The Power of History Taking

 “You must learn your history taking properly”, this is what most young medical students grow up hearing from their teachers. I still remember the second year of medical school in 1997, when we went to the wards and practiced history taking. We would carry our long notebooks with a pen in hand. We would stand awkwardly in front of the patients and ask questions one after another. Even as the patients were saying the answers, we would pause and write them down. This whole exercise was aimed at creating a coherent story to present during the case discussion with the teacher. For a major part of medical college, I never understood why we should ask so many questions some of them seemingly irrelevant. For example, we would examine a patient with an inguinal hernia, and would have to ask routine questions about type of diet, regularity of bowel movements, smoking, alcohol use, and other such questions. There would even be long winded discussions on how each of those aspects are important to arrive at a diagnosis. We used to be impatient with the history taking and rush towards looking at the patient, touching and feeling swellings, feeling the abdomen for any lumps, looking at the CT scans and MRI scans to try and identify any abnormalities. Every time we did this, our teachers used to slow us down and take us back to history taking. It seemed cruel and felt like it was a conspiracy to dampen our enthusiasm to become good doctors. But last week, I saw a patient in the OPD, who helped me see the infinite wisdom in the adage “a thorough history well done gives us the diagnosis 90% of the times”. 

 

Muthu (name changed) a burly man of 32 years, looking unkempt with a week old stubble, walked into the OP with an anxious look on his face. It was the Annual Preventive Health Screening OP. People above 30 years of age could walk in and get their health screening done to detect diabetes, cholesterol problems, high blood pressure and other such silent diseases. This man sat down quietly and spoke in a hushed voice. 

“Doctor, I keep getting this sense of having to pass urine all the time. Day and night, this sensation troubles me a lot. I haven’t slept properly over the past 3 months.” he whispered. 

He pulled out a thick folder with a bunch of papers in it and placed it gingerly on the table in front of me. He pointed to it, looked me in my eyes and said,

“See this doctor. I have seen all specialists. I have done tests worth 2 lakh rupees. I still don’t have an answer for my problem”

 

One thing my guru and teacher Dr. K.P. Misra, cardiologist, has taught me is to never look at patients’ reports without talking to them, taking a thorough history, and doing a detailed physical examination. The lesson has been driven so deeply and thoroughly in my mind that I never break the rule to this date. I gently pushed the reports aside and turned my chair to face Muthu. I put my pen down and leaned forward and looked Muthu in the eye and asked him,

“Muthu, please tell me what is troubling you. Let us start right in the beginning. I want all the details. After that I will see these reports.” 

Muthu relaxed a bit and started organizing his thoughts. I could hear the machines inside his brain start to creak, roll and crunch as he decided when, where, and how to start. 

 

“On 03 October 2022, I was doing a courier delivery in one of the suburban areas in Chennai. It was a very busy day, and I did not have any time to drink water. That night when I came home, I developed severe burning sensation in my urinary passage. I drank a lot of water after that and then the sensation went off. But from then I keep getting this feeling that I must empty my bladder. Once in every half an hour to 1 hour I must go to the toilet. Sometimes I get about 20-50 ml of urine. Sometimes, I get only a few drops. But still, I get the sensation of emptying my bladder and I go to the toilet. On 17 October 2022, I voluntarily controlled the sensation to pass urine for 4 hours. But the feeling was so intense and painful and so when I went to the toilet, I passed more than 500 ml of urine.”

 

I was surprised by the attention to details that Muthu was providing. He knew the exact dates of each event as far back as 3 months and even knew the exact quantity of urine. When I asked him how he remembered the details, he said he maintained a notebook in which he started recording the details of urine passed, the number of times he passed urine and the symptoms he had each time. 

 

“Then what happened? Did you take any treatment for it?” I lead him on. 

 

“On 18^th October, I went to the doctor near my house. The doctor ordered some urine tests. He ordered urine routine. He found that the urine routine test was normal, there was no evidence of any infection. He just told me that my urine osmolality is a bit low. He explained that low urine osmolality happens because the urine is too diluted. This could be a problem with the concentration ability of the kidney. He referred me to see a kidney specialist”

 

Muthu was a courier delivery executive. He told me he had studied only up to +2 in school and dropped out of college. For someone with only a +2-level school education, Muthu seemed to be very well informed about health-related matters. He was comfortable with medical jargon. When I asked him how, he said he has been visiting doctors frequently for the past 10 or more years and many of his friends are doctors. He opened his WhatsApp application on the phone and showed me that he was part of many health and fitness groups. Many of his frequent contacts were doctors. 

 

“What did the Kidney specialist say? What happened after that?” I probed. 

 

“Kidney doctor did another set of blood tests, urine tests, ultrasound scan of the abdomen. He saw all the reports and said everything was normal. The urine osmolality is also normal. But I was still suffering. The frequency of getting up at night increased from 4 times to almost 10 times. Most of the times I would just go and stand in the toilet and come back without passing any urine.”

 

“Was there any pain in the abdomen? Was there burning sensation while passing urine?” I asked.

 

“No doctor, you are asking to see if I had urinary tract infection. I went to another doctor after that in the hospital near my home. That doctor also asked me the same question. I told him I had no such symptoms. He did a urine culture and sensitivity test. The urine culture also did not grow any bacteria. He still prescribed some antibiotic called Nitrofurantoin. I took it for a week. Still nothing improved. I continued to suffer doctor”

 

Even as he was saying this, he was organizing the BP apparatus, the stethoscope, the notebook on the clinic table. I smiled at him as I saw him doing this. He replied,

“No doctor, I like things to be kept in order. I like to organize things”

 

“Has there been any time when you don’t have this sensation of passing urine?” I asked him. 

 

“There are times when I never have the feeling doctor. For example, on 26^th November it was my elder brother’s 50^th birthday. We all had gone for a movie with his and my family. I was happy and enjoying myself. The cinema theatre had AC in high blast, and I had drunk carbonated beverages. Still I did not feel like going to the toilet even during the interval. When I came home that night, even my wife joked about it and asked me how I did not get the urge to pass urine”  

 

“Have you noticed any pattern of when you don’t get the sensation to pass urine?” I asked. 

 

He paused and looked me in the eye deeply. After a few seconds a bright look of recognition appeared on his face and he said, “Now that you ask me, I think I never get the feeling of passing urine when I am busy, or happy, or distracted with some work. On 12^th December, I had to do an express delivery in a home that was 25 km away. The traffic was bad, and I was so determined to do the delivery on time. So, I was fully concentrating on that work. That day I never got the sensation of passing urine. In fact, I successfully delivered the courier on time, and I got a generous tip from the customer. That night also I never got up to void urine. I was so happy that day. But the very next day everything started again.” 

 

Muthu had 5 siblings. Three elder brothers and a younger sister. All of them were well settled in good jobs. Two of his elder brothers were doctors, one elder brother was an engineer working in a government agency. His younger sister was married to an IAS officer and lives in Delhi. Muthu had never completed college education. He was an object of constant ridicule and mockery during his young days at home. His father would constantly compare him with his brothers and berate him. But Muthu was a very happy child. He grew up to be a very happy man, married his high school sweetheart and doted on his only son. Though he was happy outside, deep within he harbored an inferiority complex about his underachievement amidst successful brothers and sister. 

 

“Do you get worried and afraid a lot? Do you feel low and sad?” I enquired with a rather serious expression on my face. 

 

“Yes doctor, nowadays I am always worried about my health. I am worried about the health of my son. I was 118 Kg weight 5 years ago. I used to drink and smoke. Then when I saw a friend of mine die of heart attack at 30 years of age, I got shocked and gave up smoking and drinking. I started worrying about my health. I don’t eat fatty food. I have joined yoga and gym and do running daily now. I am now only 86 kgs” 

 

“It is good that you got into a healthy lifestyle. What else are you worried about?” I enquired further. 

 

“I am worried about my son. I am worried about his studies, his exams, his health. I am worried that I should be alive for at least another 10 years by when he will finish college and get a job.”

 

The conversation started getting a bit grim. I started understanding Muthu a bit. Could the urinary sensation be originating from a deep seated psychological problem? Could it be an obsessive thought which he is finding hard to dismiss? He seemed to have features of anxiety, hypochondriasis, and obsession and compulsion. Could this urinary sensation be related to it? 

 

“Do you feel stuck with thoughts in your head that keep playing repeatedly in a loop?” I asked. 

 

Muthu went quiet at this question. “How do you know doctor? I get such thought loops many times. Sometimes it is the fear of delivering a parcel late. I get stuck with the thought, and it keeps coming again and again and I can never stop it. Sometimes I get a thought that my son is very sick. I keep getting the thought again and again.”

 

I was starting to understand Muthu’s problem now. The conversation had gone on for more than 45 minutes now. I took his file and browsed through a sea of paperwork, all of which showed normal blood tests and urine tests and scan reports. Then I took my pen and wrote down a detailed case note. I looked up and saw Muthu, as he was watching me write intently. 

 

“Muthu, I think your main problem is a thought loop. The urinary sensation that you are having is a thought loop. Just like how you get these thoughts which keep coming again and again in a loop, this urinary sensation is also a thought loop. It is a problem in your mind. It is difficult to overcome, but not impossible. I will give you an assignment to do today and come back day after tomorrow and report to me.” I told him. 

 

Muthu was eager and enthusiastic now. There was a look of understanding on his face. He said, “Yes doctor, I also think it is a thought loop. I have been thinking that this whole thing is in my mind but was afraid to suggest this to the doctors because then they may miss something serious. I agree with you doctor. Tell me what I should do” 

 

I saw in Muthu a very intelligent, discerning, and cooperative young man who was eager to have his problem resolved. I told him to consciously break the thought loop every time he gets the sensation of passing urine. Each time he got the urinary sensation, I asked him to tell himself affirmatively, “I don’t have to pass urine now. This is a thought. It is not a urinary sensation”. When Muthu left the clinic that day, he looked at ease. I was not sure if this would work but was satisfied with the history that I had taken. 

 

All the clinicians who had seen Muthu before me had seen his urinary problem from a purely biomedical angle. They had investigated for structural problems in the urinary tract, functional abnormalities in urinary system, kidney problems, infections of the urinary tract and anything that could lead to his symptoms. Even before I saw any of his reports, or examined him, I had chosen to elicit his history, as I had been taught to do. The history led me to think of a psychological origin of his symptoms. Muthu had repressed inferiority complex, he had features of health-related anxiety, he had obsessive thoughts and some compulsive behaviors. In this context, it seemed like his symptoms were largely psychological in nature. After this detailed history, I would have ordered some routine tests to rule out structural and other causes of his problems. Fortunately for me, all that had already been done. However, he had never had his history analyzed in such detail, that the other doctors sent him home as “healthy” when they did not find the disease that they were looking for. I realized the importance of history taking and heard the voice of guru loud and clear. Nothing can replace a detailed and thorough history taking in clinical medicine. 

 

Two days later Muthu came back to the OP. It was closing time and he rushed in. “I was afraid you would have gone for lunch. I am glad I could see you” he said puffing and panting as he had run up the stairs to see me. He was in his courier delivery uniform. He had had a nice haircut and shaved off his stubble. He looked cheerful and energetic. 

 

“Doctor, for the past 2 days I did not get the urinary feeling even once. I am sleeping well and carrying on with life like usual”, he said and bent down to touch my feet in respect. I was shocked and jumped away, touched his shoulder, and lifted him up. I could see tears of gratitude in his eyes. He did not speak anything more. His shoulders shook as he sobbed silently. I made him sit and offered him water. 

 

“Doctor, nobody has spent so much time with me talking and understanding my problem. No doctor has tried to understand me and my story and see my symptoms in that context. I knew it myself that my problem is in the mind. But I was afraid to accept it as I did not know if I was missing something. But when you heard my full story and said something that I was worrying about myself, I felt validated and relieved. I now clearly understand my problem and I am getting better. I have stopped all medicines; I have packed up all the lab reports and notes and have put them in my attic. I don’t think I will need all that anymore.” 

 

I felt happy to hear this, shook Muthu’s hand, gave him a warm embrace, and saw him out of the door as he beamed a big broad smile and rushed out to continue his work. Days like this make being a doctor such an exciting experience. As I write this essay, I think of my Guru, Dr. K.P. Misra and his words of infinite wisdom – “In a good history, a patient spells their whole diagnosis to the doctor”.