How to get to the right diagnosis—mastering the patient history!

Taking a thorough patient history (history of the present illness) is a form of art that should be learned from a true master! In this interview with the expert behind our Infectious Disease Essentials course, Dr John Fisher explains his ingenious approach of using the three-paragraph method when taking a patient's history. Check out the explanation video on this topic, too!

[00:00:00] Franz: So John, you have this great approach on how to take a history, the three-paragraph approach. Can you elaborate on that a little bit?

[00:00:09] John: Sure, Franz. I actually kind of stumbled into it after many years of practice. We require medical students to present in an orderly way and I wondered why do we teach them to do that? And then it dawned on me, it's not so that they can present, it's so that they can be better doctors at the bedside. So if you can think in an orderly way, you can take an accurate history and think your way to the diagnosis. So I figured out that paragraph one of this three-paragraph approach would be--

[00:00:47] Franz: And you do the paragraph, sorry for interrupting.

[00:00:50] John: Yeah.

[00:00:50] Franz: But you do it in your head, right?

[00:00:52] John: I do.

[00:00:52] Franz: That's the way you think about it.

[00:00:53] John: Yes.

[00:00:53] Franz: That you just make the, in your head, you write that first paragraph, right?

[00:00:57] John: Exactly. And so the first paragraph, I'm trying to discern what the patient's main trouble is. And you know, some patients come in with a lot of different complaints, so one of the tricks I use is I'll say, "Well, Mr. Jones, you've got a lot of different symptoms but pretend like I was a doctor that, you know, if you gave him too much to work with, I fell apart. What one thing would you have me fix first about the way you feel?" And they usually will come up, "Well, fix my shortness of breath or fix my pain." You know, so you usually can identify what the main thing is using kind of a trick like that but it ain't right. Once I feel like I understand what the main thing is, then it's my job in my head to have them stay on point until I am certain that I understand it. So they say it in their own words, I don't put words in their mouth, I hear it in their own words, but if they stray from that pain or shortness of breath, I'm going to get them back on point again, I'm going to say, "Well, Mr. Jones, I want to hear about your pain in your foot in a little bit but get back to this pain in your chest. I don't quite understand it completely. Tell me more about it." And so once I really fully understand it, that to me is paragraph one. And right away, I'm beginning to think, "You know, this sounds cardiac or this sounds respiratory or this sounds GI," whatever the complaint was, and I'm not sure that's the system yet but I'm trying to identify the system that went afoul. And so paragraph two would be, "Let's hear about the associated symptoms."

[00:02:44] Franz: That pain in the foot.

[00:02:45] John: Yeah. Tell me what else was going wrong with you? And so they tell me some other things. And now I'm saying, "Now, this really does sound cardiac or this really does sound respiratory or musculoskeletal," whatever the case may be. Because really, the history of present illness is nothing more than the exposition of some system and so I'm trying to figure out what system it is. So then, paragraph three would be for me to inventory the rest of that system that I got a hunch it is and I'll ask them about things they didn't complain about. If it's, for example, cardiac, I might ask them if they had, you know, paroxysmal nocturnal dyspnea. I don't say it that way. I might say, "How do you sleep at night?" And the say, "Well, I don't sleep so well." "You ever wake up?" "Yeah, I do." "What wakes you up?" In other words, I'm trying not to suggest anything. "Well, sometimes I have to sit up on the side of the bed." "Why is that?" So I'm getting a history of paroxysmal nocturnal dyspnea that way but I'm going through the other symptoms that the patient didn't complain about so that I can know for sure what the system is. That's my idea.

[00:04:07] Franz: That's really awesome. Thanks for sharing that.