the body should not be mentioned as icterus The oldest symptom should be mentioned first and the latest complaint should be mentioned last – Write it in chronological order, for example, if the patient complaint of respiratory distress, but he had complaint starting with fever before 8 days then the fever should be mentioned as first complaint and not respiratory distress History should be described till the date of history taking and not on the date of admission. Whether the patient improved or deteriorated after admission may also give valuable clue to diagnosis History should be started with open-ended question, like what are the ailments the patient suffering from, rather than if he/she had enteric fever/convulsion/pneumonia? Both open and closed questions have their place, and normally clinicians move gradually from open to closed questions as the interview progress[3] One should always talk in the patient’s language. In case, the student is not able to speak that language an interpreter should help. Use vocabulary the patient will understand, as some words may have different meanings for the patients, like cough for patients means expectoration, whereas some mean gargling sound or any conducted sound from the chest. So sometimes whenever in doubt it is better to clarify the meaning by asking relevant things. Although taking notes is important during consultation, equally important is to see the patient in face with direct eye contact, to show sympathy and awareness of their needs.[9] HISTORY OF PRESENTING ILLNESS Definition History of presenting illness (HOPI) describes the detailed narrative of the presenting complaints, emphasizing their onset, progression, and associated features. This history provides critical insights into the pathophysiological process, aids in formulating a differential diagnosis, and guides the clinical examination.[8] For example, if the patient had fever and convulsion which continue after hospitalization it may indicate viral encephalitis but if convulsions subside but fever persists it may be a case of febrile seizure with fever due to some other cause. On the other hand, if convulsions continue without fever, this may indicate fever precipitated seizure or seizure disorder. Very few patients present a clear, concise, and chronologically perfect history with little prompting. With most of the patients, the clinician needs to do a substantial amount of clarification by asking leading questions to reach the diagnosis. Always try to have conversations with patients, and never interrogate unless it is absolutely necessary.[9] During any consultation, nonverbal communication is equally important as the conversation with the patient. Sometimes the anxious look on the patient’s face might need more probing as he/she might be relating the illness to some hearsay adverse outcome. Some symptoms like burning in micturition might be because of urinary tract infection but on probing the problem might be the result of sexual abuse. Clinician who fills every pause of the patient with another question may prevent the patient from giving complete details. Some patients are very hesitant because of anxiety and need more time to speak out. Active listening is a core skill in clinical encounters, as it encourages patients to tell their stories.[10] Experienced clinicians make a diagnosis by recognizing pattern of symptoms. With experience, clinician will refine his questions according to the presenting symptoms, using a mental list of possible diagnosis.[10] Negative history is important as it helps the clinician clinch the diagnosis by ruling out other differential diagnosis and also helps in the assessment of possible complications. Example – In a patient with suspected rheumatic heart disease one should always ask for a history of swelling over limbs, difficulty in breathing (congestive cardiac failure), or high-grade fever, (Bacterial endocarditis). Furthermore, other relevant complaints such as rash, red color urine, etc., to rule out other problems like scarlet fever or systemic lupus erythematous. Summery The structured personal history approach not only ensures comprehensive history-taking but also underscores the importance of integrating sociocultural and environmental factors into clinical decision-making. Presenting complaint and HOPI give us the primary diagnosis and differential diagnosis which may be brought patients to our attention. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.