The unreliable historian

There are two rules in medicine - believe everything the patient says, don't believe anything the patient says

Sometimes it is obvious that a patient's history cannot be relied upon and we need to take a health skepticism about anything they say.

Sometimes the best historian is NOT the patient.

Why do we get the wrong information

• Doesn't understand the question e.g. medical jargon, NESB, different use of words, mentally disturbed
• Guilt e.g. smoking, alcohol and recreational drugs
• Embarrassment e.g. sexual history

If there are concerns about the patient's mental function then perform a quick mini-mental exam.  If they score poorly then it is not worthwhile persisting with a detailed history.  Perform a quick review of current symptoms then obtain the information from an independent source.

 Words that might mean different things to the doctor and patient

• 'Dizziness' = pre-syncope, light-headedness or vertigo
• 'Nausea' = lethargy or weakness
• 'Feeling sick' = lethargy or weakness
• 'Chest tightness' =short of breath or chest pain
• 'Sudden' = happened today but not abruptly

Questions that might get different responses

• Do you have any medical problems? vs Do you see your doctor regularly
• Have you had any operations? vs Have you ever been hospitilaised?
• Do you have any allergies? vs Are there any medications that don't agree with you?

How we can improve the history

• Don't rush your questions and ask them one at a time
• Don't jump straight into close-ended questions e.g. have you ever smoked vs do you smoke
• Don't ask leading questions e.g. you use contraception don't you?
• Get the patient to explain what you have just said to them
• Ask the question in different ways
• Try different words including slang
• Be aware of the patient's level of education and culture
• Perform the assessment in a quiet and private setting

When all else fails

• Make extensive use of 3rd party information
• Check case notes, computer records
• Read other reports e.g. ambulance records, nursing and allied health notes
• Speak to GP and specialists
• Faxed copies of notes and discharge letter