The History

“A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment.”

—Anonymous

When taking an adequate history, patience is not only a virtue, it is a vital necessity, as the following verbatim report of the first part of a prolonged consultation reveals:

Doctor: “Well, Mrs. Jones, what can I do to help you today?”

Patient: “I sure hope you can cure it.”

Doctor: “Well, I’ll try. Have you any pain?”

Patient: “Of course I have, I wouldn’t be here if I didn’t have any pain. I’m not the sort of person that keeps running to doctors with nothing wrong with them. I know you’re all very busy and if…”

Doctor: “Where is the pain?”

Patient: “Haven’t you looked at my radiographs?”

Doctor: “I will look at your radiographs after I have taken your history and completed an examination. Please tell me where your pain is located.”

Patient: “The same place it’s always been.”

Doctor: “Where is that?”

Patient: “In my back, of course.”

Doctor: “Where in your back—in the low back?”

Patient: “I don’t know whether you would call it low or high. All I can say is it’s sure a bad pain.”

Doctor: “Could you point to the pain? Ah, I see. How long have you had this?”

Patient: “Ever since I tripped on the stairs.”

Doctor: “When was that?”

Patient: “Didn’t my doctor send you my history? His nurse promised me she’d mail it to you. Oh, this is terrible. I don’t see any point in coming here if you don’t know anything about me. I wonder why…”

Doctor: “When did you have the accident on the stairs?”

Patient: “In June.”

Doctor: “What year?”

Patient: “Why, this year of course. I’m so sorry my doctor didn’t send you my history!”

Doctor: “Have you had pain every day since then?”

Patient: “Sometimes.”

Doctor: “You mean the pain is intermittent?”

Patient: “No. I mean sometimes I have the pain, and sometimes I don’t.”

Doctor: “When you have the pain, what aggravates it?”

Patient: “How do you mean aggravates?

Doctor: “Does anything make the pain worse?”

Patient: “No, it’s worse all the time.”

Doctor: “Does lifting make the pain more severe?”

Patient: “No.”

Doctor: “You can lift anything you want without hurting your back?”

Patient: “No, I can’t lift anything.”

Doctor: “Why?”

Patient: “Because of my back.”

Doctor: “Let’s just think of some things you do in your house. Vacuum cleaning, bed making, doing the laundry; do any of these things make it worse?”

Patient: “If I could do all of those things I wouldn’t be here. I don’t believe in running to the doctor with the least little thing. I can take a lot of pain, more than most people. You ask my husband. I can’t even sit down because of the pain.”

Doctor: “Does anything relieve your back pain?”

Patient: “No.”

Doctor: “What do you do when the pain is bad?”

Patient: “I lie down.”

Doctor: “Does lying down make the pain better?”

Patient: “No. It’s just as bad when I get up.”

Doctor: “When you are actually lying down, is the pain any easier?”

Patient: “Yes, but I can’t spend my life lying down.”

Doctor: “Does the pain stop you from doing anything you want to do?”

Patient: “I can’t play golf with my husband.”

Doctor: “Do you get a lot of pain in your back every time you play golf?”

Patient: “Yes.”

Doctor: “When did you last play golf?”

Patient: “Eight years ago.”

Doctor: “Why haven’t you tried to play golf again?”

Patient: “My doctor told me not to.”

It is easy to describe a color, a sound, a taste, or a smell because these are sensations that can be shared. “I went down to the beach later that evening, when the setting sun had turned the sea into a vivid red, all that could be heard was the plaintive cry of the sea gulls and the gentle splashing of the waves against the rocks.” Statements such as this make a clear impression in the mind of the listener. It is more difficult, and yet more important, to interpret the statement, “I have this uncomfortable feeling in my back—I wouldn’t call it a pain really,” or, “I was paralyzed with pain that felt like red hot rivers rushing down my legs.” Is the second patient exaggerating, or does he or she have more serious back trouble?

When taking a history, it is not good enough to find out that patients have “back pain” or that they have pain in the right leg or left leg. It is essential to obtain a description of the pain in meticulous detail. Having obtained a clear description of the discomforts from which the patient is suffering, it is then necessary to find out as much as you can about the personality of the patient and his or her activities to try to correlate the pain to the disability about which the patient is complaining. The majority of patients do not come because of pain; they come because of the disability it produces. “I’ve got this backache and I can’t play badminton.” The patient can do everything else; he or she wants you to overcome the “disability” and make him or her able to play badminton again.

You have to obtain a clear picture of the pain. From this, you must assess the possible source of pain. You have to obtain an equally clear picture of the patient who has the pain. From these facts, you have to assess why the pain is causing the complained-of disability.

Before you go any further, remember:

After listening to the patient’s story, there is an 80% chance you will know the diagnosis (you will improve the odds another 10% by doing the physical examination, and another 5% by ordering fancy, expensive tests).
If after a history, physical examination, and review of tests you are still not sure of the diagnosis, go back and repeat the history! A few minutes of good history taking can save thousands of dollars in expensive testing.

Now, you can close the book and know that all you need to do in assessing a patient with back pain (and any other complaint in most of medicine) is to listen to your patients! Can you imagine how hard it is to be a good veterinarian?

Picture of the Pain

Site of the Pain

When patients state that they have “back pain,” they may mean anywhere from the base of the neck to the buttocks. It is not good enough to ask patients where they feel the pain; they must demonstrate it. A patient’s grasp of anatomy is understandably vague. When patients say that they have pain in their backs, they may be referring to the interscapular region of the back, and even when they state that they have pain in the “small of the back,” they may be referring to the lumbodorsal junction. When patients describe pain in the “hip,” they generally mean pain in the buttock. It is necessary always to get the patients to point to where they have the pain. Let us slip in a little word about pain over the greater trochanter, so often called “trochanteric bursitis.” More often it is pain referred to the region from the lumbar area. Injecting the area with local anesthetic and cortisone can often have a placebo effect and mislead you into accepting the erroneous diagnosis of trochanteric bursitis.

The method the patient chooses to demonstrate the site of pain is instructive. The emotionally stable patient generally places the palm of the hand at the site of maximal pain and moves it across the body to demonstrate the route of radiation. The psychologically troubled patient generally points out the area of the pain with his or her thumb (Fig. 8-1). He or she never touches the painful area. The pain, so to speak, is outside his or her soma.

FIGURE 8-1 “Macnab sign.” Patients who are suffering from a significant emotional overlay will frequently point to the area of pain in the lower back with their thumbs. They never actually touch their body. (From Macnab I. Backache.

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